I N T R O D U C T I O N

Coronary heart disease (CHD) is the most common cause of death worldwide. Mortality from CHD increases with advancing age, and age-adjusted CHD rates are higher in men compared to women. There is a large regional variation in coronary mortality both within and between countries. Coronary risk factors include socioeconomic factors, classic risk factors such as hypertension or diabetes, lifestyle factors, and family history. A variety of factors such as emotional stress or acute physical exertion can trigger coronary events. Also, an increased risk has been observed in the morning hours and during winter months. Preventive efforts include lifestyle measures and appropriate medication. CHD is caused by a narrowing of the coronary arteries, leading to an imbalance between the functional requirements of the heart and the capacity of the coronary arteries to supply blood and oxygen. As a consequence, the heart muscle is damaged, which will eventually become clinically apparent with cardiac symptoms. Clinical manifestations of CHD include stable or unstable angina pectoris, myocardial infarction, cardiac arrhythmias, congestive heart failure, and/or sudden cardiac death. The main cardiac symptoms are thoracic pain and dyspnea. In the long term, CHD is associated with disability, impaired health-related quality of life, and premature death. In addition, disease-related costs as induced by medical resource utilization and loss of productivity are considerable. As what we have researched, the worlds statistics, from various sources about the causes of Coronary heart disease, it is the leading cause of cardiovascular mortality worldwide, with >4.5 million deaths occurring in the developing world. Despite a recent decline in developed countries, both CAD mortality and the prevalence of CAD risk factors continue to rise rapidly in developing countries and thats from the World Health Organization. For the Philippines statistics of Coronary artery disease, there were 4,185, 258 prevalent cases and 86, 241, 692 incidents. The word 'prevalence' of Coronary heart disease usually means the estimated population of people who are managing Coronary heart disease at any given time (i.e. people with Coronary heart disease). During the past three years, eight of the ten leading causes of morbidity in Davao Region were communicable but highly preventable diseases. The non-communicable

leading causes of morbidity were hypertensive diseases and genitourinary system diseases. In 2002- 2004, cerebrovascular diseases topped the leading causes of mortality, indicating the need to examine closely the lifestyle of the at-risk population in the region. In 2002, heart diseases including coronary artery disease ranked second to cerebrovascular diseases. We choose Mr. R.G.C. as our client since his current illness is appropriate to our concept which is metabolism. Mr. R.G.C has 4 diagnosis which are Acutegastroenteritis, Diabetes Mellitus, CAD and Left ventricular hypertrophy, but we just focused on Diabetes Mellitus which leads to other complications such as CAD, stroke and left ventricular hypertrophy. Nursing implications are as follows. For the nursing education, this can increase our knowledge in all aspects of nursing care most especially in knowing the signs and symptoms, assessing our patients comprehensively in order to detect various deviations in his body and most importantly, knowing the disease process and interventions that we must apply to obtain quality and optimum health to our patients. Since nursing is viewed holistically, we must also have a good background about the disease in order for us to know what is right and what is wrong for our patient.

O B J E C T I V E S

General Objective: That within our 3 weeks rotation at the St. Dominics Ward of San Pedro Hospital, we, the BSN 3F, of group 1, will be able to formulate a nursing case study that aims to present a comprehensive information of our patients condition in relation with the concept and theories we have in this Metabolism rotation that would utilize nursing principles and interventions to help us enhance our skills in this rotation.

Specifically, we will be able to: 1. Choose a client for our nursing case study 2. Establish rapport with our client and his significant others 3.Gather all the necessary information of our client through t he patients chart and the actual observation which will be the source of our data 4. Present an introduction that will give an overview and a brief summary on the topic that will be embarking upon in this case study; 5. Develop specific, measurable, attainable, realistic and time-bounded objectives to identify and relay the main purpose of our case study; 6. Present the clients personal data 7. Discuss the clients past health history, present health history and the genogram that would serve as an aid in the identification of problems of our client; 8. Explain the clients developmental task based on the theory of Robert Havighurst and Erik Erikson; 9. Present the normal anatomy and physiology of a human body as our baseline data for any variation in the clients anatomy and physiology 10 .Perform a thorough cephalocaudal assessment of the client; 11. Present a comprehensive physical assessment to reveal further irregularity; 12. Provide a definition of the diagnosis for further understanding of o ur clients current health status;

13. Discuss the pathophysiology of Diabetes Mellitus leading complications like CAD, stroke and left ventricular hypertrophy; 14. Present the diagnostic examinations that our client went through with all the necessary information such as the results, interpretation and the nursing Responsibilities; 15. Gather all the names of our clients prescribed medications to know their information such as their generic name, brand name, classification, the ordered and the suggested dose of the doctor, their action, indication by the drug, contraindications, drug interactions, side effects and their nursing interventions towards our client; 16. Discuss the medical and surgical managements done to our patient accordingly 17. Present the nursing management of our client to develop nursing care plans; 18 Implement health teachings to our client appropriate with his health care needs 19. Formulate our prognosis on his current health condition based on the following information that we have gathered; and 20. Enumerate the references used for the achievement of this case study.

B I O G R A P H I C A L D A T A

Name: Patient X Age: 64 Years Old Birthday: July 07, 1947 Birthplace: Australia Nationality: Australian Religion: Catholic Sex: Male Civil Status: Divorced Occupation: Former Military in Vietnam Address: Lanang, Davao City Live-in Partner: Partner Y

CLINICAL STATUS

Chief Complaint: Epigastric Pain & Vomiting Date of Admission: August 8, 2011 Admission Time: 8:00 pm Manner of Admission: Per Wheelchair Ward: St. Dominic Room and Bed no: 409-2 Attending Physician: Dr. Marilyn O. Arguelles, MD Dr. R. Cabahug, MD Dr. L. Gallardo, MD Impression: AGE with chronic Aspirin Intake
R

/O Acute Pancreatitis

Diabetic Gastropathy CAP MR DM type 2 Discharged Date: August 11, 2011 Discharged Time: 8:23 pm Final Diagnosis: Age with Some Dehydration Others: Coronary Artery Disease, Left Ventricular Hypertrophy, PAC frequent FCI Post CVA, MRE 2 DM

FAMILY HEALTH HISTORY

During the interview, we asked Patient X about their familys health status and the hereditary diseases that run in their family and he was able to recall some and provide the data we needed. The hereditary diseases present in Patient Xs on his materna l side were Hypertension, Diabetis Mellitus and Cardiac disease. His grandmother died at age of 74 due to embolism that leads to stroke. He does not remember the reason of his grandfathers death. However, he said that his grandfather had Diabetis Mellitus . Her mother had hypertension and died at the age of 34 due to stroke. He had no aunt and uncle on his maternal side. On his paternal side, when we asked our patient he said that he does not anymore remember the names of his grandparents and the hereditary that are present on them. His dad died because of lung cancer at the age of 75. He does not know the reason of death of his only uncle and if there is any hereditary diseases present on him. He had 5 siblings, their eldest JDC 66 years old, next is our patient 64 years old followed by CCC 62 years old, an obese person, then MGC 58 years old, she is mentally retarded, next BRC 56 years old and their youngest LRC 54 years old who had Polio when he was a baby. Lastly, Patient X was diagnosed of having Coronary Artery Disease, Left Ventricular Hypertrophy, PAC frequent FCI, Post CVA, MRE 2 DM.

MATERNAL SIDE

PATERNAL SIDE

GD

ED 79

AD
74

CVC 75

JC

JDC 66

64

CCC 62

MGC 58

BRC 56

LRC 54

LEGEND: HPN CARDIAC DSE. DECEASED POLIO LUNG CANCER MENTAL ILLNESS FEMALE MALE STROKE

UNKNOWN

DM

PAST HEALTH HISTORY We asked our patient some questions that was related to his health and he said that he experienced childhood illnesses such as Mumps, Chicken pox or Measles. Furthermore, he had no allergies in food. In the year 1964 our client was 17 years old and he had his first tattoo on his anterior lateral left arm, measuring 16x8cm with visible color of green and black. Our client claimed that there were no complications after the procedure. When our client was 52 years old (1999) he was forced to end his military work in Vietnam due to his post traumatic distress disorder and he became a pensioner afterwards. He was back to his home land after the end of his work in Vietnam. He was put on rehabilitation in Australia for a few weeks and the patient was given instruction on how to manage his disorder since our client stated that the doctors told him that there is no cure to the disorder, however there are drugs that should be maintained. In the year 2003, our patient stated that he started to feel chest pain which prompted his first admission in a hospital in Australia. Upon asking if he still remember the month or date the patient said that it was a long time ago so the only thing he could remember was the year. There in his admission he was diagnosed as having a Diabetis Mellitus type 2 and Coronary Artery Disease. He was supposed to be operated for a heart bypass but because his glucose level was still high due to his Diabetis Mellitus the doctors told him that they should wait till the glucose level is stabilized or within normal range before he will have the surgery. After he was stabilized the heart bypass was done to him by getting a vein in his anterior left arm and was connected to his heart by doing a Median Sternotomy for the surgical approach for CABG surgery. No complications happened after the surgery as stated by the patient. The heart bypass was a successful operation. He was given maintenance drugs of Nexium(1 tablet a day), Simvastat in(1 tablet a day), Aspirin(100mg/1 tablet a day) and Melformin GA(40 mg/2 times a day) for his diabetes.

In the year 2006 he went to the Philippines because of his Filipina girlfriend. The couples relationship did not went well and because of a lot of problems that caused him stress he ended his relationship and went back to his home land in Australia. He stated that he cannot handle the stress and because he has a disorder he decided to go back to his place. It was also on the same year that he went to the Philippines and went back to Australia. In 2009 he had another Filipina girlfriend on which he decided to go back to the Philippines and settle there. Hes relationship went well and he is staying now with her as a live-in partner. He said that his partner is the one assisting him in his maintenance medications. In the year 2010 he had his first admission in Davao city in a hospital due to abdominal pain. He also stated that he had episodes of allergy during his stay in the hospital. He stayed for the hospital for a few weeek and was discharged. Due to his traumatic experience he became very irritable until now however he sometimes can manage it by avoiding the stimulant or the problem. During his military work he usually has an intake of 3 bottles of beer a day. He is a smoker, who usually consumes 2-3 packs a day for approximately more than 40 years now. He stated that he was not as diligent in taking his medication when he was still in Australia, it was just here in the Philippines during 2009 that he was able to take them religiously. His highest blood pressure was 140/100 and his lowest was 110/80 as recorded in the chart.

HISTORY OF PRESENT ILLNESS

A week prior to admission our client complained of on and off epigastric pain described as sharp pain, minimal modulation, above condition tolerable, sought consult SPH-out patient department and was given Nexium, Durpature and was relieved to above condition. August 8, 2011, early morning he complained of gradual onset of epigastric pain, described as sharp pain relatively to peripheral area at the left and lower quadrant. He

was only able to eat toast bread and a chocolate drink for his breakfast since he wasnt feeling well. He wasnt able to consume any food during lunch time but had taken water for his drinks. Late evening around 7:30 he started vomiting. The watcher claimed that his first episode of vomiting was with food however on the 2nd up to the 5th time his vomitus was mostly water in small quantity of around 5-10ml of fluids, until such time no vomitus was noted but still exhibit vomiting response. He also complained that during those times he was suffering from abdominal pain, body malaise and headache. The watcher claimed that due to his vomiting, abdominal pain, dry lips and pale appearance which prompted them for admission at SanPedroHospital around 9:00 in the evening on that day.

In the assessment he was negative for LBM, melena, hematochezia and fever and was positive on having a dry cough. During the admission a physical assessment was done which revealed awake, afebrile, not in respiratory distress, enecteric eyes, symmetrical chest expansion, scar in midline anterior arm, soft, tender on epigastric area and negative on cold clammy skin. The watcher also reported that during the assessment the nurse wasnt able to get any blood pressure and was only able to record 80 bpm palpable on his radial pulse and after wards he was already stabilized which revealed a blood pressure of 100/60. He was then given an impression and tentative diagnosis of: AGE with chronic Aspirin intake, R/O Acute Pancreatitis, Diabetic Gastropathy, CAP MR, Diabetis Mellitus type 2.

Our client was then transported to his room per wheelchair at St Dominics ward room 409-2. Admission orders were carried out by nurse on duty.

DEVELOPMENTAL TASK
a. Psychosocial Theory Psychosocial development is how a person's mind, emotions, and maturity level develop throughout the course of their lifetime. Different people will develop psychosocially at different speeds depending on biological processes and environmental interactions. Erik Eriksons believes that people continue to develop throughout life. His Psychosocial theory describes eight stages of development. At each stage, there is a conflict between two opposing forces. The decision of each conflict or accomplishment of the developmental task of that stage allows the individual to go on to the next phase of development. Patient X, 64 years old belongs to the 7th psychosocial stage in Eriksons

theory, which is the Middle Adulthood. In this stage, the primary developmental task is one of contributing to society and helping to guide future generations. Adults need to create or nurture things that will outlast them, often by having children or creating a positive change that benefits other people. Success leads to generativity or feelings of usefulness and accomplishment, while failure results in stagnation which makes shallow involvement in the world.

STAGE

CENTRAL TASK Generativity vs.

ACTUAL MET

JUSTIFICATION Our patient has been divorced with his previous wife. However, at present he is living happily together with his

Middle Adulthood (35-65 yrs old.)

Stagnation

Task: Fulfilling life goals that involve family, career, and society

partner. Although he has been forced to end his military duty, he was able to serve his country during the times of war.

DEVELOPMENTAL TASK THEORY

Robert Havighurst defines a developmental task as one that arises at a certain period in our lives, the successful achievement of which leads to happiness and success with later tasks; while leads to unhappiness, social disapproval, and difficulty with later tasks. Havighurst uses lightly different age groupings, but the basic divisions are quite similar to those used in this book. He identifies three sources of developmental tasks. He believes that learning is basic to life and that people continue to learn throughout life. He describes growth and development as occurring during six stages, each associated with six to ten tasks to be learned. Our patient, Patient x belongs to:

STAGE

DEVELOPMENTAL TASK Achieving adult civic and social resposibility

ACTUAL

JUSTIFICATION Patient X worked as a

MET

military and served his country during the war. Our patient has became a

Middle Age

Establishing and maintaining an economic standard of living MET

pensioner since the day he was forced to end his duty. All his needs were provided by the government of Australia.

Assisting teenage children to become responsible and happy adults UNMET

Our patient does not have any children to assist to.

Developing adult leisure time activities MET

Patient X said that he spent most of his time watching TV and going to the mall and different places.

Relating oneself to ones spouse as a person MET

Patient X said that her partner gives everything he wanted, she makes sure that they talk in every problem they encounter.

Accepting and adjusting to the physiologic changes in the middle age and aging process MET

Patient X said that he accepts all the changes that is happening to his body. With rehards to this, he said that he needs to wear his eyeglasses because he is already old and he cant clearly see without his eyeglasses.

A P H Y S I C A L S S E S S M E N T

General Survey: Upon assessment the patient was placed on a moderate high back rest. He is awake, conscious and responsive to any stimuli. He is well groomed and was wearing a hospital gown, body and breath odor were not noted. He is ectomorph, with good posture. He is 65 years old, from Australia. Mouth Uniform pink in color, soft, moist, smooth in texture symmetry of contour and he was ability to purse his lips. 13 teeth were extracted- 7 upper teeth, 6 lower teeth. The color of the filling of his teeth is black. Anterior chest Scar was noted upon inspection, with a width of 2cm and a length of 21cm on the transverse scar and 3cm on the horizontal scar. The scar was due to his bypass operation. Extremities Upon inspection scar was noted at the left forearm with a length of 23cm due to his bypass. At his left leg a fresh scratch was noted.

D E F I N I T I O N O F

D I A G N O S I S

Coronary Artery Disease (CAD) is defined as a progressive atherosclerotic disorder of the coronary arteries in which a coronary luminal obstruction caused by plaque buildup of cholesterol, lipids and cellular debris infiltrating the intimal lining of the arterial wall, causing a reduced blood flow to the myocardium that resultsin narrowing or complete occlusion of the vessel lumen. It includes abnormal conditions such as arteriosclerosis and arteritis of the coronary arteries, all of which result in reduced flow of oxygen and nutrients to the Myocardium. The dominant effect of Coronary Artery Disease is the loss of oxygen and nutrients to myocardial tissue because of diminished coronary blood flow. This disease is near epidemic in the western world. It occurs more commonly in men than women, in whites and in middle-aged and elderly people. Yuan, s.(2006). Handbook of Diseases. Third edition. Lippincott williams and wilkins.pp.231-236. Coronary Artery Disease (CAD) is the most prevalent type of cardiovascular disease. It is an abnormal accumulation of lipid, or fatty, substances and fibrous tissuein the vessel wall. These blockage create blockages or narrow the vessel in a way thatreduces blood flow to the myocardium.studies indicate that atheroscleros involves a repetitious imflammatory response to artery wall injury and an alteration in the biophysical and biochemical properties of the arterial walls. Smeltzer, S., Bare, B. Brunner and Suddarths Textbook of Medical -Surgical Nursing. Vol. 1. 10th edition. Lippincott-Raven Publisher. Lippincott Williams and Wilkins. Coronary artery disease (CAD; also atherosclerotic heart disease) is the end result of the accumulation of atheromatous plaques within the walls of the coronary arteries that supply the myocardium (the muscle of the heart) with oxygen and nutrients. It is sometimes also called coronary heart disease (CHD), although CAD is the most common cause of CHD, it is not the only one. http://en.wikipedia.org/wiki/Coronary_artery_disease

Coronary artery disease (CAD) is the most common type of heart disease. It is the leading cause of death in the United States in both men and women.CAD 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, CAD can also weaken the heart muscle and contribute to heartfailure 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. http://www.nlm.nih.gov/medlineplus/coronaryarterydisease.html

Coronary artery disease is atherosclerosis of the coronary arteries, producing blockages in the vessels which nourish the heart itself. Atherosclerosis occurs when the arteries become clogged and narrowed, restricting blood flow. Without adequate blood flow from the coronary arteries, the heart becomes starved of oxygen and vital nutrients it needs to work properly. http://www.webmd.com/heart-disease/guide/heart-disease-coronary-artery-disease

P A N A T O M Y A N D H Y S I O L O G Y

The cardiovascular system provides the transport system hardware that keeps blood continuously circulating to fulfill this critical homeostatic need. Stripped of its romantic cloak, the heart is no more than the transport system pump; the hollow blood vessels are the delivery routes. Using blood as the transport medium, the heart continually propels oxygen, nutrients, wastes, and many other substances into the interconnecting blood vessels that service body cells. The blood vessels that carry blood to and from the lungs form the pulmonary circuit (pulmonos = lung), which serves gas exchange. The blood vessels that carry the functional blood supply to and from all body tissues constitute the systemic circuit.

The right side of the heart is the pulmonary circuit pump. Blood returning from the body is relatively oxygen-poor and carbon dioxiderich. It enters the right atrium and passes into the right ventricle, which pumps it to the lungs via the pulmonary trunk. In the lungs, the blood unloads carbon dioxide and picks up oxygen. The freshly oxygenated blood is carried by the pulmonary veins back to the left side of the heart. Notice how unique this circulation is. Typically, we think of veins as vessels that carry blood that is relatively oxygen-poor to the heart and arteries as transporters of oxygen-rich blood from the

heart to the rest of the body. Exactly the opposite condition exists in the pulmonary circuit. The left side of the heart is the systemic circuit pump. Freshly oxygenated blood leaving the lungs is returned to the left atrium and passes into the left ventricle, which pumps it into the aorta. From there the blood is transported via smaller systemic arteries to the body tissues, where gases and nutrients are exchanged across the capillary walls. Then the blood, once again loaded with carbon dioxide and depleted of oxygen, returns through the systemic veins to the right side of the heart, where it enters the right atrium through the superior and inferior venae cavae. This cycle repeats itself continuously. Although equal volumes of blood are pumped to the pulmonary and systemic circuits at any moment, the two ventricles have very unequal workloads. The pulmonary circuit, served by the right ventricle, is a short, low-pressure circulation, whereas the systemic circuit, associated with the left ventricle, takes a long pathway through the entire body and encounters about five times as much friction, or resistance to blood flow. This functional difference is revealed in the anatomy of the two ventricles. The walls of the left ventricle are three times as thick as those of the right ventricle, and its cavity is nearly circular. The right ventricular cavity is flattened into a crescent shape that partially encloses the left ventricle, much the way a hand might loosely grasp a clenched fist. Consequently, the left ventricle can generate much more pressure than the right and is a far more powerful pump. The three major types of blood vessels are arteries, capillaries, and veins. As the heart contracts, it forces blood into the large arteries leaving the ventricles. The blood then moves into successively smaller arteries, finally reaching their smallest branches, the arterioles, which feed into the capillary beds of body organs and tissues. Blood drains from the capillaries into venules , the smallest veins, and then on into larger and larger veins that merge to form the large veins that ultimately empty into the heart. Altogether, the blood vessels in the adult human stretch for about 100,000 km (60,000 miles) through the internal body landscape! Because arteries carry blood away from the heart, they are said to branch, diverge, or fork as they form smaller and smaller divisions. Veins, by contrast, carry

blood toward the heart and so are said to join, merge, and converge into the successively larger vessels approaching the heart. In the systemic circulation, arteries always carry oxygenated blood and veins always carry oxygen-poor blood. The opposite is true in the pulmonary circulation, where the arteries, still defined as the vessels leading away from the heart, carry oxygen-poor blood to the lungs, and the veins carry oxygen-rich blood from the lungs to the heart. The special umbilical vessels of a fetus also differ in the roles of veins and arteries.

Of all the blood vessels, only the capillaries have intimate contact with tissue cells and directly serve cellular needs. Exchanges between the blood and tissue cells occur primarily through the gossamer-thin capillary walls

Structure of Blood Vessel Walls

The walls of all blood vessels, except the very smallest, have three distinct layers, or tunics (coverings), that surround a central blood-containing space, the vessel lumen.

The innermost tunic is the tunica intima . This tunic contains the endothelium, the simple squamous epithelium that lines the lumen of all vessels. The endothelium is a continuation of the endocardial lining of the heart, and its flat cells fit closely together,

forming a slick surface that minimizes friction as blood moves through the lumen. In vessels larger than 1 mm in diameter, a subendothelial layer, consisting of a basement membrane and loose connective tissue, supports the endothelium.

The middle tunic, the tunica media, is mostly circularly arranged smooth muscle cells and sheets of elastin. The activity of the smooth muscle is regulated by sympathetic vasomotor nerve fibers of the autonomic nervous system and a whole battery of chemicals. Depending on the bodys needs at any given moment, either

vasoconstriction (reduction in lumen diameter as the smooth muscle contracts) or vasodilation (increase in lumen diameter as the smooth muscle relaxes) can be effected. Because small changes in vessel diameter greatly influence blood flow and blood pressure, the activities of the tunica media are critical in regulating circulatory dynamics. Generally, the tunica media is the bulkiest layer in arteries, which bear the chief responsibility for maintaining blood pressure and continuous blood circulation. The outermost layer of a blood vessel wall, the tunica externa is composed largely of loosely woven collagen fibers that protect and reinforce the vessel, and anchor it to surrounding structures. The tunica externa is infiltrated with nerve fibers, lymphatic vessels, and, in larger veins, a network of elastin fibers. In larger vessels, the tunica externa contains a system of tiny blood vessels, the vasa vasorum (vasah va-sorum) literally, vessels of the vessels that nourish the more external tissues of the blood directlyfrom blood in the lumen.

Hearts Anatomy (Size, Location, and Orientation)

The modest size and weight of the heart belie its incredible strength and endurance. About the size of a fist, the hollow, cone-shaped heart has a mass of between 250 and 350 gramsless than a pound. Snugly enclosed within the mediastinum , the medial cavity of the thorax, the heart extends obliquely for 12 to 14 cm (about 5 inches) from the second rib to the fifth intercostal space . As it rests on the superior surface of the diaphragm, the heart lies anterior to the vertebral column and posterior to the sternum. The lungs flank the heart laterally and partially obscure it. Approximately two-thirds of its mass lies to the left of the midsternal line; the balance projects to the right. Its broad, flat base, or posterior surface, is about 9 cm (3.5 in) wide and directed toward the right shoulder. Its apex points inferiorly toward the left hip. If you press your fingers between the fifth and sixth ribs just below the left nipple, you can easily feel your heart beating where the apex contacts the chest wall. Hence, this site is referred to as the point of maximal intensity (PMI).

The heart is enclosed in a double-walled sac called the pericardium .The loosely fitting superficial part of this sac is the fibrous pericardium. This tough, dense connective tissue layer (1) protects the heart, (2) anchors it to surrounding structures, and (3) prevents overfilling of the heart with blood.

Deep to the fibrous pericardium is the serous pericardium, a thin, slippery, two-layer serous membrane. Its parietal layer lines the internal surface of the fibrous pericardium. At the superior margin of the heart, the parietal layer attaches to the large arteries exiting the heart, and then turns inferiorly and continues over the external heart surface as the visceral layer, also called the epicardium (upon the heart), which is an integral part of the heart wall.

Between the parietal and visceral layers is the slitlike pericardial cavity, which contains a film of serous fluid. The serous membranes, lubricated by the fluid, glide smoothly past one another during heart activity, allowing the mobile heart to work in a relatively friction-free environment.

Chambers and Associated Great Vessels

The heart has four chambers two superior atria and two inferior ventricles. The internal partition that divides the heart longitudinally is called the interatrial septum where it separates the atria, and the interventricular septum where it separates the ventricles. The right ventricle forms most of the anterior surface of the heart. The left ventricle dominates the inferoposterior aspect of the heart and forms the heart apex. Two grooves visible on the heart surface indicate the boundaries of its four chambers and carry the blood vessels supplying the myocardium. The coronary sulcus, or atrioventricular groove, encircles the junction of the atria and ventricles like a crown (corona = crown). The anterior interventricular sulcus, cradling the anterior interventricular artery, marks the anterior position of the septum separating the right and left ventricles. It continues as the posterior interventricular sulcus, which provides a similar landmark on the hearts posteroinferior surface.

Atria: Except

The for

Receiving small, wrinkled,

Chambers protruding

appendages called auricles, which increase the atrial volume somewhat, the right and left atria are remarkably free of distinguishing surface features. Internally, the right atrium has two basic parts: a smooth-walled posterior part and an anterior portion in which the walls are ridged by bundles of muscle tissue. Because these bundles look like the teeth of a comb, these muscle bundles are called pectinate muscles (pectin = comb). The posterior and anterior regions of the right atrium are separated by a C-shaped ridge called the crista terminalis (terminal crest). In contrast, the left atrium is mostly smooth and undistinguished internally. The interatrial

septum bears a shallow depression, the fossa ovalis, that marks the spot where an opening, the foramen ovale, existed in the fetal heart .

Functionally, the atria are receiving chambers for blood returning to the heart from the circulation (atrium = entryway). Because they need contract only minimally to push blood downstairs into the ventricles, the atria are relatively small, thin -walled chambers. As a rule, they contribute little to the propulsive pumping activity of the heart. Blood enters the right atrium via three veins (1) The superior vena cava returns blood from body regions superior to the diaphragm; (2) the inferior vena cava returns blood from body areas below the diaphragm; and (3) the coronary sinus collects blood draining from the myocardium. Four pulmonary veins enter the left atrium, which makes up most of the hearts base. These veins, which transport blood from the lungs back to the heart, are best seen in a posterior view (Figure 18.4d).

Ventricles:

The

Discharging

Chambers

Together the ventricles make up most of the volume of the heart. As already mentioned, the right ventricle forms most of the hearts anterior surface and the left ventricle dominates its posteroinferior surface. Marking the internal walls of the ventricular chambers are irregular ridges of muscle called trabeculae carneae . Still other muscle bundles, the conelike papillary muscles, which play a role in valve function, project into the ventricular cavity.

The ventricles are the discharging chambers or actual pumps of the heart (the difference in function between atria and ventricles is reflected in the much more massive ventricular walls. When the ventricles contract, blood is propelled out of the heart into the circulation. The right ventricle pumps blood into the pulmonary trunk, which routes the blood to the lungs where gas exchange occurs. The left ventricle ejects blood into the aorta, the largest artery in the body.

Coronary

Circulation

Although the heart is more or less continuously filled with blood, this blood provides little nourishment to heart tissue. (The myocardium is too thick to make diffusion a practical means of nutrient delivery.) The coronary circulation, the functional blood supply of the heart, is the shortest circulation in the body. The arterial supply of the coronary circulation is provided by the right and left coronary arteries, both arising from the base of the aorta and encircling the heart in the coronary sulcus (Figure 18.7a). The left coronary artery runs toward the left side of the heart and then divides into its major branches: the anterior interventricular artery (also known clinically as the left anterior follows descending the anterior artery), which

interventricular

sulcus and supplies blood to the interventricular septum and anterior walls of both ventricles; and the

circumflex artery, which supplies the left atrium and the posterior walls of the left ventricle

The right coronary artery courses to the right side of the heart, where it also divides into two branches: the marginal artery, which serves the myocardium of the lateral right side of the heart, and the posterior interventricular artery, which runs to the heart apex and supplies the posterior ventricular walls. Near the apex of the heart, this artery merges (anastomoses) with the anterior interventricular artery. Together the branches of the right coronary artery supply the right atrium and nearly all the right ventricle. The arterial supply of the heart varies considerably. For example, in 15% of people, the left coronary artery gives rise to both the anterior and posterior interventricular arteries; in about 4% of people, a single coronary artery supplies the whole heart. Additionally, there may be both right and left marginal arteries. There are many anastomoses among the coronary arterial branches. These fusing networks provide additional (collateral) routes for blood delivery to the heart muscle, but are not robust enough to supply adequate nutrition when a coronary artery is suddenly occluded. Complete blockage leads to tissue death and heart attack.

The coronary arteries provide an intermittent, pulsating blood flow to the myocardium. These vessels and their main branches lie in the epicardium and send branches inward to nourish the myocardium. They deliver blood when the heart is relaxed, but are fairly ineffective when the ventricles are contracting because they are compressed by the contracting myocardium. Although the heart represents only about 1/200 of the bodys

weight, it requires about 1/20 of the bodys blood supply. As might be expected, the left ventricle receives the most plentiful blood supply.

After passing through the capillary beds of the myocardium, the venous blood is collected by the cardiac veins, whose paths roughly follow those of the coronary arteries. These veins join together to form an enlarged vessel called the coronary sinus, which empties the blood into the right atrium. The coronary sinus is obvious on the posterior aspect of the heart (Figure 18.7b). The sinus has three large tributaries: the great cardiac vein in the anterior interventricular sulcus; the middle cardiac vein in the posterior interventricular sulcus; and the small cardiac vein, running along the hearts right inferior margin. Additionally, several anterior cardiac veins empty directly into the right atrium anteriorly.

Heart Valves

Blood flows through the heart in one direction: from atria to ventricles and out the great arteries leaving the superior aspect of the heart. This one-way traffic is enforced by four valves (Figures 18.4e and 18.8) that open and close in response to differences in blood pressure on their two sides.

Atrioventricular Valves
The two atrioventricular (AV) valves, one located at each atrial-ventricular junction, prevent backflow into the atria when the ventricles are contracting. The right AV valve, the tricuspid valve, has three flexible cusps (flaps of endocardium reinforced by connective tissue cores). The left AV valve, with two flaps, is called the mitral valve because of its resemblance to the two-sided bishops miter or hat. It is sometimes called the bicuspid valve. Attached to each AV valve flap are tiny white collagen cords called chordae tendineae, heart strings which anchor the cusps to the papillary muscles protruding from the ventricular walls.

When the heart is completely relaxed, the AV valve flaps hang limply into the ventricular chambers below and blood flows into the atria and then through the open AV valves into the ventricles. When the ventricles contract, compressing the blood in their chambers, the intraventricular pressure rises, forcing the blood superiorly against the valve flaps. As a result, the flap edges meet, closing the valve. The chordae tendineae and the papillary muscles serve as guy-wires to anchor the valve flaps in their closed position. If the cusps were not anchored in this manner, they would be blown upward into the atria, in the same way an umbrella is blown inside out by a gusty wind. The papillary muscles contract before the other ventricular musculature so that they take up the slack on the chordae tendineae before the full force of ventricular contraction hurls the blood against the AV valve flaps.

Semilunar Valves
The aortic and pulmonary (semilunar, SL) valves guard the bases of the large arteries issuing from the ventricles (aorta and pulmonary trunk, respectively) and prevent backflow into the associated ventricles. Each SL valve is fashioned from three pocketlike cusps, each shaped roughly like a crescent moon (semilunar = half-moon). Like the AV valves, the SL valves open and close in response to differences in

pressure. In the SL case, when the ventricles are contracting and intraventricular pressure rises above the pressure in the aorta and pulmonary trunk, the SL valves are forced open and their cusps flatten against the arterial walls as the blood rushes past them. When the ventricles relax, and the blood (no longer propelled forward by the pressure of ventricular contraction) flows backward toward the heart, it fills the cusps and closes the valves.

P A T H O L O G Y A N D

P H Y S I O L O G Y

M M E D I C A L A N A G E M E N T

MEDICAL ORDER
DATE AND TIME DOCTORS ORDER RATIONALE

August 8, 2011 9:30pm

Admit patient under the service of Dr. Aquillas

Admission to preferred specialist is necessary in order to give special attention to the needs of the client in terms of health improvement

BP=80-100/60 HR=120 RR=21 Hgt= 327 mg/dl

VS q 4, BP monitoring q hourly until stable

Vital signs are the baseline data that a nurse collects during assessment. Any abnormalities in the results may indicate problems in the patient

Labs: -CBC

The complete blood count is the calculation of the cellular (formed elements) calculations of blood. are These generally

determined by specially designed machines that analyze the different components of blood in less than a minute.

-serum uric acid

The uric acid test is used to measure serum uric acid levels, the major end metabolite of purine. Disorders of purine metabolism, rapid destruction of nucleic acids, and conditions marked by impaired renal excretion characteristically

raise serum uric acid levels.

Measuring serum creatinine is a -S. Creatinine useful and inexpensive method of evaluating renal dysfunction.

Creatinine is a non-protein waste product of creatine phosphate

metabolism by skeletal muscle tissue. Creatinine production is continuous and is proportional to muscle mass.

-HBA1C

HbA1c is a test that measures the amount of glycated hemoglobin in the blood.

-S.Amylase

A test can be done to measure the level of this enzyme in the blood. Amylase is an enzyme that helps digest carbohydrates. It is produced in the pancreas and the glands that make saliva. When the pancreas is diseased or inflamed, amylase releases into the blood. It is the immediate measurement of blood for glucose using blood sample from a fingerstick or heelstick.

-Hgt-now

-TROP I

The troponin test measures the

levels of one of two proteins, troponin T or troponin I, in a blood sample. These proteins are released when the heart muscle has been damaged, such as during a heart attack. The more damage there is to the heart, the greater the amount of troponin T and I there will be in the blood. A fasting blood sugar (FBS) level is one of the tests used to diagnose diabetes mellitus (another being the oral glucose tolerance test).

-FBS

Lipid Profileis a group of tests that -S. lipid profile are often ordered together to

determine risk of coronary heart disease. The tests that make up a lipid profile are tests that have been shown to be good indicators of whether someone is likely to have a heart attack or stroke caused vessels arteries"). by blockage of of blood the

("hardening

An alanine aminotransferase (ALT)

-SGPT (ALT)

test measures the amount of this enzyme in the blood. ALT is found

mainly in the liver, but also in smaller amounts in the kidneys, heart, muscles, and pancreas

An abdominal X-ray is a picture of

-Xray abdominal upright and

structures and organs in the belly (abdomen). This includes the stomach, liver, spleen, large and small intestines, and the diaphragm, which is the muscle that separates the chest and belly areas. Often two X-rays will be taken from different positions. If the test is being done to look for certain problems of the kidneys or bladder, it is often called a KUB (for kidneys, ureters, and bladder). Spinal X-rays are pictures of the spine. They may be taken to find injuries or diseases that affect the discs or joints in your spine. These problems may include spinal fractures, infections, dislocations, tumors, bone spurs, or disc disease. Spinal X-rays are also done to check the curve of your spine (scoliosis) or for spinal defects.

spine (plain)

-USD of whole abdomen

Abdominal ultrasound imaging is performed to evaluate the kidneys, liver, gallbladder, pancreas, spleen, abdominal aorta and other blood vessels of the abdomen. Ultrasound may be used to provide guidance for biopsies.

include prostate in AM

Chest x rays are ordered for a -chest xray PA view wide variety of diagnostic

purposes. In fact, this is probably the most frequently performed type of x ray. In some cases, chest x rays are ordered for a single check of an organ's condition, and at other times, serial x rays are ordered to compare to previous studies.

The chest x-ray film is important in a complete evaluation of the pulmonary and cardiac sysytem. -for UGI series after xray of abdomen is viewed. An upper gastrointestinal (UGI) series looks at the upper and middle sections of the gastrointestinal tract . The test uses barium contrast material,

fluoroscopy, and X-ray. It is to detect ulcers, tumors, inflammation, or anatomic malposition.

-start venoclysis with PNSS 1L fast drip 300cc now then 120cc/hr

Meds: 1.) Pantoprazole 40mg now then OD

Pantoprazole is a gastric acidpump inhibitor that suppresses gastric secretion; blocks the final step of acid production

2.) Humulin R 6 units SQ now

Humulin R helps in lowering the blood glucose level of the patient since his blood sugar leer is aboe normal

3.) Metformin 1000 mg/ 1tab OD @HS

It is a drug for diabetic patients, it also lowers the blood glucose level in the body

-HGT q 6 and relay results

This is to monitor the blood glucose level of the patient

-refer for persistent of epigastric pain, vomiting and

To further assess the needs of the patient

any unusualities

-O2 inhalation @2L/min nasal cannula August 9,2011 2:05pm HGT 326mg/dl -11units RI SQ now then start -insulin slide scale as ff; CXR normal (+)slight pallor (+)irritabilityrefined physical examination (+) direct tenderness in all quadrants Dry lips and tongue -hold Metformin -UA (micc) HGT (<140mg/dl) no RI 141-160 mg/dl- 4 units 161-180mg/dl-6 units 181-200mg/dl-8 units 201-300mg/dl-10 units 301-400mg/dl-12 units >400mgdl-refer

Rendering an O2 inhalation helps the patient during his respiration If the patient has a high level of glucose in the blood, he would be given an regular insulin. Sliding scale serves as a guide on giving appropriate insulin base on the level of glucose in the blood.

Urinalysis is used as a screening and/or diagnostic tool because it can help detect substances or cellular material in the urine

associated with different metabolic and kidney disorders. It is ordered widely and routinely to detect any abnormalities that require follow up.

ketones urine test measures the -urine ketones presence or absence of ketones in the urine.

Hemoglobin is a protein in red -HBG(routine) blood cells that transports oxygen throughout the body. A hemoglobin test is used to determine how much hemoglobin is in the blood.

The blood test for lipase is ordered, often along with an -include serum lipase in next blood extraction amylase test, to help diagnose and monitor acutepancreatitis, chronic pancreatitis, and other disorders that involve the pancreas .

-hold FBS please HBA1c instead

-start MgSO4 drop 250cc -D5W + 2g MgSO4 to run in 24 hours -NPO except meds Decrease in urine output may indicate problem in the kidneys -increase IVF for 180cc/hr x 40 then for reassessment -120 q shift refer for UA <30cc/hr
August 9,2011 8:00am

To prevent dehydration

-hold USD -H.pylori Helicobacter pylori (H. pylori) is a

(+) smoke (23paks/day)

bacterium that may reside in the gastrointestinal tract. It is known to be a major cause of peptic ulcers and is a potential contributor to the development of stomach cancer.

9:00 am

-for UGI series with follow through -if S. creatinine is normal and UGIS is normal, plan to do CT Scan of whole abdomen To determine other problems of the patient in order to assess him thoroughly

9:55am

-endocrine rounds

To assess the other problems in endocrine system of the patient which needed an immediate medical management

-follow up HBA1c and serum creatinine -proceed humulin R every 6 hours

To determine the status of the patient

It will help lowering the glucose level in the blood as soon as possible

9:00am

For 2D echo

echocardiogram (echo) is a graphic outline of the heart's movement. During an echo test, ultrasound (high-frequency sound waves) from a hand-held wand placed on your chest provides pictures of the heart's valves and chambers and helps the sonographer evaluate the pumping action of the heart.

-aspirin 100mg/ tab, OD p.c

11:10am

-refer all CBG result -refer HBA1c and S.creatine once in

To further assess the needs of the patient.

Mg 0.41 decrease

-give MgSO4 500mg IVTT q 6 x To increase the Magnesium level 4 doses -repeat S.magnesium after 4th dose of MgSO4 of the patient

To determine if there is increase in magnesium level of the patient after administering the MgSO4 drugs

1:30pm Ongoing UGIS (+) abdominal pain BP= 120/70 2:00pm Decrease abdomi nal pain

-hold MgSO4 IV bolus already on MgSO4 drip -relay lab results once in -maintain IVF @140cc/hr -continue meds -soft diet A normal diet limited to soft, easily digestible foods. A computed tomography (CT) scan is an imaging method that uses xrays to create cross-sectional pictures of the body. Used to detect tumors, cysts and abscesses, dilated bile ducts, pancreatic inflammation and some gallstones. Also, identifies changes in intestinal wall. To prevent dehydration

-CT Scan forum

August 11,2011 7:15 am BP=120/70 HR=94 RR=20 (-) chest pain (-) dyspnea (+) epigastric pain Comfortable out in awhile ECE <BT> August 11, 2011 2:40pm

Possible discharge today: RX management Home meds -amene 25mg 1 tab OD

Advised: Lifestyle modification Strictly no smoking No strenuous activity

Promoting good lifestyle to the patient will help for fast recovery

May go home Home meds: 1.) Concore 2.0g/ tab 1tab OD 2.) Zocar 40mg/tab 1 tab OD 3.) Minidia l 10g/ 1tab 1 tab 4.) Pantoloc 40g 1tab OD It is important to continue taking the medicine even if the patient is already discharged from the hospital. The treatment should continue even if after the admission.

-Follow up after 2 weeks -for barium enema as OPD

DIAGNOSTICS
DATE COMPONENT RATIONALE RESULT INTERPRETATION/ SIGNIFICANCE A u g u s t Normal result: absence of 9, 2 0 1 1 Small: < 20 mg/dL Moderate: 30 - 40 mg/dL Large: > 80 mg/dL But if present; ketones Urine Examination desired : Ketones A ketones urine test measures the presence or absence of ketones in the urine. Ketonuria is a complication of diabetes mellitus which is one of the disease of the our patient 15mg/dl Small presence of ketones

NURSIN

RESPO Before:

1.) E During:

2.) Colle

specime

3.) Instr

collect a

catch ur

4.) Instr

hands a

collectio After:

5.) Tran

specime

promptl

DATE A U G U S T 9, 2 0 1 1

COMPONENT RATIONALE Urine Examination desired: H.Pylori This test is used to diagnose infection due to Helicobacter pylori.

RESULT positive

INTERPRETATION/ SIGNIFICANCE A positive test for H. pylori indicates that the gastrointestinal pain may be caused by due to a peptic ulcer this bacterium.

NURSING RESPONSIBILITIES Before: 1.) Explain the procedure During: 2.) Collect a fresh urine

The patient has a acute gastrointestinal and the causative agent is the H.Pylori

specimen in a urine container 3.) Instruct the patient to collect a mid stream clean catch urine specimen. 4.) instruct to wash his hands after the urine sample collection After: 5.) Transport the urine specimen to the laboratory promptly.

DATE A U G U S T 9, 2 0 1 1

COMPONENT RATIONALE Fluid serum The blood test for Test: lipase lipase is ordered, Normal values: 23-300 often along with U/L an amylase test, to help diagnose and monitor acutepancreatitis, chronic pancreatitis, and other disorders that involve the pancreas.

RESULT 283 U/L

INTERPRETATION/SIGNIFICANCE Normal

NURSING RESPONSIBILITIES 1.) Explain the procedure to the patient 2.) Inform patient that the test requires blood sample taken with the use of the syringe 3.) Inform the patient that the specimen collection takes approximately 5-10 minutes 4.) Ensure that the blood is not taken from the hand or arm that has intravenous line. Hemodilution with intravenous fluids causes a false

decrease in the values of some test 5.) Instruct the patient to continue compression of the puncture site for 2 to 5 minutes or until bleeding stops

DATE A U G U S T 8, 2 0 1 1

COMPONENT RATIONALE Specimen: blood Examination: TROP I Normal value: <0.11 ug/L The troponin test measures the levels of one of two proteins, troponin T or troponin I, in a blood sample. These proteins

RESULT <0.01 ug/L

INTERPRETATION/SIGNIFICANCE normal

NURSING RESPONSIBILITIES 1.) Explain the procedure to the patient 2.) Inform patient that the test requires blood sample taken with the use of the syringe

are released when the heart muscle has been damaged, such as during a heart attack. The more damage there is to the heart, the greater the amount of troponin T and I there will be in the blood.

3.) Inform the patient that the specimen collection takes approximately 5-10 minutes 4.) Ensure that the blood is not taken from the hand or arm that has intravenous line. Hemodilution with intravenous fluids causes a false decrease in the values of some test 5.) Instruct the patient to continue compression of the puncture site for 2 to 5 minutes or until bleeding stops

DATE A U G U S T 8, 2 0 1 1

COMPONENT RATIONALE Creatinine Normal values: 53.0115.o umol/L The creatinine blood test is used along with a BUN (blood urea nitrogen) test to assess kidney function

RESULT 95.6 umol/ L

INTERPRETATION/SIGNIFICANCE Normal

NURSING RESPONSIBILITIES PRETEST: 1.) Identify the patient 2.) Explain the purpose for the laboratory and diagnostic test to the patient 3.) Inform patient that the test requires blood sample taken

Amylase

Amylase is an

81 U/L

Normal

with the use of the syringe 4.) Inform the patient that the specimen collection takes approximately 5-10 minutes 5.) Check vital signs of the patient 6.) Inform the patient

enzymethat Normal values: 25-115 helps digest U/L carbohydrates. It is produced in the pancreas and the glands that make saliva. When the pancreas is diseased or

inflamed, amylase releases into the blood. A test can be done to measure the level of this enzyme in the blood.

who will perform the venipuncture and when and note that transient discomfort may be felt from the needle puncture and pressure of the tourniquet 7.) The patient maybe seated or in the supine position. The patients arm is in

Sodium Normal values: 136mmol/L

The sodium urine test measures the amount of salt (sodium) in a urine sample

extension. 137.2 mmol/L Normal DURING THE TEST: 8.) Ensure that the blood is not taken from the hand or arm that has intravenous line. Hemodilution with

Potassium Normal

This test measures the

intravenous fluids 4.21mmol/L causes a false

values: 3.55.5mmol/L

amount of potassium in the blood.

normal

decrease in the values of some test 9.) Inspect the antecubital fossae

A blood calcium Calcium Normal values: 2.122.52mmol/L test is ordered to screen for, diagnose, and monitor a range of conditions relating to the bones, heart, nerves, kidneys, and teeth. 2.11 mmol/L normal

of both arms to select the best vein for the venipuncture 10.) Ask the

patient to open and close hand a few times to help make the veins more visible POSTTEST: 11.) Instruct the

patient to continue compression of the puncture site for 2 to 5 minutes or until bleeding stops 12.) Assess the

patients arm to ensure that subdermal bleeding has ceased. 13.) If a

hematoma develops at the site, apply warm compress

COMPONENT Magnesium Normal values: 0.74-0.99 mmol/L

RATIONALE A magnesium test is used to measure the level of magnesium in the blood

RESULTS 8/8/11 0.41mmol/L

INTERPRETATION/ SIGNIFICANCE Low Magnesium can be excreted in the body due to the presence of gastrointestinal disorders and also diarrhea. Before the patient was admitted he experienced diarrhea and one of the electrolytes that has been excreted was magnesium.

NURSING RESPONSIBILITY PRETEST: 1.) Identify the patient 2.) Explain the purpose for the laboratory and diagnostic test to the patient 3.) Inform patient that the test requires blood sample taken with the use of the syringe

8/10/11 0.8mmol/L

4.) Inform the patient normal that the specimen collection takes approximately 5-10 minutes 5.) Check vital signs of the patient 6.) Inform the patient who will perform the venipuncture and

when and note that transient discomfort may be felt from the needle puncture and pressure of the tourniquet 7.) The patient maybe seated or in the supine position. The patients arm is in extension. DURING THE TEST: 8.) Ensure that the blood is not taken from the hand or arm that has intravenous line. Hemodilution with intravenous fluids causes a false decrease in the values of some test

9.) Inspect the antecubital fossae of both arms to select the best vein for the venipuncture 10.) Ask the

patient to open and close hand a few times to help make the veins more visible POSTTEST: 11.) Instruct the

patient to continue compression of the puncture site for 2 to 5 minutes or until bleeding stops 12.) Assess the patients arm to ensure that

subdermal bleeding has ceased. 13.) If a

hematoma develops at the site, apply warm compress

DATE A U G U S T 2, 2 0 1 1

COMPONENT

RATIONALE

RESULT 69.9 umol/L

Creatinine The creatinine Normal values: blood test is 53.0- 115.0umol/L used along with a BUN (blood urea nitrogen) test to assess kidney function

INTERPRETATION/ SIGNIFICANCE Normal

NURSING RESPONSIBILITIES PRETEST: 1.) Identify the patient 2.) Explain the purpose for the laboratory and diagnostic test to the patient 3.) Inform patient that

ALT (Alanine 39 An alanine aminotransferase) aminotransferase Normal values: 30-65 U/L (ALT) test

Normal

the test requires blood sample taken with the use of the

measures the amount of this enzyme in the blood. ALT is found mainly in the liver, but also in smaller amounts in the kidneys, heart, muscles, and pancreas. ALT was formerly called serum glutamic pyruvic transaminase (SGPT).

syringe 4.) Inform the patient that the specimen collection takes approximately 5-10 minutes 5.) The patient maybe seated or in the supine position. The patients arm is in extension. DURING THE TEST: 6.) Ask the patient to open and close hand a few times to help make the veins more visible 7.) Cleanse the skin with 70% alcohol, and allow it to airdry POSTTEST:

8.) Instruct the patient to continue compression of the puncture site for 2 to 5 minutes or until bleeding stops 9.) Assess the patients arm to ensure that subdermal bleeding has ceased. 10.) If a

hematoma develops at the site, apply warm compress

DATE A U G U S T 8, 2 0 1 1

COMPONENT Hemoglobin

RATIONALE To measure the oxygen carrying

RESULT

123 g/L

Normal values: Male:140-180g/L Female: 120-160 g/dL

capacity of the blood

INTERPRETATION/SIGNIFICANCE NURSING RESPONSIBILITY Low PRETEST: A Low hemoglobin level indicates 1.) Identify the patient anemia. 2.) Explain the purpose for the laboratory and

To detect the severity anemia of

diagnostic test to the patient 3.) Inform patient that the test requires

Transport oxygen bound to hemoglobin molecules; also transport amount carbon dioxide small of

blood sample taken with the use of the syringe 4.) Inform the patient that the specimen collection takes approximately 510 minutes 5.) The patient maybe

Erythrocytes (RBC) male: 4.-5.0

To measure the amount of RBCs in the blood and Low 3.5410^12/L It is associated with anemia.

seated or in the supine position. The patients arm

10^12/L

aid in the diagnosis and classification of anemia, polycythemia or dehydration. To determine needs for further test such as WBC differential and bone marrow biopsy. To monitor response to chemotherapy and radiation therapy. Assist in determining the cause of an elevated WBC

is in extension. DURING THE TEST: 6.) Ask the patient to open and close hand a few times to help make the veins more visible 7.) Cleanse the skin with 70% alcohol, and allow it to airdry POSTTEST: 8.) Instruct the patient to continue compression of the puncture site for 2 to 5 minutes or until bleeding stops 9.) Assess the patients arm to ensure that

Hemoglobin Male: 140-180

A test used to determine the amount of hemoglobin in the blood. Hgb is the pigment part of the erythrocyte, and the oxygencarrying part of the blood. 123 Low It indicates anemia.

subdermal bleeding has ceased. 10.) If a

hematoma develops at the site, apply warm compress

MCH ( Mean Corpuscular Hemoglobin) Normal value: 27.0-33.0 pg)

It measures the weight of hemoglobin in each cell 34.7 High It is associated with macrocytic anemia.

MCV (Mean Corpuscular Volume) Normal value: 80-

It indicates the relative size of Red Blood Cells 106.1 fl

High It is associated with macrocytic anemia.

96 fl

MCHC (Mean Corpuscular Hemoglobin Concentration) Normal value: 510.0 g/dl

Concentration of hemoglobin in the average Red Blood Cell 32.7 g/dl Normal

Leukocytes Normal value: 510 10^g/L

To assess presence of inflammation and infection.

8.4 10^g/dl Normal

Neutrophils Normal value: 0.55-0.65 10^g/dl

It responds to tissue damage or infection

0.77 10^g/dl High It is high because our patient has infection

Lymphocytes Normal value:

Lymphocytes are a type of 0.11 % Low

0.25-0.40 %

white blood cells present in a vertebrate's immune system, and responsible for protecting the body against the damage caused by bacterial and viral infections.

A low lymphocyte count indicates that the body's resistance to fight infection has been substantially lost and one may become more susceptible to certain types of infection

Monocytes Normal value: 0.02-0.06 % To determine whether there is allergy or parasitic infections 0.10 % High There is presence of infection in our patient

Eosinophils Normal value: 0.01-0.05 % 0.01 % Normal

Basophils

It contains large

Normal value: 0.000-0.005 %

amount of histamine. It helps body resist systemic allergic reactions and anaphylactic states.

0.01 %

High Due to presence of infection, the patients body releases antihistamine to fight the antigens.

Hematocrit Normal value: Male: 0.40-0.48 % It measures percentage by volume of packed red blood cells in a whole blood sample. 0.38 % Low Since the patient is anemic, his body contains low level of red blood cells and hematocrit also is low

Thrombocytes Normal value: It is necessary normal

150-300 10^g/dl

for blood clotting

163 10^g/dl

DATE A U G U S T 10, 2 0 1 1

COMPONENT Color Normal: Brown

RATIONALE The normal color of the feces is brown.

RESULT Dark Brown

INTERPRETATION/SIGNIFICANCE NURSING RESPONSIBILITY Normal 1.) Tell patient to urinate first to prevent any urine from mixing with his feces later on.

Consistency Normal: soft, well-formed

Well-formed Normal

2.) Provide proper containers 3.) Instruct patient that he must also

Parasite/ ova Normal: negative/ no parasite found

No ova/ parasite seen

Normal

wear gloves when it's time to handle stool and transfer it to a safer container 4.) Instruct to wash the perineal area after transferring the specimen

5.) Instruct patient to wash hands after the collection of the specimen 6.) Instruct patient that the collected samples must be brought to the laboratory as soon as possible

Echocardiography (ECG) Also known as a cardiac ultrasound, it uses standard ultrasound techniques to image twodimensional slices of the heart. Echocardiography is used to diagnose cardiovascular diseases. It can provide a wealth of helpful information, including the size and shape of the heart, its pumping capacity and the location and extent of any damage to its tissues. It is especially useful for assessing diseases of the heart valves. Echocardiography also helps determine whether any chest pain or associated symptoms are related to heart disease. ECHOCARDIOGRAPHIC AND VASCULAR LABORATORY Echocardiography Result Left ventricle Lvsd LVEDd Pwd LVESd PWc IVSs 12 38 12 25 13 15 LV function LVEDV LVESV SV EF LV Mass HR CO (92-125ml) Result A0 33mm LA 37 MPA 25 normal value 30-35mm 30-35mm

EPSS Right ventricle RVEDD 27 RA 29 Doppler spectral data Valves Mitral Aorta Tricuspid Pulmonary PAT Findings: -concentric left ventricular hypertrophy with hypokinesia of lateral posterior left ventricular tree wall from mid to apex with doppler evidence of relaxation abnormalities. Ejection fraction is 64%. 135msec maximum velocity (m/sec) 0.6/0.68 0.76 0.49/0.57 0.73 gradients 1.86/0.57 2.3 1.09/0.34 2.12

-normal right ventricular dimension with adequate wall motion and contractility. -normal left and right atrial dimensions -thickened mitral and aortic valve leaftlets without restriction of motion, aortic annular calcification -thickened tricuspid and pulmonic valve leaflets with good opening and closing motion. -normal main pulmonary artery and aortic root dimensions. -Doppler: Reversed E/A ratio note: there are frequent ectopic beats during the study

Nursing Responsibility: 1.) Instruct patient to remove all clothing and jewelry in the area to be examined. 2.) Instruct patient wear a gown during the procedure 3.) instruct patient not to eat or drink for as many as six hours before the procedure

Urinalysis- is the microscopic, physical and chemical examination of urine. There are a number of tests that are conducted under this to help in the detection and the measurement of a number of compounds that are passed through the urine

Component WBC Reference range: 0-11/UL

Rationale To detect if there is presence of infection

Results 8/2/11 38 8/9/11 77

Interpretation/significance Nursing responsibility High This is due to presence of infection in the patient Before: 1.) Explain the procedure During: 2.) Collect a fresh urine specimen in a urine container 3.) Instruct the patient to collect a mid stream clean

12 RBC Reference range: 0-11/UL To determine the level of red blood cells present in urine. This also may indicate infection

34 High Due to the presence of infection.

catch urine specimen. After: 4.) Transport the urine specimen to the laboratory promptly.

Epith.cells Reference range: 0-11/UL

cells that line your hollow organs and form the skin in the urine, the presence of epith.cells may indicatea sign of a

15

22

High This may indicate another serious disease

tumor.

Cast Reference range: 0-1U/L Cast is a tube-shaped protein. The test is done to determine for the presence of protein the urine

12

High It indicates the presence of high protein in the urine

Bacteria 5 Reference range: 0-111 To determine the number of bacteria in the urine 16 Normal

Clarity: clear to faintly hazy

Slightly cloudy

Slightly cloudy

The urine may be cloudy due to the presence of infection

Color: Clear straw colored liquiddark yellow

Yellow

Dark yellow

Normal

Reaction: 6.0 4.5-8.0 To measure the alkalinity or acidity of the urine Specific gravity 1.015-1.030 To determine how concentrated or dilute is the urine. 1.025 1.030 Normal 6.0 Normal

Glucose (negative) To measure the amount of glucose in the urine sample +++ (-)

(+++) glucose Glycosuria is also present to those patient having Diabetes Mellitus. Our patient is diabetic and so presence of glucose in the urine can be seen.

Positive Protein Proteinuria is the (negative) To determine if there is problem in the kidneys or in the bladder ++ + presence of protein the urine. One of the most common causes of

proteinuria is diabetes. since our patient is diabetic it is expected that there will be presence of protein in the urine.

Test

Rationale

Results 8/9/11 8/10/11

Interpretation/significance Nursing responsibility High Since the patient is 1.) Explain the procedure to the patient 2.) Instruct the patient not to eat 2 hours prior the test 3.) If the patient

Hemoglucose To determine test Normal value: 80120mg/dl the level of glucose in the blood

5am 326 10 u RI given

11am 5pm 129 191 8 u RI SQ given

5am 3pm 5am diabetic it is expected that he has high level of 148 135 138 glucose in the blood

Abdomen plain and upright (Upper Gastrointestinal Series)- An upper gastrointestinal (UGI) series looks at the upper and middle sections of the gastrointestinal tract. The test uses barium contrast material, fluoroscopy, and X-ray. Before the test, patient will drink a mix of barium (barium contrast material) and water. The barium is often combined with gas-making crystals. The doctor watches the movement of the barium through your esophagus, stomach, and the first part of the small intestine (duodenum) on a video screen. Several X-ray pictures are taken at different times and from different views.

An upper gastrointestinal (UGI) series is done to:

Find the cause of gastrointestinal symptoms, such as difficulty swallowing, vomiting, burping up food, belly pain (including a burning or gnawing pain in the center of the stomach), or indigestion. These may be caused by conditions such as hiatal hernia.

Find narrow spots (strictures) in the upper intestinal tract, ulcers, tumors, polyps, or pyloric stenosis. Find inflamed areas of the intestine, malabsorption syndrome, or problems with the squeezing motion that moves food through the intestines (motility disorders).

Find swallowed objects.

Result: August 8,2011 No differential air fluid levels and evidence of pneumoperitoneum noted in the upright film The bowel gas pattern is unremarkable No abnormal calcifications demonstrated

Mottled fecaloid densities are noted in the colonic segments Rectal gas demonstrated Sternotomy wires are noted in the visualized lower chest The rest of the included structures are unremarkable Impression: (-) Abdominal study Date: August 9, 2011 Result: Preliminary film shows an unremarkable bowel gas pattern. Small bony spurs are seen along the lateral margins of the lumbar spine. Single sternotomy wire is seen in place. The rest of the included soft tissue shadows and osseus structures appear normal Contrast study shows free flow of contrast medium through a normal esophagus. The stomach has regular rugal folds with pliable walls. No ulcer niche, filling defects nor deformity seen. The duodenal bulb forms well. The C-loop and the rest of the small intestine are unremarkable. Transit time is normal. Impression: normal upper gastrointestinal series with follow through degenerative spurs, lumbar spine Nursing Responsibilities:

Ask the patient if allergic to any medicines, barium, or any other X-ray contrast material. Tell the patient to eat a low-fiber diet for 2 or 3 days before the test. Tell the patient to stop eating for 12 hours before the test

Tell the patient to take a laxative to help clean out your intestines Tell patient to sign a consent form

DATE

TEST

RATIONALE

RESULT

INTERPRETATION/SIGNIFICANCE NURSING RESPONSIBILITY

A U G U S T

Chest PA

A chest film is -study commonly

done

in There will be a critical deficit in the Before: blood supply to and of to the the heart in for 1.) Explain the procedure to the patient. 2.) Tell the patient that no fasting is required 3.) Instruct the patient to remove clothing During the test 4.) Ensure the patients safety at all times, particularly when there is a risk of patient falling. The radiography table has no side rails. A Velcro

used Anteroposterior

for x-ray study. It projection can be done in -lung fields are clear the radiology -heart is not enlarged and -aortic knob

proportion oxygen

demands

nutrients.

Rapid

progression

atherosclerotic

department

is lesions may cause ischemia and may result in the development of and acute coronary syndromes of

also in a patients calcified 8, room depending -diaphragm

on the machine castrophenicsulci are unstable angina, MI, and sudden 2 0 1 1 being used. It is intact used to determine -sternotomy lung wires death.

ventilation; and surgical clips are

heart position and seen in the midline size; patterns chronic vascular -the rest of the

in included

structures

are unremarkable

respiratory disease; and the Impression: presence Atelectasis, Hydrothorax, Pneumothorax, Infection, TB, lung tumors, infiltrates. and of Athersclerotic aorta

waist restraint may be used, but sometimes the restraint interferes with the positioning and imaging needed. 5.) Position the patient for the specific views needed. Instruct the patient to remain motionless during the imaging. Sometimes the patient is instructed to inhale deeply and hold the breath until the image is taken. 6.) The patient must often wait in the imaging area as the decisions made concerning whether to take additional films. Provide a blanket or extra gown for the patient who is chilled in the cool room.

Post test 7.) Assist the patient in dismounting from the radiography table and getting dressed as needed.

August 3,2011 Ultrasound of whole abdomenUltrasound imaging, also called ultrasound scanning or sonography, involves exposing

part of the body to high-frequency sound waves to produce pictures of the inside of the body. Ultrasound exams do not use ionizing radiation (as used in x-rays). Because ultrasound images are captured in real-time, they can show the structure and movement of the body's internal organs, as well as blood flowing through blood vessels. Ultrasound imaging is a noninvasive medical test that helps physicians diagnose and treat medical conditions. An abdominal ultrasound produces a picture of the organs and other structures in the upper abdomen.

Result: The liver shows moderate diffuse increase in parenchymal echopattern with slight visualization of intrahepatic vessel borders and diaphragm. External outline is smooth. No focal lesions. There are no dilated intrahepatic biliary ducks and vessels. The gallbladder is adequately distended with non-thickened walls. No intraluminal echoes seen. The widest anteroposterior diameter of the common duct measures 2.6mm. The pancreatic head and body are normal in size and configuration. However a cystic structure is noted at the tail region measuring approximately 5.1cm x 4.0 cm x 4.4 cm (LWT) Spleen: Patient Craniocaudal Anteroposterior Transverse 8.9 8.3 3.9 Maximum normal values 14cm 10cm 6cm

The spleen is normal in size exhibiting a homogenous parenchymal echopattern and a regular outline. No focal lesions were seen. The abdominal aorta is well demonstrated in its entire course. There is no evident focal dilatation or abnormality in its walls or in its lumen

There are no enlarged nodes or masses demonstrated in the vicinity of the abdominal aorta Patient Left kidney Length Width Thickness Cort. Thickness 11.1cm 5.0cm 4.2cm 1.3cm normal value 10.8+- 0.8 4.2+- 0.5 4.8+_0.5 1.5 Right kidney 11.0cm 5.6cm 6.1cm 2.0cm normal value 9.7+-0.7 4.3+-0.5 3.9+-0.5 1.5

There is no significant disparity in size, shape and location of the kidneys. Both show intact central echocomplexes with maintained corticomedullary differentiation. No focal or diffuse lesions. No calculi or dilated collecting system. The ureters are not visualized and are probably not dilated The urinary bladder distends adequately. It has smooth non-thickened walls. No abnormal intraluminal echoes The prostate gland measures 36mm x 32mm x 28mm (LWT) 17grams. Parenchymal echopattern is not unusual with smooth external outline. No focal or diffuse lesions noted

Impression: moderate fatty liver Left upper quadrant cyst probably in the tail of the pancreas Ultrasonically normal gallbladder, biliary tree, spleen, abdominal aorta, para-aortic areas, kidneys, ureters, urinary bladed and prostate gland.

Interpretation: one of the causes of having fatty liver is excessive alcohol intake. The patient has a history of being a heavy alcohol drinker and it may be the cause of having him a fatty liver disease. The diet of the patient also is one of the possible causes of this disease because he mostly eat beef steaks.

Nursing Responsibilities:

For ultrasound of the liver, gallbladder, spleen, and pancreas, patient may be asked to eat a fat-free meal on the evening before the test and then to avoid eating for 8 to 12 hours before the test.

For ultrasound of the kidneys, patient may not need any special preparation. Patient may be asked to drink 4 to 6 glasses of liquid (usually juice or water) about an hour before the test to fill his bladder. Patient may be asked to avoid eating for 8 to 12 hours before the test to avoid gas buildup in the intestines. Gas could interfere with the evaluation of the kidneys, which lay behind the stomach and intestines.

DATE

TEST

RATIONALE

RESULT

INTERPRETATION/SIGNIFICANCE

NURSING RESPONSIBILITY

A U G U S T

Pulmonary Care ABG Service

1.) Assess the patient for

any bleeding problems or if he had taken blood thinners, such as aspirin or

pH normal 7.35-7.45

It

is

a 7.458 of

Normal

warfarin(Coumadin) 2.) Assess the patient for allergy to any medicines, such as those used to numb the skin.

value: measurement

the acidity of the blood, the reflecting of ions

10,

number

2 0 1 1

hydrogen present.

Low PCO2 (Partial of It reflects the the amount of carbon dioxide gas dissolved in the blood. 34.3 Terr This may indicate pulmonary

Pressure Carbon Dioxide)

embolism

Normal value: 35-45 Terr

PO2

(Partial of

It reflects the amount of oxygen gas dissolved in

83.9 torr

Normal

Pressure Oxygen) Normal

value:

the blood. It primarily measures the effectiveness of the lungs in pulling oxygen into the blood stream from the atmosphere.

80-100 Torr

HCO3 (bicarbonate) Normal value:

Bicarbonate is a chemical (buffer) that keeps the pH of blood from becoming too acidic or too 24

Normal

21-28 mEq/L

basic.

TCO2

(Total This test is used

Normal

Carbon Dioxide to measure the 25 Content) Normal 23-30 total value: concentration of

all forms of CO2 in serum, plasma, or whole blood

samples.

BE Base Excess (positive number) or Base Deficit (negative number) Normal value:

1.1

Normal

(-2) (+2)

O2 Saturation Normal value: 80-100%

It measures the percent of hemoglobin which is fully combined with oxygen.

95.3 %

Normal

DATE

TEST

RATIONALE

RESULT

INTERPRETATION/SIGNIFICANCE

NURSING RESPONSIBILITY

GlycoHemoglobin

It is a blood test 7.0% that checks the amount of sugar

High Since the patient has diabetic

PRETEST: 1.) Identify the patient 2.) Explain the purpose for the laboratory and diagnostic test to the patient 3.) Inform patient that the test requires blood sample taken with the use of the syringe 4.) Inform the patient that the specimen collection takes approximately 5-10 minutes 5.) The patient maybe seated or in the supine position. The patients arm is in

mellitus, one of the signs is high level of glucose in the blood

Normal 4.8-6 %

value: (glucose)

bound

to hemoglobin

extension. DURING THE TEST: 6.) Ask the patient to open and close hand a few times to help make the veins more visible 7.) Cleanse the skin with 70% alcohol, and allow it to air-dry POSTTEST: 8.) Instruct the patient to continue compression of the puncture site for 2 to 5 minutes or until bleeding stops 9.) Assess the patients arm to ensure that subdermal bleeding has ceased. If a hematoma

develops at the site, apply warm compress

DATE

TEST

RATIONALE

RESULT

INTERPRETATION/SIGNIFICANCE

NURSING RESPONSIBILITY

A U G U S T

Cholesterol Ref. interval: 0.0-5.2mmol/L

A total cholesterol test measures all the cholesterol in the blood. done to determine risk for heart disease

3.6 mmol/L

Normal

PRETEST: 1.) Identify the patient 2.) Explain the purpose for the laboratory and diagnostic test

LDL density

(Low

2.0 mmol/L

Normal

to the patient 3.) Inform patient that the test requires blood sample taken

9, 2 0 1 1

lipoprotein)

Ref. interval: 0.0-3.4mmol/L

with the use of the syringe 4.) Inform the patient that the specimen collection takes

TGL Triglycerides) Ref. interval: 0.00-1.70 mmol/L

( The triglyceride level is a laboratory test to measure the amount of triglycerides in the blood.

1.25

Normal

approximately 5-10 minutes 5.) The patient maybe seated or in the supine position. The patients arm is in extension. DURING THE TEST: 6.) Ask the patient to

AHDL

(HDL-

1.05

Normal

open and close hand a few times to help make the veins more visible 7.) Cleanse the skin with 70% alcohol, and allow it to air-dry POSTTEST: 8.) Instruct the patient to continue compression of the puncture site for 2 to 5 minutes or until

cholesterol)

bleeding stops 9.) Assess the patients arm to ensure that subdermal bleeding has ceased. If a hematoma

develops at the site, apply compress warm

POSSIBLE DIAGNOSTICS

Nuclear scanning is sometimes used to show damaged areas of the heart and expose problems with the heart's pumping action. A small amount of radioactive material is injected into a vein, usually in the arm. A scanning camera records the nuclear material that is taken up by heart muscle (healthy areas) or not taken up (damaged areas).

Coronary angiography (or arteriography) is a test used to explore the coronary arteries. A fine tube (catheter) is put into an artery of an arm or leg and passed through the tube into the arteries of the heart. The heart and blood vessels are then filmed while the heart pumps. The picture that is seen, called an angiogram or arteriogram, will show problems such as a blockage caused by atherosclerosis.

Radionuclide stress test Radionuclide stress testing involves injecting a radioactive isotope (typically thallium or cardiolite) into the patient's vein after which an image of the patient's heart becomes visible with a special camera. The radioactive isotopes are absorbed by the normal heart muscle. Nuclear images are obtained in the resting condition, and again immediately following exercise. The two sets of images are then compared. During exercise, if a blockage in a coronary artery results in diminished blood flow to a part of the cardiac muscle, this region of the heart will appear as a relative "cold spot" on the nuclear scan. This cold spot is not visible on the images that are taken while the patient is at rest (when coronary flow is adequate). Radionuclide stress testing, while more time-consuming and expensive than a simple ECST, greatly enhances the accuracy in diagnosing CAD. Stress echocardiography Another supplement to the routine ECST is stress echocardiography. During stress echocardiography, the sound waves of ultrasound are used to produce images of the

heart at rest and at the peak of exercise. In a heart with normal blood supply, all segments of the left ventricle (the major pumping chamber of the heart) exhibit enhanced contractions of the heart muscle during peak exercise. Conversely, in the setting of CAD, if a segment of the left ventricle does not receive optimal blood flow during exercise, that segment will demonstrate reduced contractions of heart muscle relative to the rest of the heart on the exercise echocardiogram. Stress

echocardiography is very useful in enhancing the interpretation of the ECST, and can be used to exclude the presence of significant CAD in patients suspected of having a "false-positive" ECST. CT scan. Computerized tomography (CT) technologies, such as electron beam computerized tomography (EBCT) or a CT coronary angiogram, can help the doctor visualize the arteries. EBCT, also called an ultrafast CT scan, can detect calcium within fatty deposits that narrow coronary arteries. If a substantial amount of calcium is discovered, coronary artery disease may be likely. A CT coronary angiogram, in which you receive a contrast dye injected intravenously during a CT scan, also can generate images of your heart arteries. Magnetic resonance angiogram (MRA). This procedure uses MRI technology, often combined with an injected contrast dye, to check for areas of narrowing or blockages although the details may not be as clear as those provided by coronary catheterization.

DRUG STUDY

Generic Name: simvastatin Brand Name: Zocor Classification: Lipid-Lowering Agent Action: inhibits HMG-COA reductase enzyme, which reduces cholesterol synthesis; this enzyme is needed for cholesterol production. Indication: It is indicated to the patient since the patient has fatty liver and so as Coronary heart disease also known as Coronary arterial disease. It will reduce low density lipoprotein (LDL) cholesterol, apolipoprotein beta, and triglycerides. To increase high density lipoprotein (HDL) cholesterol. It is also used to adjunct therapy in most likely with our patient. Contraindication: hypersensitivity to the component of the drug. Active liver disease or unexplained persistent elevation of the tranaminase. Ordered Dose: 1 tab OD @ hour of sleep Adverse effect/Side effect: CNS: dizziness, headache, insomnia, weakness CV: chest pain, peripheral edema EENT: rhinitis, blurred vision Resp: Bronchitis

G.I.: abdominal cramps, constipation, diarrhea, flatus, heartburn, altered taste, drug induced hepatitis, dyspepsia, elevated liver enzyme, nausea and pacreatitis GU: erectile dysfunction Derm: rashes, pruritus MS: Rhabdomyolysis, arthralgia, arthritis, myalgia, myositis. Drug Interaction: atorrvastatin,lovastatin, simvastatin and rosuvastatin are metabolized by CYP3A4 metabolic pathway. It may interact with CYP3A4 inhibitors, bioavailability and effectiveness may decrease by

cholesthyramin and colestipol, risk of mayopathy with this drugs may increase together with amiodarone, cyclosporine, gemfribrozile, clofibrate, diltiazem, verapamil, erythromycin, clarithromycin, telithromycin,

nefazodone, large dose of niacin and azole antifungal. Nursing responsibilities: Assess nutrition like fat, protein, carbohydrates; nutritional analysis should be completed by dietitian before treatment is initiated. Monitor creatine phosphokinase levels due to possibility of myopathy,

serum cholesterol (total and fractionated). Monitor triglycerides, cholesterol baseline and throughout treatment. Assess liver function tests prior to therapy and periodically thereafter. Evaluate therapeutic response (reduction in lipid levels) and adverse reaction on a regular basis (e.g. rash, myalgia, blurred vision abdominal pain, cough) throughout the therapy.

Instruct patient to take drug with the evening meal because taking this enhances absorption and increase cholesterol biosynthesis.

Teach patient about proper dietary management of cholesterol and triglycerides. When appropriate, recommend weight control and exercise.

Tell patient to notify physician if adverse reaction occur, particularly muscle aches and pain.

Generic Name: glipizide Brand Name: Minidiab Classification: Hypoglycemic-Oral Action: it belongs to a group of medicines called sulphonylureas. These medicines lower high blood glucose by increasing the amount of insulin produced by your pancreas. Indication: non-insulin dependent diabetes mellitus (NDDM) not controlled by diet alone. Maturity-onset DM. Contraindication: hypersensitivity to sulfonylureas; diabetes complicated Ordered Dose:10 mg 1/2 tab bid pre meal Adverse Effect/side effect: CNS: dizziness, drowsiness, headache GI: constipation, diarrhea, stomach pain, nausea

Derm: hives, itching, sensitivity to light, skin rash and eruption Meta: low blood sugar Drug Interation: Drug to drug: effectiveness may decrease by current use of diuretic, corticosteroids phenothiazine, oral contraceptive, estrogen thyroid preparation, phenytoin, niacin, sympathomimetics, and isoniazid. Alocohol, androgen (testosterone), chloramphenicol, MOA inhibitor, NSAIDs, salicylate, sulfonamide, and warfarin may increase risk of hypoglycemia. Flouroquinolones may increase effect of glyburide. Concurrent use of warfarin may alter the response to both agents, close monitoring is needed in change of the dosage. Beta blockers may mask the signs and symptom of hypoglycemia. Nursing responsibilities: Assess the potential for interaction with other prescription medication. Assess result of the laboratory tests, therapeutic effects, and adverse effect response. Assess hypoglycemic/hyperglycemic soon after meals. Confirm if the patient is diabetic before administering oral hypoglycemic agents. Instruct the patient to check for symptoms of cholestatic jaundice: dark urine, pruritus, yellow sclera: if these occur, the physician should be notified. Teach the patient that diabetic is a lifelong illness and the drug is not the cure. Instruct the patient that it is best to take medication in the morning to avoid hypoglycemic effect at night. Instruct patient that the drug must be continued on daily basis, explain consequence of discontinuing the drug abruptly may cause sudden increase in glucose level with worst effect.

Generic Name: bisoprolol Brand Name: concore Classification: Beta-Blockers Action: preferentially and competitively blocks simulation of beta-1 adrenergic receptor with cardiac muscle (decrease rate of SA node discharge, increase recovery time), slows conduction of AV node, decrease the heart rate, which decrease O2consumption in myocardium, decreases rennin-aldosterone-angiotensium system; inhibits beta2-receptors in bronchi and vascular smooth muscle at high doses. Indication: hypertension, coronary heart disease, treatment of stable chronic moderate to severe heart failure w/ reduced systolic ventricular function. Contraindication: Acute heart failure or during episodes of heart failure; decompensation requiring IV inotropic therapy; cardiogenic shock; 2nd- or 3rd-degree AV block; sick sinus syndrome; SA block; bradycardia w/ <60 beats/min; hypotension; severe bronchial asthma or severe COPD; late stages of peripheral arterial occlusive disease & Raynaud's syndrome; untreated pheochromocytoma; metabolic acidosis. Ordered dose: 2 mg 1 tab OD Adverse Effect/Side Effect: Drug Interaction: Ca antagonist, MAOIs (except MAO-B inhibitors), clonidine. Antiarrhythmics, parasympathomimetics, eye drops containing -blockers, antidiabetic agents, anesth, digitalis, prostaglandin synthetase inhibitors, ergot derivatives, sympathomimetics, barbiturates, psychotropic drugs,

rifampicin&mefloquine.

Nursing Responsibilities: Monitor blood pressure before and periodically during the treatment. Obtain renal and liver function before starting therapy. Monitor hydration if adverse GI reaction occurs: skin turgor and dryness of mucous membranes especially in elderly. Monitor glucose level of the patient since he is diabetic since beta blockers may mask evidence of hypoglycemia such as tachycardia. Tell the patient not to discontinue the drug abruptly since it can cause precipitate angina. Teach the patient to take the drugs as prescribed and warn not to double or skip dose, missed dose may be taken as soon as remembered if at least 8 hours until the next dose. Instruct patient to comply with weight control, dietary adjustment and modification. Remind patient that this drug may mask the symptoms of hypoglycemia. Advise patient to report occurrence of drug induced adverse reaction.

Generic Name: pantoprazole Brand Name: Pantoloc Classification: anti-ulcer, proton pump inhibitor Action: inhibits both basal and stimulated gastric acid secretion suppressing the final steps in acid production, through the inhibition of the proton pump by binding to and inhibiting hydrogen-potassium adenosine triphosphatase, the enzyme system located at the secretory surface of the gastric parietal cell. Indication: Duodenal and gastric ulcer, moderate and severe reflux, esophagitis. Eradication of H. pylori in patient with peptic ulcer. Zollinger-edison syndrome and other pathologig hypersecretory condition. Symptomatic improvement and healing of the mild reflux esophagitis. Prevention of gastro-duodenal ulcers induced by NSAID in patient at risk with need for continuous NSAID treatment. Contraindication: long-term therapy, hypersensitivity, and history of acute porphyria. Ordered Dose: 4omg IU OD Adverse Effect/Side Effect: CNS: headache, dizziness, hallucination, depression, insomnia CV: cardiac arrhythmias, bradycardia GI: nausea, vomiting, abdominal discomfort, diarrhea, constipation, pancreatitis Meta: hyperglycemia Musc:back pain, neck pain, arthralgia. Respi: bronchitis, increased cough, dyspnea. Drug Interaction: Drug-drug: may alter bioavailability and effect of the drugs which absorption is pH dependent (ketoconazole).

Nursing Responsibilities: Monitor possible drug induced reaction. Monitor hepatic enzyme. Instruct patient to take drug at the same time each day. Inform patient antacid does not affect drugs absorption. Advice patient to report persistence of symptoms like diarrhea and bleeding.

Generic Name: metformin Brand Name: Diabex Classification: antidiabetics, beguanides Action: decrease intestinal absorption of glucose and hepatic glucose production. It also improves insulin sensitivity (increase peripheral glucose uptake and utilization. Indication: Non-insulin dependent diabetes mellitus (Type II). Contraindication: Renal impairment, cardiac failure, diabetic coma, severe liver disorder, pancreatitis, severe feverish ailments. Ordered Dose: 1000mg tab, I tab BID with meals Adverse Effect/Side Effect: CNS: headache, dizziness. GI: diarrhea, nausea, vomiting, abdominal discomfort, flatulence indigestion, metallic taste. Hema: megaloblastic anemia.

Meta: lactic acidosis. Drug interaction: Drug-drug: Ameloride, digoxin, morphin, procanomide, quinidine, ranitidine, triamterine, trimethoprim, calcium channel blockers and vancomycin may complete for elimination pathways with metformin, altered response may occur. Nursing responsibilities: Assess for hypoglycemic/hyperglycemic reaction. Assess renal status, before therapy or annually. Monitor possible drug induced reaction. Closely monitor patient in times of stress such as infection or trauma. Insulin therapy may be necessary. Assess for lactic acidosis. Educate patient on sign and symptoms of hyperglycemia/hypoglycemia and proper action regarding each condition. Teach patient how to assess lactic acidosis like hyperventilation, fatigue, malaise and chills.

Generic Name: insulin Brand Name: Insulin Human Regular Classification: Antidiabetic, hormone, pancreatic Action: decrease blood glucose; by transport of glucose into the cell and the conversion of glucose into glycogen which indirectly increase blood

pyruvate and lactate thus decrease phosphate and potassium thus decreasing blood sugar. Indication: it is indicated to Type II diabetic person like our patient. Contraindication: hypoglycemia, insulinoma, hypersensitivity reactions, IV administration of insulin suspension, diabetic coma. Ordered dose: 6 U Adverse Effect/Side Effect: Derm: rashes, hives, swelling, or inflammation. Drug interaction: Beta blockers, clonidine and reserpine may mask some of the sign of hypoglycemia. Corticosteroids, thyroids supplement, estrogen, isoniazid, niacin, phenothiazine and rifampin may increase insulin requirements. Nursing responsibilities: Monitor fasting blood glucose 2 hours after meals. Monitor urine ketones during illness. Inform patient sign of decrease blood glucose like sweating, shaking, moodiness, irritability, and confusion. Inform patient the importance of diet and exercixe. Explain to the patient that this medication controls blood glucose but does not cure diabetes.

Generic Name: aspirin Brand Name: Aspilets Classificatin: salicylate, antipyritics nonopioids analgesics, anti-platelet Action: relieves pain and reduces inflammation by inhibition of peripheral prostaglandin synthesis, it also inhibits the synthesis action of other mediators of inflammation. It acts on the hypothalamic heat-regulating center to relieve fever, by promoting sweating and vasodilation, leading to heat platelet aggregation by preventing formation of thromboxane A, a platelet aggregation substance. Indication: treatment of mild to moderate pain, fever, various inflammatory conditions; reduction of risk of death or MI in patient with previous infarction or unstable angina pectoris or recurrent transient brain ischema cause by platelet emboli. Contraindication: Ordered Dose: 100mg 1 tab OD Adverse Effect/Side Effect: CNS: dizziness GI: nausea, dyspepsia, heartburn Hema: increased bleeding time, anemia decreased iron concentration Drug Indication: Drug-drug: Aspirin may increase risk for bleeding with warfarin, heparin, heparin like agents. Nursing Responsibilities: Monitor liver function. Monitor renal function Instruct patient to take water and sit upright for 30 minutes to facilitate passing into the stomach.

Advice patient of the possibility for allergic reactions. Teach patient to recognize and report any symptoms of hapatotoxicity like dark urine, clay-colored stools, yellow skin and sclera, renal toxicity like deceased urine output.

Instruct patient not to exceed recommended dosage.

C A N U R S I N G P L A N R E

DATE/TIM E A U G U S T 10, 2 0 1 1 @

CUES Subjective: I feel pain over my stomach Pain scale: 3 out of 5 0- No pain 1- Slightly 2- Slightly moderate 3- Moderate 4- Severe pain 5- Very severe pain Objective:

NEE D A C T I V I T Y E X E R C I S E P A T T E R N

NURSING DIAGNOSI S Acute pain related to inflammator y process as evidenced by epigastric pain common cause of gastritis is infection from H.pylori bacteria and some other, this bacteria will invade the normal protection of the stomach lining and if this protective barrier will be penetrate by the bacteria it

OBJECTIVE OF CARE

NURSING INTERVENTION 1. Give aspirin 100mg 1 tab OD this will relieve pain that acts as analgesic 2. Give patoloc 40 mg IU OD. Prevention of gastroduodenal ulcers. 3. Position the patient properly. proper positioning like supine with semifowlers position can reduce pain in abdominal area. 4. Teach patient for deep breathing exercise. this will reduce pain

EVALUATION

Within our 4hrs span of care our patient will be relieve from pain as evidenced by: a. Pain scale of 2 out of 5 b. Verbalization relief of pain c. Demonstration of relaxation skill and divertional activities d. Absence of grimaced face e. RR within normal range: 16-25cpm

August 10, 2011 @ 11 am Goal Met!!! Within our 4hrs span of care our patient was relieve from pain as evidenced by: a. Pain scale of 2 out of 5 b. Verbalization relief of pain c. Demonstration of relaxation skill and divertional activities by talking to his wife d. Absence of grimaced face e. RR =25

7:00 AM Grimaced face Guarding behavior Limited range of motion Nausea/vomiting RR:26 Meds: Aspirin100mg 1 tab OD Pantoloc 40mg IU OD

will cause inflammatio n s manifested by epigastric discomfort usually describe as burning aching, abdominal tenderness, cramping, severe nausea and vomiting.

in abdominal area. 5. Provide adequate rest and sleep. this will lessen irritability of the patient as he feels pain. 6. Encourage watcher to divert the attention of the patient by talking to her when her husband feel pain. this may divert the attention of the patient and forget about the pain. 7. Modify diet of the patient. discourage patient to take caffeine, milk, fatty and salty food that may trigger

the epigastric pain. 8. Educate patient that some of the prescribe drugs have side effects that cause GI discomfort. medication like pantoloc, concore, minidiab, zocore.

DATE & TIME

CUES
Subjective:

NSG. DIAGNOSIS
Impaired skin integrity related to impaired blood circulation secondary to type 2 DM In Diabetes Mellitus type 2 patients, the blood is more viscous due to the high glucose content. This leads to compromised circulation especially to parts of the body away from the heart, which are the peripheries, especially the lower extremities. With poor glycemic control wound will heal slowly because the damaged vascular system cannot carry sufficient oxygen.

NEED
N U T R I T I O N A L M E T A B O L I C P A T T E R N

OBJECTIVE OF CARE
That within my 8 hours span of care my patient will be able to display signs of healing as evidenced by: a. Wound edges clean or pink without signs of infection b. Able to maintain physical well being c. HGT result will decrease within normal range d. VS within normal range PR: 80-90bpm RR: 16-20CPM CR: 80-90BPM BP: 110/70130/90mmHg

INTERVENTIONS
1. Assessed skin. Note color, turgor, and sensation. Described wound and observed changes. Establishes comparative baseline providing opportunity for timely intervention. 2. Compare the wound upon admission and before discharge. provides information about effectiveness of therapy and identifies additional needs. 3. Demonstrated good skin hygiene, eg. Wash thoroughly and pat dry carefully Maintaining clean dry skin provides a barrier to infection. Patting skin dry reduces risk of dermal trauma 4. Emphasized importance of adequate nutrition and fluid intake improved nutrition and hydration will improve skin condition. 5. Perform passive range of motion exercises improves circulation 6. Note extent of body

EVALUATION
August 8, 2011 @ 3pm Goal Partially Met At the end of 8 hours span of care my patient was able to display signs of healing as evidenced by: a. Wound edges clean or pink without signs of infection

A U G U S T 8, 2 0 1 1 @ 7:00 AM

Objective: - HGT monitoring with the result of 326mg/dl. (H) -history of DM -has an open wound in his right gastrocnemius area -slow wound healing -decrease range of motion -initial VS of PR: 115bpm RR: 26cpm CR: 87bpm BP: 140/90mmHg

b. Able to maintain physical well being c. HGT result will decreas e within normal range

Reference:

capacity to assess what extent of activities the client can perform Provide restful environment reduces stress, conserves energy and lowers O2 demand 8. discourage sitting and standing for long periods, and not wearing tight clothing and socks compromise circulation 9. continuously monitor quality of pulses assessment and reassessment to not for progress 10. administer medications as ordered - give RI if HGT result >140mg/dl - minidiab - zocor to prevent further complications 7.

d. VS within normal range PR: 80-90bpm RR: 16-20CPM CR: 80-90BPM BP: 110/70130/90mmHg

Date/ Time CUES Need Nursing Diagnosis Objectives of care Nursing Interventions Evaluation

A U G U S T

Subjective: Objective:
-Vital Signs: TempPR- 85bpm CR-87bpm RR-20cpm

A C T I V I T Y -

Risk for decreased cardiac output secondary to Coronary Artery Disease

That within my 8 hour span of care my patient will be able to demonstrate adequate cardiac output as evidenced by:

1. Maintain bed/chair rest in position of comfort. Decreases O2consumption/ demand, reducing myocardial workload

August 10, 2011 @ 3:00pm

10,

BP-110/70 mmHg

2 0 1 1

-Chest PA(Radiologic Findings) Impression: Atherosclerotic Aorta

E X E R C

@ Echocardiogra m: Left Ventricular

I S

7:00

characterized by the accumulation of plaque within coronary arteries, which progressively enlarge, thicken and calcify. This causes critical narrowing of the coronary artery lumen (75% occlusion), resulting in a decrease in coronary blood flow and an inadequate supply of oxygen to the heart muscle.

1.)BP and pulse rate are within normal 2. Monitor Vital Signs ranges: (e.g., heart rate, BP) BP:100/70-130/90 Tachycardia may be mmHg present because of pain, CR:70-90bpm(male) anxiety, hypoxemia, and reduced cardiac output. RR:16-20 cpm Changes may also occur in BP because of cardiac PR:70-90bpm(male) response. 2.)Strong pulses 3) Auscultate for breath sounds and heart sounds. Listen for murmurs. S3, 3) ability to tolerate S4, or crackles can occur activity e.g. standing, with cardiac sitting walking, decompensation without symptoms of Development of murmurs dyspnea, or chest pain may reveal a valvular

GOAL MET

At the end of my 8 hours span of care my patient was able to demonstrate adequate cardiac output as evidenced by: 1.)BP and pulse rate are within normal ranges: BP:120/80mmHg CR:88bpm RR:20 cpm PR:89bpm

2. Strong Pulses

PM

Hypertrophy

cause for chest pain or papillary cause for rupture

-Coronary Artery Disease

P A T 4.provide for adequate rest periods . assist with perform self care activities, as indicated. Conserves energy, reduces cardiac workload

3. Able to tolerate activity without symptoms of dyspnea, or chest pain

-diet: fatty meat products

T E R

-Zocor 60g OD (hypolipidemic drug)

5)Stress importance of avoiding straining/ bearing down, especially during defecation. valsalva maneuver causes vagal stimulation, reducing heart rate, which may impair cardiac output.

6. Encourage immediate reporting of pain for prompt administration of medications as indicated. timely interventions can reduce oxygen consumption and myocardial workload and

may prevent / minimize cardiac complications

7. Evaluate mental status, noting the development of confusion, disorientation reduced perfusion of the brain can produce observable changes in sensorium.

8. Note skin color and presence/ quality of pulses. peripheral is reduced when cardiac output falls, giving the skin pale or gray color and diminishing the strength of peripheral pulses.

9. administer supplemental oxygen as needed increases oxygen available for myocardial uptake to improve contractility, reduce ischemia

Date

Cues

Need

Nursing Diagnosis

Objectives of Care

Nursing Interventions

Evaluation

A U G U S T

Subjective:

A C

Risk for another stroke related to coronary artery bypass surgery.

At the end of our 8 hours span of care our patient will be able to maintain and his status prevent

1. Establish rapport to the patient and to the significant others. Establishing rapport can induce cooperation of the patient in doing all the nursing interventions that follows. Collaborating with the

August 10, 2011 @ 3pm Goal Partially Met At the end of our 1 day span of care our patient was tomaintain status prevent occurrence of able his and

Objective: Vital Signs: TempPR- 85bpm CR-87bpm

T I V I T Y E X E R C I S E

occurrence of stroke. Use of a bypass surgery increases the risk of blood clots forming in your blood vessels. Clots can travel to the brain or other parts of the body and block the flow of blood, which may cause a stroke Thus, the patient

10,

RR-20cpm BP-110/70

would be able to: a. maintain stable vital signs; b. demonstrate techniques that help prevent of

2 0 1 1

mmHg Chest PA(Radiologic Findings) Impression:

occurrence stroke; c. verbalize

@ 7am

Atherosclerotic Aorta Echocardiogra

understanding

m: Ventricular

Left

or other problems.

of

safety

significant others, the nurse can have the knowledge in knowing the significant factors and lifestyle habits of the patient .

stroke evidenced

as by

measures; P A T T E R N

Hypertrophy Coronary Artery Disease Diet: fatty meat products -Zocor 60g OD (hypolipidemic drug) Had a bypass surgery (+) DM smoker

stable vital signs 120/80-BP, 88-

PR, 89-CR, 22RR; demonstrated techniques prevents occurrence of that

2. Monitor vital signs. Vital signs must be recorded and checked to know the current condition of the

stroke such as maintaining bed rest.

patient.Abnor mal vital sign may that there is indicate something is wrong with the patient 3.Place patient in comfortable position to enhance proper oxygenation. 4.Teach the patient relaxation techniques. this prevents the body especially the

cardiovascular system from stress in which can cause angina 5. Reinforce the importance of notifying nursing staff whenever angina pain is experienced. notifying nursing staff is necessary in order to have prompt intervention which is needed in order to

reduce such condition 6. Inform the patient about the safety measures This gives the patient the knowledge on how to prevent such illness 7. Administer Antilipid medications as ordered. To decrease blood cholesterol and

tricglyceride levels in patients with elevated levels 8. Nutrition Management: Assisting with or providing a balanced dietary intake of foods and fluids This improves the lifestyle of the client in which affects his health. 9. Review specific factors that

affect CAD development and progression. Highlight those riskfactors that can be modified and controlled to reduce the risk.

D I S C H A R G E P L A N

Medication Instruct to comply with all the home medications as prescribed by the physician.

Completion of the medication therapy is a necessity to achieve the optimum level of wellness on the part of the client Treatment regimen is important to have an immediate recovery. Emphasize the importance of taking the medications at the prescribed schedule, dosage, and frequency. To be knowledgeable in administering the drugs will avoid any accidents regarding drug administration. 1. Bisoprolol 2mg/ 1tab OD 6am 2. Zocor 40mg/ 1tab OD 6am 3. Minidiab 10mg/ 1tab OD 5pm 4. Pantoloc 40g/ 1tab OD 6am

Instruct watcher of the client not to administer other medications unless prescribed by the doctor.

Non-prescription drugs may have an antagonistic or synergistic effect if taken with other drugs. Instruct the watcher of the client to instantaneously report any adverse effects of the drug to their physician. Immediate consultation to the physician regarding side effects or adverse reactions can help to prevent further complication.

Encourage the patient to take the medications with a full glass of water and with meals unless contraindicated.

Taking it with a full glass of water and with meals prevents gastric irritation and any other side effect of the drug

Remind the family of the client to check the medication label and its expiration date before giving the drug

To ensure safety in drug administration. Instruct patient to avoid drinking alcoholic beverages pre, during or post- drug administration. Alcoholic beverages have chemical substances which alter the components and therapeutic effects for the body.

Exercise Instruct to avoid strenuous activities

To have adequate rest periods Encourage to have a regular exercise and set realistic goals for physical activity like in inactive patient should start with activity that lasts 3 minutes such as increase the walking time. Moderate physical activity increases HDL levels and reduces triglycerides levels. These reduces cardiovascular risk factors at the same time improves circulation and muscle tone. Instruct the patient to engage in an activity or variety of activities that interest them.

 To maintain motivation Instruct the client to balance activities with adequate rest periods.

To manage stress Inform the patient to stop any activity if he develops chest pain.

To prevent further complication

Treatment Explain the purpose of treatment to be at home.

To make clients watcher aware that treatment does not only end at hospital but needs to be continued at home to make the client responsible towards medication. Explain to the watcher of the client the medical condition involved and provide her with factual information regarding the illness To have a comprehensive understanding of the condition of the client and be able to determine what appropriate interventions must be rendered.

Instruct the watcher of the client to have regular consultations with the physician.

This is necessary to provide her with information regarding the prognosis of the client. Instruct the watcher of the client to maintain compliance with the prescribed medications. This aids for the fast recovery of the client

Hygiene Encourage continuity of hygienic measures practiced at present such as daily bathing, wearing footwear, trimming his nails and toenails, and maintaining own supplies/ items for personal necessities. Hygiene promotes comfort and cleanliness to the patient. In order to keep client away from contamination and infectious disease. Instruct the SO to provide good, clean, and safe environment. To prevent the occurrence of further complications Out Patient Order Inform the patient that follow-up check up is important to have continuous monitoring and care even after attainment of course medical therapy. Through constant visits as outpatient, the physician would know the progress of the therapeutic intervention availed by the patient. Encourage client to carry out follow up diagnostic treatments.

To alleviate the condition.

Report to the physician immediately any unusualities or problems regarding the patients condition and development.

Early detection is important in order to assess the patients condition. Continue giving medicines as prescribed.

Continuous complying with the prescribed drugs prevents further complications. Continuous assessment of cognition, social functioning and physical functioning should be rendered to client Inability of performing these tasks are one of the most common disability with coronary artery disease patients have.

Diet Instructed to reduce intake of fatty foods and limit total intake of cholesterol.

This approach may help to reduce risk factors such as elevated serum cholesterol levels, which are associated with the development of coronary artery diseases, the leading cause of death and disability among people with diabetes.

Emphasize the importance of avoidance of alcohol intake.

Alcohol consumption may lead to excessive weight gain, hyperlipidemia, and elevated glucose levels.

Instruct client and significant others to follow prescribed diet.

Nutrition, diet, and weight control are the foundation of diabetes and CAD management.

Encourage to eat fiber rich foods such as fruits and vegetables.

increasing fiber in the diet may also improve blood glucose levels and decrease the need for exogenous insulin. This kind of diet also plays a role in lowering total cholesterol and low-density lipoprotein cholesterol in the blood.

Encourage to stop tobacco use

inhalation of smoke increases the blood carbon monoxide level, causing hemoglobin to combine more readily with carbon monoxide than with oxygen. A decrease amount of oxygen may decrease the hearts ability to pump.

P R O G N O S I S

Diabetic macrovascular complications result from changes in medium to large blood vessels. Blood vessel walls thickened and it become occluded. Eventually, blood flow is blocked. These atherosclerotic changes tend to occur at an earlier age in diabetes. Also cerebral blood vessels are similarly affected by atherosclerosis. According to research heart disease will develop at >45 years for men. In the case of our patient, he was already 64 years old with type 2 DM which predisposes him to develop coronary artery disease. He seek for medical help and he was advised to undergo CABG. According to Black J.M./Hawk J.H. (2009).,recent studies documented an improvement in perceived quality of life after Coronary artery bypass grafting CABG including improvement in physical functioning, social functioning and mood states. Since our client has already undergone CABG, his underlying ailment has already been managed. Our patient complies with his treatment with an according support from his live in partner. If he goes back to Australia, he has free charges for the tests and medications so no instances that he may not cope with medical advices. In terms of his family and money theres no such a conflict because they all comply to achieve a good health for him. He even undergone on a bypass surgery as a respond to the physicians advice. With regards to his age, he is old but his body can still cope and respond to the treatments done to him. His present illness such as CAD, DM 2, LVH didnt manifest severe complications in a way he can still walk and do activities of daily living alone without receiving help from another. He can also answer questions asked to him in an organized speech. Our client and his live in partner have also been willing to learn the health teachings we have given him. A downside is that our client is a smoker and alcoholic drinker, which not only affects his current ailment, but also his overall health. In their place, our client lives in a healthy environment in which theres no definite reason for the disease to become worse so the prognosis of our client is good.

R E F E R E N C E