ANGELES UNIVERSITY FOUNDATION COLLEGE OF NURSING S.Y.

2013 2014

CASE STUDY ABOUT CORONORY ARTERY DISEASE WITH UNSTABLE ANGINA

SUBMITTED BY: BUENAFE, PATRICIA MARIE MANALANG, MA. CLARELLE SULA, JANNICA BSN III 3 (GROUP 11)

SUBMITTED TO: DENNISON JOSE C. PUNSALAN, RN, MN CLINICAL INSTRUCTOR

OCTOBER 11, 2013

I. INTRODUCTION Every man's disease is his personal property. -Alonzo Clark

A person should be able to take care of his body in order to maintain a healthy life. It is because health refers to the levels of functional or metabolic efficiency of living beings. In humans, it is the general condition of a person's mind and body, usually meaning to be free from illness, injury or needless pain. That is why the quote said that a sick person is in his personality. During the Ottawa Charter for Health Promotion in 1986, the WHO said that health is a resource for everyday life, not the objective of living. Health is a positive concept emphasizing social and personal resources, as well as physical capacities (http://www.medicalnewstoday.com/articles/150999.php) but since health is a basic need of a person and it does not mean that if you are not sick, you are healthy, it is now presented as a complete physical, mental and social well-being and not merely the absence of disease or infirmity or simply health is the wholeness of one person. As a person is growing up, he or she cannot prevent a certain disease coming from his body parts like the brain and heart. The etiology may be coming from the hereditary/genetics, age or idiopathic. That is a disease is being manifested by a person whether it is symptomatic or asymptomatic. (http://www.medicalnewstoday.com/articles/150999.php)

Coronary Artery Disease happens when the arteries that supply blood to heart muscle become hardened and narrowed. This is due to the buildup of cholesterol and other material, called plaque, on their inner walls. This buildup is called atherosclerosis. As it grows, less blood can flow through the arteries. As a result, the heart muscle can't get the blood or oxygen it needs. This can lead to chest pain (angina) or a heart attack. Most heart attacks happen when a blood clot suddenly cuts off the hearts' blood supply, causing permanent heart damage. Over time, this can also weaken the heart muscle

and contribute to heart failure and arrhythmias. Heart failure means the heart can't pump blood well to the rest of the body. Arrhythmias are changes in the normal beating rhythm of the heart. The most common disease of the coronary arteries is arteriosclerosis, commonly called "hardening of the arteries." Plaque a combination of cholesterol and other fats, calcium and other elements carried in the blood builds up in the small blood vessels that feed the heart. When this condition exists in other parts of the body, it is called atherosclerosis. This plaque buildup can, in time, narrow the arteries so severely that blood flow to the heart is inadequate and symptoms of insufficient blood flow called angina develop. Angina is a term meaning strangling or oppressive heaviness and pain, but it has become synonymous with angina pectoris or chest pain caused by lack of oxygen to the heart due to poor blood supply. In addition to angina or chest pain, arteriosclerosis can produce fatigue, shortness of breath and an abnormal heart beat or arrhythmia. Plaque also can tear the artery walls and form blood clots that can lead to a heart attack. Often, there are no symptoms of arteriosclerosis until a heart attack occurs.

(http://www.ucsfhealth.org/conditions/coronary_artery_disease/signs_and_symptoms.ht ml) Arteriosclerosis is diagnosed through various tests including:

Coronary

Angiography

Coronary

angiography,

also

called

cardiac

catheterization, is a minimally invasive study that is considered the gold standard for diagnosing coronary artery disease. This test is performed under local anesthesia and involves injecting X-ray dye or contrast medium into the coronary arteries via tubes called catheters. An X-ray camera films the blood flow to show the location and severity of artery narrowing. This test can show if the blood vessels in your heart have narrowed, your heart is pumping normally and blood is flowing correctly and your heart valves are functioning properly. It also can

identify any heart abnormalities you may have been born with or congenital abnormalities.

Echocardiogram (ECHO) This non-invasive test translates sound waves from your chest into pictures of your heart. It provides information about how the heart is pumping, how blood flows in the heart and blood vessels, how large the heart is and how the valves are working.

Electrocardiogram (ECG or EKG) The electrocardiogram records the heart's electrical activity. Small patches called electrodes are placed on your chest, arms and legs, and are connected by wires to the ECG machine. Your heart's electrical impulses are translated into a wavy line on a strip of paper, enabling doctors to determine the pattern of electrical current flow in the heart and to diagnose arrhythmias and heart damage.

Stress Echocardiogram Stress tests are performed to see how the heart performs under physical stress. The heart can be stressed with exercise on a treadmill or in a few instances, a bicycle. If you can't exercise on a treadmill or bicycle, medications can be used to cause the heart rate to increase, simulating normal reactions of the heart to exercise. During the stress test, you will wear ECG electrodes and wires while exercising so that the electrical signals of your heart can be recorded at the same time.

Stress Thallium Test Stress thallium tests have two components a treadmill stress test and heart scan after injection of a radionuclide material, such as thallium, which allows doctors to see the coronary arteries and the shape and function of the heart. It has been used in this manner safely for many years to demonstrate the amount of blood the heart is getting under various conditions rest and stress.

(http://www.ucsfhealth.org/conditions/coronary_artery_disease/diagnosis.html) Medications and sometimes lifestyle changes, such as quitting smoking or losing weight, can help improve heart efficiency to reduce angina but can't eliminate the plaque blockages. Medications may include cholesterol-lowering drugs, Beta-

blockers, nitroglycerin, calcium channel blockers, angiotensin-converting enzyme inhibitors and others. These are the other management for CAD: Plaque Removal - to remove plaque from arteries, the following procedures are performed:

Angioplasty - also called percutaneous transluminal coronary angioplasty or PTCA, involves inserting a long flexible tube called a catheter into a blood vessel through a small incision in your skin. The catheter has a deflated balloon on its tip. Once the catheter reaches the blocked blood vessel, the balloon is inflated and compresses the plaque against the sides of the blood vessel. The balloon may be inflated and deflated several times. Often, the procedure is done in conjunction with a small metal tube called a stent that is left in the artery to serve as a scaffold to keep the artery open and prevent the plaque from springing back toward the center of the vessel.

Coronary Artery Bypass Graft surgery - an open-heart operation in which an artery or a piece of vein taken from your leg is attached to the blood vessel to detour blood around the blockage. During part of the operation, your heart will be stopped and a heart-lung machine will be used to pump your blood and help you breathe. As with most major large incision operations, it takes about six weeks to recover. CABG is the most successful and most common major heart surgery in the Western world.

Coronary Stent - a small, latticed, high-grade stainless steel tube that is used to hold the coronary artery open and minimize the chance of abrupt closure after angioplasty. It is placed in the coronary artery using the same procedure as the angioplasty. The stent is typically positioned at the narrowed area of the artery. When the catheter's balloon is inflated, the stent expands and is pressed against the vessel wall. The balloon is deflated and withdrawn, leaving the stent permanently in place. After a stent is placed, you will be prescribed an antiplatelet medication, Clopidogrel, also known as Plavix, for one month. This is used to minimize the risk of clot formation in the stent while tissue grows around the stent to incorporate it into the blood vessel wall. Within a month, the body no

longer "sees" the stent, and the medication is no longer needed. You should continue to take aspirin, if it has been prescribed, along with the Clopidogrel.

Rotational Atherectomy - widens narrowed arteries using a high-speed rotational device to "sand" away plaque. This technique is used in particular situations, such as with plaque with large amounts of calcium or to widen blockages within a stent.

(http://www.ucsfhealth.org/conditions/coronary_artery_disease/treatment.html) Although CAD can be a life-threatening condition, the outcome of the disease is in many ways up to the patient. Damage to the arteries can be slowed or halted with lifestyle changes, including smoking cessation, dietary modifications and regular exercise, or by medications to lower blood pressure and cholesterol levels. Additional goals of treatment, which may involve medication and sometimes surgery, are to relieve symptoms, ease circulation and prolong life.

(http://www.nlm.nih.gov/medlineplus/coronaryarterydisease.html)

A. Current trends MANILA, Philippines - Recent data last July 9, 2012, from the National Statistics Office (NSO) showed that five out of 10 deaths in the country were of cardiovascular causes.

The NSO reported that 100,908 people died of heart diseases in 2009. This accounted for 21 percent of all deaths in the country. It was followed by cerebrovascular disease, which claimed 56,670 lives in the same year. It accounted for 11.8 percent of all deaths in 2009. "Within three years (2007-2009), the top five causes of deaths remained on their posts and proved to be fatal among other causes of deaths," the NSO said. The World Health Organization (WHO) has said that an estimated 17 million people die of cardiovascular diseases every year. Most of these were heart attacks and strokes. "A substantial number of these deaths can be attributed to tobacco smoking,

which increases the risk of dying from coronary heart disease and cerebrovascular disease 23 fold. Physical inactivity and unhealthy diet are other main risk factors which increase individual risks to cardiovascular diseases," the WHO said. The NSO also reported that most females die in their older age compared to their male counterparts. "It was noted that the most number of deaths was at the age of 80 and over with 85,705 or 17.8 percent. From these, 59.6 percent (51,074) were females while the remaining 40 percent (34,631) were males," the NSO said. The age group 10 to 14 had the least number of deaths, accounting for only 1 percent of all total deaths. "It has been observed that as the age increases, the rate of dying also increasing. From age group 10 onwards it shows that the number of deaths continuously increase though a slight decrease were seen at ages 75-79 then it went up again at age 80 and over," the NSO said. Deaths in 2009 reached 480,820, which was 4.2 percent higher than the previous year. The most number of deaths in the country occurred in the National Capital Region, which accounted for 75,019 or 15.6 percent of all deaths in the country. Learn about coronary artery disease, its symptoms and about the latest developments in treatment. Coronary artery disease is caused when plaque buildup creates blockages or narrowing in the arteries. The blockages restrict blood flow and reduce the amount of oxygen delivered to the heart, potentially putting a person at risk for a heart attack. Common symptoms of coronary artery disease include chest pain, shortness of breath, fatigue and overall weakness. Simple lifestyle changes can help prevent and manage coronary artery disease. These include managing obesity and high blood pressure, living an active lifestyle, making healthy dietary choices and stopping smoking.

(http://www.philstar.com/breaking-news/2012/07/09/826043/5-out-10-filipinos-die-heartdisease-nso)

Improved Treatments Staying on top of the latest medical advances helps ensure you and loved ones secure the best treatment available.

Last March 28, 2013, a new treatment was found for patients with CAD. One advancement in treatment is supported by new results from the FAME 2 Study funded by St. Jude Medical and published in the New England Journal of Medicine. The study found that use of a blood-flow measurement technology, called Fractional Flow Reserve (FFR) during treatment of stable coronary artery disease will result in better health outcomes. FFR technology offers physicians a better assessment of where blood flow blockages occur in the coronary arteries and whether treatment to open an artery narrowing, along with medication, can help lower a patient's risk of chest pain and heart attack. From less likelihood of a patient being readmitted to the hospital for urgent care, to a reduction in health care costs, FAME 2 research demonstrates that patients who receive FFR-guided treatment experienced better outcomes than those treated with medication alone. The FAME 2 Study results offer further evidence that FFR should be considered the standard of care for treating patients with coronary heart disease," said Frank J. Callaghan, president of the Cardiovascular and Ablation Technologies Division at St. Jude Medical.

B. Statistics Coronary artery disease (CAD) is the leading cause of death in the United States, affecting over 5 million Americans. CAD is a narrowing of the coronary arteries, the vessels that supply blood to the heart muscle, generally due to the buildup of plaques in the arterial walls, a process known as atherosclerosis. Plaques are composed of cholesterol-rich fatty deposits, collagen, other proteins, and excess smooth muscle cells.

Atherosclerosis, which usually progresses very gradually over a lifetime, thickens and narrows the arterial walls, impeding the flow of blood and starving the heart of the oxygen and vital nutrients it needs (also called ischemia). This can cause muscle cramp-like chest pain called angina. Blood clots form more easily on arterial walls roughened by plaque deposits and may block one or more of the narrowed coronary arteries completely and cause a heart attack. Arteries may also narrow suddenly as a result of an arterial spasm. (Spasms are most commonly triggered by smoking.) Heart disease is the leading cause of death for both men and women. More than half of the deaths due to heart disease in 2009 were in men. About 600,000 people die of heart disease in the United States every yearthats 1 in every 4 deaths. Coronary heart disease is the most common type of heart disease, killing more than 385,000 people annually. Every year about 715,000 Americans have a heart attack. Of these, 525,000 are a first heart attack and 190,000 happen in people who have already had a heart attack. Coronary heart disease alone costs the United States $108.9 billion each year. This total includes the cost of health care services, medications, and lost productivity. (http://www.cdc.gov/heartdisease/facts.htm) According to the latest WHO data published in April 2011 Coronary Heart Disease Deaths in Philippines reached 57,864 or 13.73% of total deaths. The age adjusted Death Rate is 121.63 per 100,000 of population ranks Philippines #79 in the world. Review other causes of death by clicking the links below or choose the full health disease) profile. (http://www.worldlifeexpectancy.com/philippines-coronary-heart-

C. Reason for choosing such case for presentation The student nurses are hopeful for the realization of the essence of this study to the involved and to those of which this study can be of any help. Since the case of Coronary Artery Disease is very rampant, the student nurses would like to be of service in decreasing the probability of what is fast occurring. The aim of the group is not just to present what we have researched or learned from time to time but to put into profession in order to be of great help to others, to increase awareness, to educate, to prevent, to promote and to restore health.

D. Objectives Short Term During the course of the study, the student nurse will be able to: Establish rapport with the patient Explain the purpose in conducting the interview Collect information regarding the demographic data of the patient Collect information regarding socio economic and cultural beliefs of the patient and environmental factors Collect data regarding the patients family health illness and history, post and present illness List the diagnostic procedures done and explain Identify the different medical, surgical and nursing management Emphasize the importance of health teaching

Long Term After the completion of the study, the student nurse will be able to: Associate abnormal diagnostic findings with his disease condition Demonstrate nursing interventions for procedure done Formulate recommendations to be imparted to patients same condition Provide critical thinking skills necessary for providing safe and effective nursing care. Provide a comprehensive assessment and implement care base on our knowledge and skills of the condition Familiarize us with effective inter-personal skills to emphasized health promotion and illness prevention. Impart the learning experience from direct patient care.

Short Term During the course of the study, the patient will be able to: Develop trust with the student nurse Understand the purpose in conducting such interview Provide information regarding his demographic data Provide information regarding his socio economic and cultural beliefs Demonstrate compliance to medical regimen Identify risk factors

Long Term After completion of the study, the patient will be able to: Continue cooperating with physical assessment Express feelings regarding his condition Will be able to accept his situation and have sense of control Understand his manifestation related to him condition Gain the basic information concerning Coronary Artery Disease Eradicate activities that may worsen his condition Comply with the treatment given upon discharge

II. NURSING PROCESS A. Assessment 1. Personal History

a. Demographic Data Our patients name is Mr. Corona D. Sease for the purpose of confidentiality and he is 56 years old. He is approximately 52 feet in height and weighs 45 kilograms in weight. He has a pale fair skin complexion. His eyes are round and his teeth are slightly yellowish. His role in the family is to work for his family as a grass cutter at a certain subdivision. He does have 6 children. He lives in Bulaon Rest City of San Fernando, Pampanga. He was born on May 16, 1957 at their house in Del Paz Norte by Normal Spontaneous Delivery. His nationality is a Filipino and ethnicity is a Kapampangan. He was admitted September 17, 2013 at around 1:40 AM. His chief complaint was difficulty of breathing and chest tightness. He is still admitted at a local hospital in Pampanga. He was diagnosed with Coronary Artery Disease with Unstable Angina.

b. Socio-Economic and Cultural Factors Mr. Corona D. Sease lives together with his wife and his 6 children and they are pure Kapampangan. They are currently living at Bulaon Rest City of San Fernando, Pampanga. Their house is made of sement and wood house in a 1 story building and only has 1 window. They are still living there even a typhoon already flooded and destroyed some of the parts of the house like the floors. Mr. Corona D. Seases work is a grass cutter during weekdays from 7AM to 5PM at a certain subdivision. He owns 5,200 pesos every month. They are categorized as poor because each member receives 900 pesos only. According to NEDA 2004, a family must have a total income of 2768.60 per family member to be classified as not poor and meet the basic needs of each member.

(http://localweb.neda.gov.ph/regional.html)

His wife budgets the money for their basic needs. They buy their food at a local market. Their source of water is from a distilled water company. Their garbage is collected once a week by the city government entities. According to Mr. Sease, their food source comes from the maket and they dont have any electricity but they use candles as their source of light. They buy things for their hygiene purposes like shampoo, soap, tooth brush and tooth paste. They ride tricycles and jeepneys as means of transportation. They save money that was left for emergency purposes like medications. He gives money for his childrens projects and allowance. Some of his income was given to his relatives since his relatives are asking. Basic Needs Food Rice Viand Water Supply No Electricity Suppy but for Candles Hygiene Suppy Transportation Savings for Emergency purposes Education for his children For his relatives Others 900 pesos 800 pesos 140 pesos 60 pesos 200 pesos 112 pesos 500 pesos 500 pesos 1500 pesos 488 pesos Expenses (Per Week)

Mr. Sease only reached Grade 5 as his highest educational attainment in a public school. He was forced to stop her studies because of the financial constraint in the family. They are affliated with Roman Catholic religion and they go to mass every

Sunday. Regarding their cultural factors affecting health, they take herbal medicines such as Malunggay and Bawang as an alternative of a medicine but they do not believe in faith healers. If one of the family members got sick, they immediately go to a hospital. Mr. Sease does not smoke but he drinks alcohol 4 times a week. He is fond of eating vegetables and has a high fat diet. TIME ACTIVITIES OF DAILY LIVING OF MR. CORONA D. SEASE 4:00 AM 6:00AM Freshen up including dressing up for 30 minutes, Cooking and Preparing their Breakfast for 40 minutes, Breakfast for 30 minutes, Cleaning the Dishes for 15 minutes, Getting Ready for His Work for 5 minutes 6:00 AM 6:45 AM 7:00 AM 12:00 NN 12:00 NN 1:00 PM 1:00 PM 5:00 PM 5:00 PM 5:45 PM 6:00 PM 6:30 PM 6:30 PM 7:00 PM 7:00 PM 7:30 PM 7:30 PM 10:00 PM Travel Time Going to His Work Working Hours Lunch Break Working Hours Travel Time Going Back to His House Rest for 30 minutes Dinner Doing Household Chores Bonding with Family for 30 minutes, Going to His Friends House and Drinks Alcohol for 2 Hours 10:00 PM 4:00 AM Sleeping Hours

C. Environmental Factors Seases family live in Bulaon Rest, City of San Fernando, Pampanga. Their house is a sement and wood type of house. It is a 1-storey building house. They have 1 window and 1. They are still living their even there was a typhoon that flooded the house. His wife cleans the house every week.

3. History of Past Illness Mr. Corona D. Sease is complete with his immunizations when he was 1 year old at the year of 1958. He experienced tigdas at the age of 10 years old at the year of 1967 and did not have any chicken pox and mumps during his childhood years. He does not have any allergies like in dust, pollens and foods such as shrimps or chickens. Sometimes, he experience fever. His highest temperature when he experiences his fever on October 2005 was 38.5 degree Celsius. His wife only did tepid sponge bath and bed rest. When he has cough and colds and flu, he drinks Lagundi as his alternative medicine when they lack of financial resources. If he is severe ill, he immediately goes to the hospital.

4. History of Present Illness Mr. Corona D. Sease experienced chest pain or angina pectoris in medical term when he was 55 years old on December 2012. He experienced chest pain again last January and August 2013 and was brought at a local hospital in Pampanga. He did not buy his take home medications because of lack of financial resources. The day before his admission, last September 17, 2013 at around 4:30 PM, he experienced sudden difficulty of breathing and chest tightness when he was still in work. He was brought to a local hospital here in Pampanga at around 6:30 PM by the worker, where he was

working. His chief complaint was difficulty of breathing and chest tightness. He admitted that before the day of admission, he ate high fat foods like chicharon and sisig and he drank alcohol straight 4 days in that week. The physician made the admitting and final diagnosis as Coronary Artery Disease. Hence, he was admitted on September 17, 2013.

5. Physical Examination

(September 17, 2013 Lifted from the chart) Skin: (-) Dermatitis Head-EENT: AS, PPC Lymph Nodes: (-) Claps Chest: Lungs - SF, Crackles in BLF

Cardiovascular: Angina Pectoris o Abdomen: Flat, Soft o Musculoskeletal: (+) grade # edema o Admitting Impression: T/c ACS with CHF

(September 18, 2013 First Day of Assessment) General Appearance: Mr. Corona D. Sease is lying on bed, with an IVF of 5% Dextrose in Water 500 cc, with an O2 Inhalation. He looks weak in appearance. He has pale skin and conjunctiva.

Vital Signs Temperature: 36.5 degree Celsius Pulse rate: 74 bpm Respiratory rate: 31 cpm Blood Pressure: 110/80 mmHg

o Hair Short, black hair, no pediculosis and lesions noted, evenly distributed o Skin Pale complexion, good skin turgor, absence of edema and jaundice o Nails Long and untrimmed o Head Round, smooth without lesions o Eyes Pale palpebral conjunctiva, round eyes o Ears No presence of discharge o Mouth No sores, reddish in color o Nose No nasal discharge o Lips Pale and slightly dry o Neck No lymph nodes were palpated o Heart Diminished in heart rate, irregular heart rhythm o Lungs Crackles and rales were auscultated in BLF o Abdomen - Skin is as the same color as with that of that body or lighter. Hair is evenly distributed. Bluish discoloration of the umbilicus is not presence. Bowel sounds are 15 per minute/quadrant. Pain is not felt during urination. o Legs and feet Negative Homans sign, edema

(September 19, 2013 Second Day of Assessment) General Appearance: Mr. Corona D. Sease is lying on bed, with an IVF of 5% Dextrose in Water 500 cc, with an O2 Inhalation. He looks weak in appearance. He has pale skin and conjunctiva.

Vital Signs o o o o o o o o o o o o o Temperature: 35.8 degree Celsius Pulse rate: 77 bpm Respiratory rate: 31 cpm Blood Pressure: 110/80 mmHg Hair Short, black hair, no pediculosis and lesions noted, evenly distributed Skin Pale complexion, good skin turgor, absence of edema and jaundice Nails Long and untrimmed Head Round, smooth without lesions Eyes Pale palpebral conjunctiva, round eyes Ears No presence of discharge Mouth No sores, reddish in color, had excessive sputum Nose Presence of nasal discharge Lips Pale and slightly dry Neck No lymph nodes were palpated Heart - Diminished in heart rate, irregular heart rhythm Lungs Crackles and rales were auscultated in BLF Abdomen - Skin is as the same color as with that of that body or lighter. Hair is

evenly distributed. Bluish discoloration of the umbilicus is not presence. Bowel sounds are 15 per minute/quadrant. Pain is not felt during urination. o Legs and feet Negative Homans sign, edema

(September 20, 2013 Third Day of Assessment) General Appearance Mr. Corona D. Sease is lying on bed, with an IVF of 5% Dextrose in Water 500 cc, with an O2 Inhalation. He looks weak in appearance. He has pale skin and conjunctiva.

Vital Signs o o o o o o o o o o o o o Temperature:36.8 degree Celsius Pulse rate: 78 bpm Respiratory rate: 26 cpm Blood Pressure: 120/80 mmHg Hair Short, black hair, no pediculosis and lesions noted, evenly distributed Skin Slightly pale complexion, good skin turgor, absence of edema and Nails Long and untrimmed Head Symmetrical, round, smooth without lesions Eyes Slightly pale palpebral conjunctiva Ears No presence of discharge Mouth No sores, reddish in color Nose Presence of nasal discharge Lips Pale and slightly dry Neck No lymph nodes were palpated Heart - Diminished in heart rate, irregular heart rhythm Lungs Crackles and rales were auscultated in BLF Abdomen - Skin is as the same color as with that of that body or lighter. Hair is

jaundice

evenly distributed. Bluish discoloration of the umbilicus is not presence. Bowel sounds are 15 per minute/quadrant. Pain is not felt during urination. o Legs and feet Negative Homans sign, edema

Diagnostic/Laboratory Procedures > Complete Blood Count Hemoglobin

Date Ordered Date Resulted

Indications or Purposes

Results

Normal Values/ Units used in Hospital

Analysis and Interpretation of results (Client-centered)

DO: 09-172013 DS: 09-182013

Measures the amount of Hgb, protein found in RBC in the blood Measures the proportion of the blood that is made up of RBC Numerates the number of WBC in the blood, a decrease and increase in this may suggest presence of

130

115 155 g/L The result is normal, can be seen by client having the absence of dehydration

Hematocrit

DO: 09-172013 DS: 09-182013

0.44

0.38 0.48

Same of Hgb, hydration status is normal

White Blood Cells

DO: 09-172013 DS: 09-182013

5 10 x 10^9/L

The client did not acquire any infections as a result to normal WBC

illness Neutrophils DO: 09-172013 DS: 09-182013 This test measures the amount of neutrophils type of WBC in the blood if disease or toxicity is suspected Lymphocytes DO: 09-172013 DS: 09-182013 This test measures amount of neutrophils type of WBC in the blood if disease or toxicity is suspected 0.27 0.20 0.35 The amount of lymphocytes in the blood is normal as evidenced by clients absence of infection; this is related to WBC and neutrophils since neutrophils and lymphocytes are types of WBC 0.49 0.45 0.65 Client did not manifest infection as evidenced by normal neutophils

Platelet

DO: 09-172013 DS: 06-182013

To determine any bleeding disorders or bone marrow diseases and for unexplained bruises

298

150 400 x 10^9

The client did not have any spontaneous bleeding, bone marrow disorder or leukemia which results to a normal platelet count

> Blood Chemistries

Fasting Blood Sugar

DO: 09-172013 DS: 09-182013

This is to measure the amount of glucose present in the body Measures amount of urea nitrogen is the blood

6.02

4.1 9.00 mmol/L

Clients glucose level is within normal range. No signs of diabetes

Blood Urea Nitrogen

DO: 09-172013 DS: 09-182013

4.1

1.7/8.3mmol/ L

Result is normal as evidenced by clients normal kidney function

Creatinine

DO: 09-172013 DS: 09-182013

Measures the amount of creatinine present is the blood and/or urine

130.8

58120mmol/L

The client is dehydrated. His urine is tea-colored. Pain is felt when urinating but there is no presence of blood.

Sodium (Na)

DO: 09-172013 DS: 09-182013

Measures the level of Na is the blood

146.6

135 145 mmol/L

Client is in good hydration status

Potassium (K)

DO: 09-172013 DS: 09-182013

Measures the amount of K present is the blood Urinalysis can reveal diseases that have gone unnoticed because they do not produce striking signs and symptoms

4.23

3.55 5 mmol/L

Clients K level is within normal range

Urinalysis

DO: 09-172013 DS: 09-182013

Color Yellow Yellow to amber in color

Normal Patient has lightyellow color urine.

There is presence of suspended particles in the Transparency urine such as normal urine crystals and mucus because of inflammation of the

Determination of

gallbladder.

urine composition and possible abnormal components (e.g. protein or glucose) or infection

Turbid

Clear

Normal This means that the patient has normal Specific Gravity hydration status AEB patient didnt manifest signs of dehydration such as poor skin turgor, etc.

1.013

1.010 1.025

Normal Sugar There is absence of sugar in the urine which means that the patient is not indicative of diabetes.

Negative

Negative

Microscopic Findings Pus Cells 0-1 /hpf The patient has mild inflammation of the gallbladder and mild infection. 0-1/hpf

RBC

The patient has mild inflammation of the gallbladder and mild infection.

12

(Negative or Rare)

Normal This indicates that the patient is not Epithelial Cells indicative of inflammation in the bladder and present of epithelial cells represent possible contamination of the specimen with skin bacteria

Few

Rare

Bacteria Few

Bacteria in urine are unusual, but few bacteria can due to contamination None

Electrocardiogram There is an Elevated ST Segment which means independent of changes in ventricular activation and that

may be the result of global or segmental pathologic processes that affect ventricular repolarization and has Occasional Pulmonary Vascular Resistance.

7. ANATOMY AND PHYSIOLOGY The heart is located in the chest between the lungs behind the sternum and above the diaphragm. It is surrounded by the pericardium. Its size is about that of a fist, and its weight is about 250-300 g. Its center is located about 1.5 cm to the left of the midsagittal plane. Located above the heart are the great vessels: the superior and inferior vena cava, the pulmonary artery and vein, as well as the aorta. The aortic arch lies behind the heart. The esophagus and the spine lie further behind the heart. (Williams and Warwick, 1989).

The walls of the heart are composed of cardiac muscle, called myocardium. It also has striations similar to skeletal muscle. It consists of four compartments: the right and left atria and ventricles. The heart is oriented so that the anterior aspect is the right ventricle while the posterior aspect shows the left atrium. The atria form one unit and

the ventricles another. This has special importance to the electric function of the heart, which will be discussed later. The left ventricular free wall and the septum are much thicker than the right ventricular wall. This is logical since the left ventricle pumps blood to the systemic circulation, where the pressure is considerably higher than for the pulmonary circulation, which arises from right ventricular outflow. The cardiac muscle fibers are oriented spirally and are divided into four groups: Two groups of fibers wind around the outside of both ventricles. Beneath these fibers a third group winds around both ventricles. Beneath these fibers a fourth group winds only around the left ventricle. The fact that cardiac muscle cells are oriented more tangentially than radially, and that the resistivity of the muscle is lower in the direction of the fiber has importance in electrocardiography and magneto cardiography. The heart has four valves. Between the right atrium and ventricle lies the tricuspid valve, and between the left atrium and ventricle is the mitral valve. The pulmonary valve lies between the right ventricle and the pulmonary artery, while the aortic valve lies in the outflow tract of the left ventricle (controlling flow to the aorta). The blood returns from the systemic circulation to the right atrium and from there goes through the tricuspid valve to the right ventricle. It is ejected from the right ventricle through the pulmonary valve to the lungs. Oxygenated blood returns from the lungs to the left atrium and from there through the mitral valve to the left ventricle. Finally blood is pumped through the aortic valve to the aorta and the systemic circulation.

In the heart muscle cell, or myocyte, electric activation takes place by means of the same mechanism as in the nerve cell - that is, from the inflow of sodium ions across the cell membrane. The amplitude of the action potential is also similar, being about 100 mV for both nerve and muscle. The duration of the cardiac muscle impulse is, however, two orders of magnitude longer than that in either nerve cell or skeletal muscle. A plateau phase follows cardiac depolarization, and thereafter repolarization takes place. As in the nerve cell, repolarization is a consequence of the outflow of potassium ions. (Netter, 1971).Associated with the electric activation of cardiac muscle cell is its mechanical contraction, which occurs a little later. For the sake of comparison, Figure 6.5 illustrates the electric activity and mechanical contraction of frog sartorius muscle, frog cardiac muscle, and smooth muscle from the rat uterus (Ruch and Patton, 1982). An important distinction between cardiac muscle tissue and skeletal muscle is that in cardiac muscle, activation can propagate from one cell to another in any direction. As a result, the activation wavefronts are of rather complex shape. The only exception is the boundary between the atria and ventricles, which the activation wave normally cannot cross except along a special conduction system, since a nonconducting barrier of fibrous tissue is present. Located in the right atrium at the superior vena cava is the sinus node (sinoatrial or SA node) which consists of specialized muscle cells. The sinoatrial node in humans is in the shape of a crescent and is about 15 mm long and 5 mm wide (see Figure 6.6). The SA nodal cells are self-excitatory, pacemaker cells. They generate an action potential at the rate of about 70 per minute. From the sinus node, activation propagates throughout the atria, but cannot propagate directly across the boundary between atria and ventricles, as noted above. The atrioventricular node (AV node) is located at the boundary between the atria and ventricles; it has an intrinsic frequency of about 50 pulses/min. However, if the AV node is triggered with a higher pulse frequency, it follows this higher frequency. In a normal heart, the AV node provides the only conducting path from the atria to the ventricles. Thus, under normal conditions, the latter can be excited only by pulses that propagate through it. Propagation from the AV node to the ventricles is provided by a specialized conduction system. Proximally, this system is composed of a common

bundle, called the bundle of His (named after German physician Wilhelm His, Jr., 18631934). More distally, it separates into two bundle branches propagating along each side of the septum, constituting the right and left bundle branches. (The left bundle subsequently divides into an anterior and posterior branch.) Even more distally the bundles ramify into Purkinje fibers (named after Jan Evangelista Purkinje (Czech; 17871869)) that diverge to the inner sides of the ventricular walls. Propagation along the conduction system takes place at a relatively high speed once it is within the ventricular region, but prior to this (through the AV node) the velocity is extremely slow. From the inner side of the ventricular wall, the many activation sites cause the formation of a wavefront which propagates through the ventricular mass toward the outer wall. This process results from cell-to-cell activation. After each ventricular muscle region has depolarized, repolarization occurs. Repolarization is not a propagating phenomenon, and because the duration of the action impulse is much shorter at the epicardium (the outer side of the cardiac muscle) than at the endocardium (the inner side of the cardiac muscle), the termination of activity appears as if it were propagating from epicardium toward the endocardium.

8. THE PATIENT AND HIS ILLNESS a. PATHOPHYSIOLOGY (BOOK-CENTERED) Schematic Diagram Non-modifiable Factors: Age (older adults) Gender (male and menopause women) Hereditary(Including Race) Modifiable Factors: Smoking Physical Inactivity Obesity Diabetes Stress Homocysteine Levels Inflammatory Response Menopause

Change in the condition of the plaque in the coronary artery

Activation platelet

Thrombus formation

Myocardial ischemia

Anaerobic metabolism

Prolonged unrelieved ischemia

Lactic Acid Production

Acidosis

Angina

Myocardial cell death

Altered repolarization

Conduction system Release of lysosomal enzymes disorder

Elevated ST segment Elevated Cardiac Biomarkers

Dysrhythmias

Heart Contractility

SNS Stimulation

LV Function

Tachycardia

Increased Oxygen Demand

Increased Afterload

Increased Preload

Decreased CO

Tachypnea

Vasoconstriction

Increased

CVP and
PCWP

b. Synthesis of the disease b.1. Definition of the disease Coronary artery disease develops when your coronary arteries the major blood vessels that supply your heart with blood, oxygen and nutrients become damaged or diseased. Cholesterol-containing deposits (plaque) on your arteries are usually to blame for coronary artery disease. When plaques build up, they narrow your coronary arteries, causing your heart to receive less blood. Eventually, the decreased blood flow may cause chest pain (angina), shortness of breath, or other coronary artery disease signs and symptoms. A complete blockage can cause a heart attack. Because coronary artery disease often develops over decades, it can go virtually unnoticed until you have a heart attack. But there's plenty you can do to prevent and treat coronary artery disease. Start by committing to a healthy lifestyle. Coronary artery disease is a narrowing or blockage of the arteries and vessels that provide oxygen and nutrients to the heart. It is caused by atherosclerosis, an accumulation of fatty materials on the inner linings of arteries. The resulting blockage restricts blood flow to the heart. When the blood flow is completely cut off, the result is a heart attack. Coronary artery disease, also called coronary heart disease or heart disease, is the leading cause of death for both men and women in the United States. According to the American Heart Association, deaths from coronary artery disease have declined some since about 1990, but more than 40,000 people still died from the disease in 2000. About 13 million Americans have active symptoms of coronary artery disease. Coronary artery disease occurs when the coronary arteries become partially blocked or clogged. This blockage limits the flow of blood from the coronary arteries, which are the major arteries supplying oxygen-rich blood to the heart. The coronary arteries expand when the heart is working harder and needs more oxygen. Arteries expand, for example, when a person is climbing stairs, exercising, or having sex. If the

arteries are unable to expand, the heart is deprived of oxygen (myocardial ischemia). When the blockage is limited, chest pain or pressure, called angina, may occur. When the blockage cuts off the flow of blood, the result is heart attack (myocardial infarction or heart muscle death). Healthy coronary arteries are clean, smooth, and slick. The artery walls are flexible and can expand to let more blood through when the heart needs to work harder. The disease process in arteries is thought to begin with an injury to the linings and walls of the arteries. This injury makes them susceptible to atherosclerosis and blood clots (thrombosis). b.2. Nonmodifiable HEREDITARY (INCLUDING RACE) Children whose parents had heart disease are at higher risk for coronary artery disease. This increased risk is related to genetic predisposition to hypertension, elevated lipid levels, diabetes and obesity, all of which increase the risk f coronary artery disease. For people 35 to 74 years of age, the age adjusted death rate from coronary artery disease for African American women is 72% higher than that for white women and Native Americans. The prevalence of coronary is lowest among Mexican American AGE Age influences both the risk and the severity of coronary artery disease. Symptomatic coronary artery disease appears predominantly in people older than 40 years of age and 4 of 5 people who die of coronary artery disease are age 65 years or older. Angina and Myocardial Infarction, however, can occur in a persons 30s and even in ones 20s. at older ages, women who have heart attacks are twice as likely as to die from the heart attack.

GENDER Coronary artery disease is the number one killer of both men and women. In 1999 mortality from coronary artery disease was almost equal for men and women. Although men are at higher risk for heart attacks at younger ages, the risk for women increases significantly at menopause, so that coronary artery disease rates in women after menopause are two to three times that of women the same age before menopause. Women who take oral contraceptives and who smoke or have high blood pressure are at greater risk for coronary artery disease. Women with an early menopause are also at higher risk than are women with a normal or late menopause.Two lifestyle changes during the past 2 decades may be responsible for the increased incidence of coronary artery disease among women. More women (many with full responsibility for the household and children) have entered the work force, and more women have begun to smoke tobacco at an earlier age. Modifiable SMOKING Both active smoking and passive smoking have been strongly implicated as a risk factor in the development of coronary artery disease. Currently 23% of men and 18% of women are smokers. The prevalence of smoking is higher in people with 11 years of education or less. Smoking triples the risk of heart attack in women and doubles the risk of heart attack in men. It also doubles the risk of dying from a heart attack and may quadruple the risk of sudden death. Nonsmokers who are exposed to second hand tobacco smoke at home or work may also have a higher death rate from coronary artery disease. The risk of coronary artery disease is decreased by 50% 1 year after smokers quit. The risk is further reduced to that of nonsmokers within 5 to 10 years after smoking cessation.Tar, nicotine, and carbon monoxide contribute to the damage. Tar contains hydrocarbons and other carcinogenic substances. Nicotine increases the release of epinephrine and norepinephrine, which results in peripheral vasoconstriction, elevated blood pressure and heart rate, greater oxygen consumption, and increased likelihood of dysrhythmias. In addition, nicotine activates platelets and stimulates smooth muscle cell

proliferation in the arterial walls. Carbon monoxide reduces the amount of blood available to the intima of the vessel wall and increases the permeability of the endothelium. PHYSICAL INACTIVITY In the United States about 25% of adults report no leisure time physical activity, even though regular aerobic exercise is important in preventing heart and blood vessel disease. There is an inverse relationship between exercise and the risk of coronary artery disease. Those who exercise reduce their risk of coronary artery disease because they have (1) higher HDL levels; (2) lower LDL cholesterol, triglyceride and blood glucose levels; (3) greater insulin sensitivity; (4) lower blood pressure; and (5) lower body mass index. The AHA recommends 30 to 60 minutes of physical activity on most days of the week. OBESITY Obesity places an extra burden on the heart, requiring the muscle to work harder to pump enough blood to support added tissue mass. In addition obesity increases the risk for coronary artery disease because it is often associated with elevated serum cholesterol and triglyceride levels, high blood pressure, and diabetes. The prevalence of obesity has increased to 30% in the years 1999 to 2002 compared to 22% from 1988 to 1994. Since 1993 the prevalence of those who are obese increased to 61%. Distribution of body fat is also important. A waist measurement is a way to estimate fat. For men a high risk waistline measurement is more than 40 inches and for women a high risk waist measurement is more than 35 inches. Body mass index is another measure to estimate body fat. A BMI from 18.5 to 24.9 is considered healthy. Extreme obesity, or a BMI greater than 40, is estimated to occur in 4.9% of the population. People can lower their heart disease risk by losing as little as 10 to 20 pounds. An altering pattern of weight gain and weight loss, however, is associated with an increased risk for coronary artery disease.

DIABETES Since 1990 the prevalence of people diagnosed with diabetes increased by 61%. In addition, the prevalence of diabetes has increased by 8% since 2000 to 2001. Contributing to these statistics is the increased frequency of obesity and sedentary lifestyles. A fasting blood glucose level of more than 126 mg/dl or a routine blood glucose level of 180 mg/dl and glucosuria signals the presence of diabetes and represents an increased risk for coronary artery disease. Clients with diabetes have a two to four fold higher prevalence, incidence, and mortality from all forms of coronary artery disease. STRESS A persons response to stress may contribute to the development of coronary artery disease. Some researchers have reported a relationship between coronary artery disease risk and stress levels, health behaviors, and socioeconomic status. Stress response appears to increase coronary artery disease risk through its effect on major risk factors. For example, some people respond to stress by overeating or by starting or increasing smoking. Stress is also associated with elevated blood pressure. Although stress is unavoidable in modern life, an excessive response to stress can be a health hazard. Significant stressors include major changes in residence, occupation, or socioeconomic status. HOMOCYSTEINE LEVELS Researchers have reported that elevated levels of plasma Homocysteine (an amino acid produced by the body) are associated with an increased risk of coronary artery disease. Scientists do not know whether homocysteine directly or indirectly increases coronary artery disease risk, however, because homocysteine levels are related to renal function, smoking, fibrinogen, and C reactive protein (CRP). Elevated homocysteine levels can be reduced by treatment with folic acid, vitamin B6, and vitamin B12. Experts currently recommend that homocysteine levels be measured in people with a history of premature coronary artery disease, stroke, or both in the absence of other risk factors.

INFLAMMATORY RESPONSE A newly identified risk factor currently being researched is the presence of any chronic inflammatory state that leads to an increase in the bodys production of @ reactive protein (CRP). Too much CRP tends to destabilize plaque inside artery walls. When plaque lesions crack or break, a clot is formed and this may lead to a heart attack. Researchers have discovered that a high CRP level is a marker for coronary disease. This means that clients with chronic inflammatory diseases, such as arthritis, lupus, and autoimmune deficiency, may be at higher risk for heart attack.

MENOPAUSE The incidence of coronary heart disease markedly increases among women after menopause. Before menopause estrogen is thought to protect against coronary artery disease risk by raising HDL and lowering LDL level. Epidemiologic studies have shown that the loss of natural estrogen as women age may be associated with increase in total and LDL cholesterol and a gradually increasing coronary artery disease risk. If menopause is caused by surgical removal of the uterus and ovaries, the risk of coronary artery disease and myocardial infarction increase. b.3. Signs And Symptoms If your coronary arteries become narrowed, they can't supply enough oxygen-rich blood to your heart especially when it's beating hard, such as during exercise. At first, the decreased blood flow may not cause any coronary artery disease symptoms. As the plaques continue to build up in your coronary arteries, however, you may develop coronary artery disease symptoms, including:

Chest pain (angina). You may feel pressure or tightness in your chest, as if someone were standing on your chest. The pain, referred to as angina, is usually triggered by physical or emotional stress. It typically goes away within minutes

after stopping the stressful activity. In some people, especially women, this pain may be fleeting or sharp and noticed in the abdomen, back or arm. Shortness of breath. If your heart can't pump enough blood to meet your body's needs, you may develop shortness of breath or extreme fatigue with exertion. Heart attack. If a coronary artery becomes completely blocked, you may have a heart attack. The classic signs and symptoms of a heart attack include crushing pressure in your chest and pain in your shoulder or arm, sometimes with shortness of breath and sweating. Women are somewhat more likely than men are to experience less typical signs and symptoms of a heart attack, including nausea and back or jaw pain. Sometimes a heart attack occurs without any apparent signs or symptoms.

PATHOPHYSIOLOGY (CLIENT CENTERED) Schematic Diagram Non-modifiable Factors: Age (older adults) Gender (male) Hereditary Modifiable Factors: Physical Inactivity Stress High fat diet Alcohol drinking

Change in the condition of the plaque in the coronary artery

Activation platelet

Thrombus formation Myocardial ischemia Prolonged unrelieved ischemia Anaerobic metabolism

Lactic Acid Production

Myocardial cell death Acidosis Angina On September 18, Elevated ST segment September 18, 2013 The patient has Heart Contractility Dysrhythmias 2013

Altered repolarization

Release of lysosomal enzymes

Conduction system disorder

the patient verbalized difficulty of breathing

occasional PVC.

SNS Stimulation

LV Function

September 18, 2013 The Increased Oxygen Demand September 18, 2013 The patient manifested Tachypnea Decreased CO patient

manifested paleness of skin, conjunctivas, body weakness and dry membrane. mucous Rales

increased respiratory rate of 31cpm

and crackles were also heard during

auscultation.

NONMODIFIABLE FACTORS (CLIENT CENTERED) HEREDITARY Children whose parents had heart disease are at higher risk for coronary artery disease. This increased risk is related to genetic predisposition to hypertension, elevated lipid levels, diabetes and obesity, all of which increase the risk f coronary artery disease. AGE Age influences both the risk and the severity of coronary artery disease. Symptomatic coronary artery disease appears predominantly in people older than 40 years of age and 4 of 5 people who die of coronary artery disease are age 65 years or older. GENDER Coronary artery disease is the number one killer of both men and women. In 1999 mortality from coronary artery disease was almost equal for men and women. Men are at higher risk for heart attacks at younger ages.

MODIFIABLE FACTORS PHYSICAL INACTIVITY In the United States about 25% of adults report no leisure time physical activity, even though regular aerobic exercise is important in preventing heart and blood vessel disease. There is an inverse relationship between exercise and the risk of coronary artery disease. Those who exercise reduce their risk of coronary artery disease because they have (1) higher HDL levels; (2) lower LDL cholesterol, triglyceride and blood glucose levels; (3) greater insulin sensitivity; (4) lower blood pressure; and (5) lower body mass index. The AHA recommends 30 to 60 minutes of physical activity on most days of the week. STRESS A persons response to stress may contribute to the development of coron ary artery disease. Some researchers have reported a relationship between coronary artery disease risk and stress levels, health behaviors, and socioeconomic status. Stress response appears to increase coronary artery disease risk through its effect on major risk factors. For example, some people respond to stress by overeating or by starting or increasing smoking. Stress is also associated with elevated blood pressure. Although stress is unavoidable in modern life, an excessive response to stress can be a health hazard. Significant stressors include major changes in residence, occupation, or socioeconomic status. HIGH FAT DIET The vessels that bring blood to the heart are called the coronary arteries. They are like narrow tubes. A fatty substance called plaque (say this: plak) can build up in these arteries and make them narrow, so less blood gets to the heart. A diet high in saturated fat greatly increases your risk of heart disease. Saturated fat increases your LDL cholesterol. LDL cholesterol is bad cholesterol. SIGNS AND SYMPTOMS

 Pain and discomfort are the main symptoms of angina. Angina often is described as pressure, squeezing, burning, or tightness in the chest. The pain or discomfort usually starts behind the breastbone. Pain from angina also can occur in the arms, shoulders, neck, jaw, throat, or back. The pain may feel like indigestion. (September 18, 2013) Difficulty of breathing due to tightness of chest brought about interruption in the artery. Pallor manifested on September 18, 2013 due to poor perfusion, poor venous return and decreased oxygen level in the blood. Restlessness manifested on September 18, 2013 caused by loss of oxygen and nutrients to the myocardial tissue because of inadequate coronary blood flow.

PLANNING (NURSING CARE PLAN) Problem#1: Ineffective airway clearance related to retained secretions due to decreased cardiac output Assessment Diagnosis Scientific Explanation S= O=The patient may manifest: -restlessness -Increased RR -dyspnea -cyanosis -excessive sputum -rales -crackles -fatigue Ineffective airway clearance related retained secretions When mucus Short term: secretion and mucus to clearance are not balance, excessive airway mucus can serious problems. This condition is called cause in After hours nursing interventions , the patient 2-3 of Objective Nursing Intervention 1. assess 1. to Rationale Expected Outcome Short term: The patient shall have verbalized

patients condition 2. monitor

determine possible problems 2. for

understanding of disease process.

and record vital signs.

baseline data 3. To maximize effort 4. to decrease pressure in the diaphragm enhance ventilation loosen Long term: The patient shall secretion have maintained 6. to reduce 5. to and

will verbalize 3. encourage understandin deep breathing g of disease exercises process. 4. elevate head of bed and Long term: After days nursing interventions change position

impaired airway clearance.

two every 2 hours of 5. encourage hydration 6. balance

the Excess, often sticky mucus may accumulate in the airways in conditions as varied as

patient rest periods with fatigue 7. to maintain

airway patency

will maintain activities airway patency 7. position head appropriate for condition 8. patient importance ambulation

open airway 8. help maintain adequate lung

Instruct expansion the of

cystic fibrosis, cerebral palsy, chronic obstructive pulmonary disease bronchiectasi s. Retained and

secretions are universal problem people in with a

artifical airways (tracheostomi es) or those who on depend assisted

ventilation.

As

consequence of retained

mucus, breathing becomes labored. More energy effort required and are to

take in vital oxygen to and exhale

carbon dioxide. Although underlying causes diverse, consequence s are the are

same: vulnerable individuals are caught up in the vicious cycle recurrent, everworsening episodes of of

inflammation, pulmonary infection, increased

production of excess mucus, airway obstruction, lung damage, and respiratory failure. and

Problem#2: Decreased Cardiac Output related to Increased Vascular Resistance ASSESSMENT DIAGNOSIS SCIENTIFIC EXPLANATION S- O-The patient Decreased cardiac output increased vascular resistance -Increased BP CAD narrowing r/t blood This causes Short term: of vessels. condition After 2-3 hours of nursing OBJECTIVE NURSING INTERVENTIONS 1. Assess patients 1. To condition determine possible problems RATIONALE EXPECTED OUTCOME Short term: The shall patient have

may manifest: -Restlessness

leads to intense pressure exerted on the walls of the blood vessels. bodys The

interventions, the patient will verbalize understanding of disease 2. Monitor record signs and vital

verbalized understanding

2. To

obtain of disease baseline process. data Long term:

-Cold skin

clammy

compensatory mechanism is to

process. 3. Encourage patient verbalize concerns to 3. To

-Decreased peripheral pulses

increase

the

Long term: After two days of nursing

workload of the heart and thus the patient decreased has

patient make The shall have client express his participated in feelings activities decrease the to in

interventions the patient will participate activities

-Dyspnea

cardiac output

in 4. Encourage patient to

4. To improve to venous return

hearts

workload

decrease in the

change position

hearts -Prolonged capillary refill workload

every two hours

5. Encourage patient to do

5. To reduce stress

relaxation -Jugular distention 6. Encourage patient -Edema engage divertional activities -Weight gain to in 6. To divert vein techniques

attention and patient lessen experience d pain and help

-Pallor

anxiety

7. Reinforced -Oliguria

low 7. To prevent further salt and low fat complicatio diet ns of the disease.

Problem#3: Ineffective Tissue Perfusion related to decreased cardiac output ASSESSMENT NURSING DIAGNOSIS S- O- The patient manifested the following: -Shortness of breath Ineffective SCIENTIFIC EXPLANATION a chest Short term: After 3 hours of nursing interventions, the patient able demonstrate behaviors how to on have will be to 1. Established therapeutic relationship. 2. Assessed pt.s condition. 3. Monitored and recorded vital signs. 4. Performed morning care 5. Noted color and temperature of the skin. 6. Monitored After 1- 2 days of the nursing interventions, the peripheral pulse. 7. Provided a The patient shall be free from of Long term: The pt. shall have demonstrated behaviors on how to have effective airways. PLANNING INTERVENTIONS EXPECTED OUTCOME Short term:

tissue During

perfusion related to pain, vessels of decreased cardiac the heart, such as output secondary the coronary can

to Coronary Artery arteries, Disease

become occluded with intravascular plaques. heart absorb does The not blood the wall.

-Fatigue

through myocardial

effective airways.

Instead, blood is - The patient may manifest: -Pallor pumped through Long term:

shortness breath.

the heart's own vasculature during relaxation

(diastole) between -Cool temperature beats. occlusion blood known -Decrease pulse clinical designation

period patient heart able

will

be to

warmth environment. 8. Encouraged active rom. 9. Monitored urine output.

An demonstrate of a adequate tissue is perfusion the evidenced palpable peripheral warm skin, as by

vessel by

"thrombus." If a pulses, cardiac -Decrease urine output plaque and dry

breaks off from adequate urinary one vessel and output, and the becomes lodged absence of

in another vessel, respiratory the tissue-fed distress.

oxygen-rich blood is inadequately

perfused.

Problem#4: Acute Pain ASSESSMENT NURSING DIAGNOSIS S- O- The patient manifested: -Pain scale of 8/10 Acute Pain SCIENTIFIC EXPLANATION Coronary artery Short Term: 1. Established therapeutic After 3 hours of Nursing Interventions, the patient, relationship 2. Assessed pt.s condition. 3. Monitored and recorded vital signs 4. Assessed pains location Long term: Long term: After 2 days of Nursing Interventions, the patient will demonstrate behavior of and intensity/seve rity with. 5. Provided diversional activities like arising The patient shall have participated willingly in necessary activities. The patient shall have identified and used techniques to enhance activity intolerance. PLANNING INTERVENTIONS EXPECTED OUTCOME Short term:

disease (CAD) is caused by a

narrowing of the arteries that

supply the heart muscle -Increase respiratory rate with

pain scale will decrease from 8 to 6.

blood. When the arteries blood reduced. reduced -Chest pain narrow, flow is The blood

flow causes the heart muscle to receive less than it

-The patient may manifest:

oxygen

needs to function properly. When

-Restlessness -Irritability - (+) guarded behavior -(+) facial grimaces -Crying -v/s change -Diaphoresis -Sleep disturbance

ischemia patients

occurs typically

being

relieved

having conversation w/ patient. 6. Stressed patient to the the

from pain and will from be free the

develop angina or chest originating pain from

complications of condition. the

the heart. It has been described as chest pain or that

importance of providing adequate rest period to the patient. 7. Administered meds ordered. as

discomfort

has a squeezing or pressure-like

quality, usually felt behind breastbone (sternum), but the

sometimes felt in the shoulders,

arms, neck, jaws, or back.

Problem#5: Fatigue related to Poor Physical Condition ASSESSMENT DIAGNOSIS SCIENTIFIC EXPLANATION S-The may patient Fatigue Fatigue is OBJECTIVE NURSING INTERVENTIONS and 1. To RATIONALE EXPECTED OUTCOME obtain Short term: The shall patient have

an Short term: 1. Monitor After 2 hours of nursing record vital signs

verbalize related to poor overwhelming physical condition sense exhaustion resulting decreased to of

baseline data

overwhelming lack of energy

interventions , the patient 2. Determine ability will be able to verbalize participate activities 2. To to in enhance commitme nt

verbalized understanding of condition

O-The

patient

capacity perform

to activities

may manifest:

and causative

at the usual level. -Lethargy or drowsiness This is due to the patients poor

understandin g condition and causative factors. Long term: After 3 days of nursing of

to factors. promoting Long term: optimal outcomes The shall patient have

physical condition -Disinterest surroundings in brought about by the condition. -Decreased performance disease

performed 3. Establish realistic activity goals with client 3. To maximize participatio n ADLs participate desired activities/level of activity. and in

interventions , the patient

will be able -Listlessness to perform 4. Plan care ADLs and allow participate in individually desired activities/lev el of activity. -Introspection adequate periods, schedule activities periods client for when has the to

4. To encourage patients cooperatio rest n

-Compromised concentration

most energy

5. Provide environment conducive health to

5. To maintain/in crease strength and muscle tone and to enhance sense of

well-being.

6. Give medication 6. To as ordered

lessen

fatigue

Problem#6: Activity intolerance related to imbalance oxygen supply and demand

Assessment

Diagnosis

Scientific Explanation

Objective

Nursing Intervention

Rationale

Expected Outcome

S= O=The patient may manifest: -restlessness -Increased RR -cold clammy skin -decreased peripheral

Activity

Coronary artery

Short term: After 2-3 hours of nursing interventions, the patient will verbalize understanding of disease

1. assess patients condition 2. monitor and record vital signs 3. encourage patient to verbalize

1. to determine possible problems 2. for baseline data 3. to make client express his feelings 4. to improve

Short term: The patient shall have verbalized understanding of disease process.

intolerance disease results related to imbalance oxygen from the interruption of blood supply to

supply and a part of the demand heart, causing heart cells to die. Typical symptoms

pulses -pallor -cyanosis -fatigue

include sudden chest pain (typically radiating to the left arm or left side of the neck), shortness of breath, nausea, vomiting, palpitations, sweating, and anxiety. Women may experience fewer typical symptoms than men, most commonly shortness of breath, weakness, a

process.

concerns 4. encourage

venous return 5. to reduce stress 6. to divert attention and help patient lessen experienced pain and anxiety 7. to prevent further complications of the disease 8. to prevent overexertion 9. to reduce fatigue 10. to conserve energy Long term: The patient shall have maintained her breathing pattern as evidenced by: vital signs within the normal range

Long term: After two days of nursing interventions the patient will be able to maintain her breathing pattern as

patient to change position every two hours 5. encourage patient to do relaxation techniques

evidenced by: 6. Encourage patient to vital signs within the normal range engage in diversional activities such as chatting with family and friends. 7. reinforced

feeling of indigestion, and fatigue resulting in musculoskeletal impairment and/or pain, cognitive impairment and anxiety, metabolic abnormalities.

low salt and low fat diet 8. adjust activities 9. balance rest periods with activities 10. increase activity levels gradually

C. IMPLEMENTATION 1. MEDICAL MANAGEMENT a. IVFs, NGT feeding, Nebulization, TPN, Oxygen therapy, etc Medical Management/ Treatment Date Ordered Date Performed Date Changed General Description Indication Or Purposes D5W is initially infused, Lactated Ringers and Mr. Corona D. Sease it is an isotonic 5% Dextrose, to is was able to maintain Mr. good hydration status as as evidenced by good solution, but when the indicated Date performed: 09/17/2013 dextrose metabolized, solution Clients Response to Treatment

D5W 500ccx KVO

Date ordered: 09/17/2013

is Corona D. Sease

the a source of water and skin turgor and moist actually calories or as an oral membrane. mucous

becomes hypotonic, a solution osmotic where pressure

alkalinizing agent.

causes fluid to shift into cells.

Nursing Responsibilities Prior Verify the Doctors order Prepare all the equipment needed Do not administer unless solution is clear and container is undamaged. Properly label the IV fluid. Explain the purpose of the procedure and what to expect

During Provide patient's safety Locate for a good vein Apply antiseptic to the puncture site Check if it is the correct type of IV fluid

After Secure the IV tubing Discard unused portion Regulate the IV fluid as prescribed Document the procedure

Medical Management/ Treatment

Date Ordered Date Performed Date Changed

General Description

Indication Or Purposes

Clients Response to Treatment

O2

Inhalation Date ordered: 09/17/2013

Inhalation of oxygen O2 aimed toward at

Inhalation, to

is Mr. Corona D. Sease Mr. was able to maintain as normal respiratory

regulated at 2-3 LPM

restoring indicated

normal

any Corona D. Sease source

Date performed: 09/17/2013

physiologic alterations a

of breathing pattern.

of gas exchange in the supplementary cardiopulmonary system, as by the use of a respirator, nasal catheter, tent, oxygen.

chamber, or mask.

Nursing Responsibilities Prior Verify the Doctors order Prepare all the equipment needed

During Provide patient's safety Place properly on patients nose Regulate at 2-3LPM as ordered

After Document and record

b. Drugs 1. Aspirin

Name of Drug; Generic name; Brand name

Date Ordered/ Date Taken Date Changed Route, Dosage and Frequency

General Action, Mechanism of Action

Indication or Purposes

Clients Response to the Medication with Actual Side Effect

Generic name: Aspirin (acetylsalicylic acid)

Date ordered: 08/17/2013

PO, 80 mg 1 tab , OD

General action: NSAID; Anti-platelet

Indicated for Mr. Corona D. Mr. Corona Sease

D. Sease for responded well treatment of in the drug as mild to evidenced by

Date taken: 08/17/2013

aggregation

Brand Name: Asaphent

Mechanism action: Inhibits prostaglandin synthesis,

of moderate pain; reduction of

normal platelet count.

risk of death or unstable

resulting in anti- angina inflammatory pectoris, or

activity, platelet aggregation inhibition;

and recurrent transient ischemia attacks

reduces fever by (TIAs). acting brain's on the heat-

regulating center to promote and

vasodilation sweating.

Nursing responsibilities Prior Verify the doctor's order Give necessary information to the patient Obtain a history of previous use and reactions to medication.

During Administer medication as ordered Verify/check the medication again

After Monitor fungal/bacterial super infection Monitor sodium level

2. Clopidogrel Name of drug; Generic Name; Brand Name Date ordered/ Date Taken/ Date Changed Route, Dosage and Frequency General Action, Mechanism of Action Indication or Purposes Clients Response to the medication with Actual Side Effect

Generic name: Clopidogrel

Date ordered: 09/17/2013

PO, 75mg/tab, 1 tab General action: OD Inhibits aggregation

It was indicated Mr. Corona D.

platelet for Mr. Corona D. Sease by Sease AD prevention for responded well of in the drug as by

Brand name: Plavix

Date taken: 09/17/2013

blocking Preceptors platelets

on thrombosis along evidenced ,preventing with Aspirin and normal to vascular prevent count.

platelet

clumping of platelets

Mechanism action:

of ischemic events.

It was found to inhibit prostaglandin synthesis and to

complete for binding

at the prostaglandin receptor sites, giving analgesic and antiinflammatory effect

Nursing Responsibilities Prior Check the doctors order three times and verify the patient Check the label of the drug, its name and its expiration date. Explain the importance of compliance in medication regimen Obtain a history of previous use and reactions to medication.

During Instruct patient to notify prescriber if unusual bleeding or bruising occurs. Tell patient to inform all health care providers, including dentist, before undergoing procedures or starting new drug.

After Evaluate the effect of the medication to the patients condition Tell patient to refrain from activities in which trauma and bleeding may occur.

3. Enoxaparin Name of drugs; Generic name; Brand name Date Ordered/ Date Taken/ Date Changed Route, Dosage and Frequency General Action, Mechanism of Action Indication or Purposes Clients Response to the Medication with Actual Side Effect

Generic name: Enoxaparin

Date ordered: 09/17/2013

SQ, 0.4 cc, BID x 5 General action: days Anti coagulant drug

It was indicated Mr. Corona D. to prevent Mr. Sease

Corona D. Sease responded well Brand name: Clexane, Lovenox Date taken: 09/17/2013 Mechanism action: of from blood clots as evidenced by and from absence chest pain. of

Accelerates formation complications of anti-thrombin III from angina and

thrombin and

complex heart

attacks

deactivates with oral aspirin and ST-

thrombin, preventing therapy conversion fibrinogen to of Acute fibrin. segment

Drug has a higher elevation MI. anti factor Xa to antifactor IIa activity ratio than heparin.

Nursing Responsibilities Prior Check the doctors order three times and verify the patient Check the label of the drug, its name and its expiration date. Explain the importance of compliance in medication regimen. Obtain a history of previous use and reactions to medication.

During Instruct patient and SO to watch for signs of bleeding or abnormal bruising and notify prescriber immediately if any occur. Tell patient to avoid OTC drugs containing aspirin or other salicylates unless ordered by prescriber

After Evaluate the effect of the medication to the patients condition

4. Captopril Name of drugs; Generic name; Brand name Date Ordered/ Date Taken/ Date Changed Route, Dosage and Frequency General Action, Mechanism of Action Indication or Purposes Clients Response to the Medication with Actual Side Effects

Generic name: Captopril

Date ordered: 09/17/2013

PO, 25 mg/tab , 1 General action: tab B.I.D Antihypertensive

It was indicated Mr. Corona D. for hypertension Sease of Mr. Corona D. responded well

Brand name: Capoten

Date taken: 09/17/2013

Mechanism action: Inhibits

of Sease,

and

to as evidenced by blood

vasodilate blood lower ACE, vessels so blood pressure. more and can more

preventing conversion flows of angiotensin I to smoothly angiotension potent II, a the pump heart

vasoconstrictor. Less efficiently. angiotensin II

decreases peripheral arterial resistance,

decreasing aldosterone secretion, which

reduces sodium and water retention and lowers pressure. blood

Nursing Responsibilities Prior Check the doctors order three times and verify the patient Check the label of the drug, its name and its expiration date. Explain the importance of compliance in medication regimen. Obtain a history of previous use and reactions to medication. Instruct patient to take drug 1 hour before meals.

During Inform patient that light headedness is possible, especially during the first few days of therapy. If fainting occurs, he should stop the drug and call the prescriber.

After Evaluate the effect of the medication to the patients condition Tell patient to use caution in hot weather and during exercise. Advise patient to report signs and symptoms of infection, such as fever and sore throat. Urge patient to promptly report swelling of the face, lips, mouth or difficulty breathing.

5. Rosuvastatin Name of Drugs; Generic Name; Brand Name Date Ordered/ Date Taken/ Date Changed Route, Dosage and Frequency General Action, Mechanism of Action Indication or Purposes Clients Response to the Medication with Actual Side Effects

Generic name: Rosuvastatin Calcium

Date ordered: 09/17/2013

PO,

20

mg/tab, General action: Antilipemic

It

was

indicated risk of

to Mr. Corona D. Mr. Sease

OD HS

reduce

Corona D. Sease in responded well Date taken: Mechanism action: of death from CV disease as and CV events in by evidenced reduced

Brand name:

09/17/2013

Crestor

Competiting

patients at high risk of cholesterol events, to level.

inhibitors HMG CoA coronary reductase. enzyme the

This reduce total and LDL catalyzes cholesterol, rate apolipoprotein B, and

early

limiting step in the triglyceride levels and synthesis cholesterol. Decreased cholesterol, triglycerides, VDL,LDL increased Does basal cortisol testosterone level not of increase cholesterol level HDL in

patients with primary hyperlipidemia and

mixed dyslipidemia; to and reduce HDL. density reduce cholesterol plasma patients very low

lipoprotein level in with

or dysbetalipoproteinemia

Nursing Responsibilities Prior Check the doctors order three times and verify the patient.

Check the label of the drug, its name and its expiration date. Explain the importance of compliance in medication regimen. Obtain a history of previous use and reactions to medication. Instruct patient to take drug in the evening.

During Teach patient about proper dietary management of cholesterol and triglycerides Tell patient to inform prescriber if adverse reactions occur, particularly muscle aches and pains or tenderness or weakness with malaise or fever. After Evaluate the effect of the medication to the patients condition

6. Lactulose Name of Drugs; Generic Name; Brand Name Date Ordered/ Date Taken Date Changed Route, Dosage and Frequency General Action, Mechanism of Action Indication or Purposes Clients Response to the Medication with Actual Side Effects

Generic name: Lactulose

Date ordered: 09/17/2013

PO, 30CC, OD HS

General action: Laxatives

Indicated for Mr. Mr. Corona D. Corona D. Sease Sease to prevent experiences bowel

Brand name: Lilac, Rilax

Date taken: 09/17/2013

Mechanism action:

of constipation and regular to

prevent movement. while that

Produces an osmotic straining effect resulting in colon; defecating distention could

increase

promotes peristalsis. the workload of Also ammonia, decreases the heart. probably

as a result of bacterial degradation, lowers the which pH of

colon contents.

Nursing Responsibilities Prior Check the doctors order three times and verify the patient Check the label of the drug, its name and its expiration date. Explain the importance of compliance in medication regimen Obtain a history of previous use and reactions to medication.

During After Evaluate the effect of the medication to the patients condition Monitor mental status and potassium levels Replace fluid loss Instruct patient not to take other laxatives during lactulose therapy.

7. Furosemide Name of Drugs; Generic Name; Brand Name Date Ordered/ Date Taken/ Date Changed Route, Dosage and Frequency General Action, Mechanism of Action Indication or Purposes Clients Response to the Medication with Actual Side Effects

Generic name: Furosemide

Date ordered: 09/17/2013

IV, 40 mg, every 6 General action: hours for 3 days Loop Diuretic

Indicated for Mr. Mr. Corona D. Corona D. Sease Sease to treat high established a

Brand name: Lasix

Date taken: 09/17/2013

Mechanism action: Acts by

of blood

pressure blood

pressure normal and no was

and to prevent within inhibiting excessive the accumulation range of edema

NKCC2, luminal Na-K-2Cl

fluid of the body noted. can be

symporter in the thick that ascending the loop of

limb of cause by heart Henle. failure.

The action on the distal tubules is

independent of any

inhibitory carbonic

effect

on

anhydrase

or aldosterone; it also abolishes corticomedullary osmotic gradient and blocks negative, as well as positive, free water clearance. the

Nursing Responsibilities Prior Check the doctors order three times and verify the patient Check the label of the drug, its name and its expiration date. Explain the importance of compliance in medication regimen Obtain a history of previous use and reactions to medication. Instruct patient to take drug 1 hour before meals,

During Inform patient that light headedness is possible, especially during the first few days of therapy. If fainting occurs, he should stop the drug and call the prescriber.

After Evaluate the effect of the medication to the patients condition Tell patient to use caution in hot weather and during exercise. Advise patient to report signs and symptoms of infection, such as fever and sore throat. Urge patient to promptly report swelling of the face, lips, mouth or difficulty breathing.

8. Salbutamol Name of Drugs; Generic Name; Brand Name Date Ordered/ Date Taken/ Date Changed Route, Dosage and Frequency General Action, Mechanism of Action Indication or Purposes Clients Response to the Medication with Actual Side Effects

Generic name: Albuterol Sulfate

Date ordered: 09/18/2013

Nebulizer doses minutes

3 General action: 15 Bronchodilator

Indicated for Mr. Mr. Corona D. Corona D. Sease Sease to relieve cooperated with medication and

every

Date taken: Brand name: 09/18/2013

Mechanism of action: A

bronchospasm brought

about shown a slight

Accuneb

substance that dilates the bronchi and bronchioles,

the compensatory mechanism

improvement with of pattern breathing

decreasing resistance lungs to maintain in the respiratory adequate oxygen

airway and increasing supply. airflow to the lungs.

Nursing Responsibilities Prior Check the doctors order three times and verify the patient Check the label of the drug, its name and its expiration date. Explain the importance of compliance in medication regimen

During Position patient on high back rest

After Evaluate the effect of the medication to the patients condition Do back tapping Instruct patient to take food immediately.

9. Hydrocortisone Name of Drugs; Generic Name; Brand Name Date Ordered/ Date Taken/ Date Changed Route, Dosage and Frequency General Action, Mechanism of Action Indication or Purposes Clients Response to the Medication with Actual Side Effects

Generic name: Hydrocortisone

Date ordered: 09/18/2013

IV, 100mg , PRN

General action: Corticosteroid

Indicated for Mr. Mr. Corona D. Corona D. Sease Sease to relieve from cooperated with

Brand name: Hydrotex,

Date taken: 09/18/2013

Mechanism action:

of short-term inflammation.

medication and relieved

Synacort

Enter they

cells combine

where with

inflammation.

steroid receptors in cytoplasm combination nucleus enters it

where

controls synthesis of protein, enzymes regulate vital including that cell

activities over a wide range of metabolic

functions including all aspects inflammation. of

Nursing Responsibilities Prior Check the doctors order three times and verify the patient Check the label of the drug, its name and its expiration date. Explain the importance of compliance in medication regimen

During Watch out for adverse reactions

After Evaluate the effect of the medication to the patients condition

C. DIET Date ordered/ Type of Diet Date started/ Date changed General Description Indication/ Purpose Specific Food Taken Clients Response to Treatment

Low Salt, Low Fat Diet

Date ordered: 08/17/2013

A type of diet It was indicated which in food to prevent Mr. provided the Corona D.

Rice and fish

Mr.

Corona

D.

Sease

responded well on the diet by not eating food that are salty and fatty and by just eating such as boiled food.

client is low Sease to have fat Date started: 08/17/2013 sodium and a fluid retention and decreased metabolic

content, with in a

strict demand.

precaution to aspiration which patient be the must

position

into

semi-

fowlers or the head is being elevated.

Nursing Responsibilities: Prior Check physicians order Inform the patients SO about the type of diet. Explain the purpose of the diet ordered the consequences of not following such diet and how it will be implemented.

During Monitor if the patient complies with the given diet. Monitor intake and output.

After Monitor patients reaction and compliance with diet. Instruct patient to maintain the optimal nutritional status Provide oral hygiene after meals

D. ACTIVITY/EXERCISE Type Date Ordered/ Performed/ Changed General Description Indications/ Purposes Clients Response/ Reaction

Bed with

Rest Date ordered: 09/17/2013

Confined him on bed to Indicated to restore the energy rest but can do some light and promote D. rest of that Mr. to

Mr. Corona D. Sease complied on the instructed exercise AEB he limits his activity and was able to take a rest and sleep properly to promote wellness

bathroom privilege

activities like going to the Corona bathroom and some

Sease

walking. decreased the workload of limited heart.

Date performed: 09/17/2013

Having

strenuous movement.

Nursing Responsibilities: Prior Check physicians order Inform the patients SO about the type of activity.

Explain the purpose of the activity ordered the consequences of not following such diet and how it will be implemented. Provide proper positioning.

During Assist the client in doing any activities.

After Document response of the patient.

2. SURGICAL MANAGEMENT No surgical management was done

3. NURSING MANAGEMENT (ACTUAL SOAPIERs)

SEPTEMBER 18, 2013 S= Medyo nahihirapan akong huminga as verbalized by the patient.

O=Received patient in sitting position, conscious and coherent with an IVF of D5 in water x KVO @ 4500cc level, with 02 inhalation of 2-3LPM, with signs of fatigue, with pale palpebral conjunctivas, with prolonged capillary refill, body weakness, cold clammy skin, VS as follow: T= 36.5C, HR=74bpm, RR=31bpm, BP=110/80mmHg.

A= Decreased cardiac output related to altered cardiac function secondary to CAD

P=After 2 hours of nursing interventions patient will be able to verbalized understanding and importance of hemodynamic stability

I= INDEPENDENT > Established rapport > Monitored and recorded VS > Provided bed side care > Oral medications given and noted

> Kept client on semi fowlers position > Evaluated clients reports and evidence of extreme fatigue > Monitored cardiac rhythm continuously > Scheduled activities and assessment > Assisted patient in performing self-care > Provided health teachings in reducing activities that may stimulate an increase in oxygen demand >Provided adequate rest > Assisted patient in changing position DEPENDENT >For 2Decho/requested

E= Patient verbalized understanding and importance of hemodynamics stability

SEPTEMBER 19, 2013 S= Agad akong napapagod as verbalized by the patient

O= Received patient on a sitting position, conscious and coherent, with ongoing IVF of D5W x KVO @ 450cc level, with O2 inhalation of 2-3 LPM, with foley catheter draining on a yellowish brown output @ 800cc level, with pale nail beds, seemed weak and restlessness, with presence of productive cough, move with assistance, VS taken as follows: T= 35.3C, HR=91bpm, RR=28bpm, BP=110/80mmHg.

A= Fatigue related to decreased muscle strength as evidenced by decreased in performance

P=After 3 hours of nursing interventions the patient will participate in desired activities of level ability

I= INDEPENDENT >Establishes rapport >Provided morning care >Assessed general condition > Monitored and recorded VS > Instructed to have adequate rest > Encouraged to practice deep breathing technique > Encouraged to have passive range of motion exercise > Provided support when moving > Instructed to avoid foods with caffeine or high sugar > Oral medications given as ordered DEPENDENT >For 2Decho-advised E= Patient participated to the desired activities at level ability

 SEPTEMBER 20, 2013 S= O

O= Received patient on a lying position, conscious and coherent, with ongoing IVF of D5W x KVO @ full level, with foley catheter draining on a yellowish brown output @ 100cc level, with pale nail beds, seemed weak and restlessness, with presence of productive cough, move with assistance, with excessive sputum seen in a cup at the bed side, rales and crackles are heard during auscultation VS taken as follows: T= 36.8C, HR=78bpm, RR=26bpm, BP=120/80mmHg.

A= Ineffective airway clearance related to retained secretions as evidenced by excessive sputum seen in a cup at the bed side.

P= after 3 hours of nursing interventions the patient will verbalize understanding of causes and therapeutic management regimen.

I= INDEPENDENT >Establishes rapport >Provided morning care > Kept patient comfortable >Assessed general condition > Monitored and recorded VS

> Instructed to have adequate rest > Encouraged to practice deep breathing technique > Elevate head of bed and change position every 2 hours > Encouraged increase fluid intake

E= the patient verbalized understanding of causes and therapeutic management regimen.

D. EVALUATION Clients Daily Progress DAYS ADMISSION 9/17/13 Nursing Problems 1. Ineffective Airway 1st NPI 9/18/13 2nd NPI 9/19/13 3rd NPI 9/20/13

Clearance

2.

Decreased

Cardiac

Output 3. Ineffective Tissue Perfusion 4. Acute Pain X X X X X

5. Activity Intolerance

6. Fatigue

Vital Signs Temperature Pulse Rate Respiratory Rate Blood Pressure 36.5C 74 bpm 31 bpm 110/80 mmHg 35.8C 77 bpm 31 bpm 110/80 mmHg 36.8C 78 bpm 26 bpm 120/80 mmHg

DX/Lab Procedures >Blood Chemistry Hgb 130

Hct WBC Neutrophils Lymphocytes Platelet Fasting Blood Sugar BUN Creatinine Sodium Potassium

0.44 7 0.49 0.27 298 6.02 4.1 130.8 146.6 4.23

>Urinalysis Color Transparency Specific gravity Sugar Yellow Turbid 1.013 Negative

Medical Management: >D5W

Drugs >Aspirin >Clopidogrel >Enoxoparin >Captopril >Rosuvastatin >Lactulose >Lanoxin >Furosemide >Salbutamol X

>Hydrocortisone

Diet >LSLF with SAP

Activity/Exercise > CBR with BRP

2. DISCHARGE PLANNING a. General Condition of Client Upon Discharge The patient prior to discharge demonstrated the following indications of good health and alleviation from the previous diagnosis: - Patient was able to cope up with his/her ADLs - Patient was able to return to normal appetite to increase body nutrition - Patient was able to verbalize needs - Patient was portraying absence or decreased pain - Patient together with the S.O was able to comply with health teachings given prior discharge

b. METHODS M(edications) Instructed the patient to continue medication as ordered 1. Salbutamol Neb 1 Neb twice a day 2. Aspirin 80 mg/tab 1 tab once a day 3. Clopidogrel 70 mg/tab 1 tab once a day 4. Enalapril 5 mg/tab 1 tab once a day 5. Atovastatin80mg/tab 1 tab once a day 6. Lactulose 30cc once a day 7. Lanoxin 0.25gmg/tab once a day 8. Acetylcysteine 200mg/sachet 1 sachet in 1 glass water three times a day 9. Prednisone 20mg/tab two times a day E(xercise) Instructed the patient to do exercise as tolerated such as walking

-Instructed patient to obtain adequate rest periods T(reatment) Instructed patient to continue medication H(ealth Teachings) Encouraged patient to increase fluid intake Encourage patient to eat foods rich in vitamins especially vitamin C and nutritious foods Encouraged patient to avoid salty and fatty foods Instructed patient to limit her activity for 24 to 48 hours after discharge

O(ut-patient Department) Advised patient to have OPD follow-up check up on September 27, 2013 at 10 am D(iet) Encouraged patient to eat smaller than normal amounts of food at meal time Encourage Low Salt Low Fat Diet

S(pirituality) Encouraged patient to communicate with God Encourage patient to communicate with other people

III. SUMMARY OF FINDINGS Case study is indeed one essential part of a Nursing student. It can serve as a step to enhance our knowledge, skills, and even our attitudes. It wouldnt only benefit to us students, but also the patient we are assessing. Interview is one major part of this. With the information gathered from the patient, the group was able to find out the different factors that affected the patients condition which is not visible on the chart. The group had also found out that socio-economic stress was one of the factors that could bring to CAD Unstable Angina. The patient has a large family composing of 6 children and a wife therefore he needed to earn more to sustain the needs of his family. The patient went into different diagnostics test to validate the initial diagnosis of the patient. The tests done were CBC; to see if blood components are normal, ECG; to monitor the hearts performance, and Urinalysis; to reveal diseases that are unnoticed. The patients drug are mostly composed of anti-platelet aggregation which are Aspirin, Clopidogrel and Enoxaparin. The other drugs are Captopril, Furosemide which are hypertensive drugs, Salbutamol which is a bronchodilator, Hydrocortisone an anti-inflammatory, Rosuvastatin an anti-lipemic and Lactulose a laxative. Our patient had Coronary Artery Disease and certain interventions should be done. Since we all know that Nursings major role to the patient is to aid him to be treated and help him to be healthy. The nurse should be able to administer medications at the right time, at the right dosage. With all the things that happened there were several lessons that weve learned and improved. We had learned to develop my knowledge and certainly my skills. With that we have enhanced my nursing techniques. We had also learned the benefits of Case Study. It helped the patient to improve his health and also learned the different task he needs to attend.

IV. CONCLUSION Coronary artery disease (CAD) is characterized by atherosclerosis in the epicardial coronary arteries. Atherosclerotic plaques, the hallmark of atherosclerosis, progressively narrow the coronary artery lumen and impair antegrade myocardial blood flow. The reduction in coronary artery flow may be symptomatic or asymptomatic, occur with exertion or at rest, and culminate in a myocardial infarction, depending on obstruction severity and the rapidity of development. According to the National Center for Health Statistics 2011 report, cardiovascular disease (CVD) remains the leading cause of mortality in the United States in men and women of every major ethnic group. It accounted for nearly 616,000 deaths in 2008 and was responsible for 1 in 4 deaths in the U.S. in the same year. CAD is the most common type of heart disease and in 2008, 405,309 individuals died in the U.S. from this specific etiology. Every year, approximately 785,000 Americans suffer a first heart attack and another 470,000 will suffer an additional myocardial infarction (MI). In 2010, CAD alone was projected to cost the U.S. $108.9 billion including the cost of health care services, medications, and lost productivity. CVD claims more lives each year than the next 4 leading causes of death combinedcancer, chronic lower respiratory diseases, accidents, and diabetes mellitus. Most individuals with coronary artery disease show no evidence of disease for decades as the disease progresses before the first onset of symptoms, often a "sudden" heart attack, finally arises. After decades of progression, some of these atheromatous plaques may rupture and (along with the activation of the blood clotting system) start limiting blood flow to the heart muscle. A distinction should be made between myocardial ischemia and myocardial infarction. Ischemia means that the amount of oxygen supplied to the tissue is inadequate to supply the needs of the tissue. When the myocardium becomes ischemic, it does not function optimally. When a large area of the myocardium becomes ischemic, there can be impairment in the relaxation and contraction of the myocardium. If the blood flow to the tissue is improved, myocardial ischemia can be reversed. Infarction means that the tissue has undergone irreversible death due to lack of sufficient oxygen-rich blood.

V. RECOMMENDATIONS The group recommends that Coronary Artery Disease should be studied and researched for treatment by the health care professionals and to the World Health Organization. This case study was made to make the individuals more knowledgeable regarding this certain disease. Gaining more knowledge will help the individuals

minimize and prevent the development of this disease. For the health care providers, they should provide appropriate health teachings and ways to prevent the occurrence of such diseases. Assessing well of the patients past and present history is essential in proper diagnosis and treatment of patients. For us student nurses, we should learn how to manage and provide appropriate nursing interventions for patients with this disease. We should maximize all possible resources available. Monitoring patients vital signs, keep in mind that any deviation from normal range of vital signs may reflect a significant affectation in the condition of the patient. Emphasize early detection of disease and adopting multiple strategies to prevent complications and if disease occurs, decreasing its severity and alleviate its signs and symptoms.

VI. LEARNING DERIVED The conditions this patient went through were all discussed in Nursing Care Management 103 and it was interesting to see manifestations of heart conditions during duty. The most interesting part of using this patients diagnosis, understood the pathophysiology of the heart and how different conditions can affect specific parts of the body. Having the sense of awareness thus moved us to further study of the disease so to provide the appropriate nursing intervention towards promoting wellness. It is essential to ensure patients are fully involved in care decisions in a nursing responsibility We learned how important it is to make therapeutic relationship to our patient because we are not just there to give them their medicine but to care for them holistically. We realized how important the heart is for the human body and that the person should always take good care of it to prevent Coronary Artery Disease.

BIBLIOGRAPHY Book Sources: Black, Joyce M., et al., Medical-Surgical Nursing, Clinical Management for possible outcome. Eighth Edition. Elseview Saunders, Missouri, USA, 2004 Internet Source: http://www.medicalnewstoday.com/articles/150999.php http://www.cdc.gov/heartdisease/facts.htm http://www.worldlifeexpectancy.com/philippines-coronary-heart-disease http://www.webmd.com/heart-disease/guide/heart-disease-coronaryartery-disease http://www.heart.org/HEARTORG/Conditions/More/MyHeartandStrokeNe ws/Coronary-Artery-Disease---The-ABCs-ofCAD_UCM_436416_Article.jsp