IX.

MEDICAL MANAGEMENT

128

IDEAL MANAGEMENT

ACTUAL MANAGEMENT

Vital signs monitoringtemperature, pulse rate, respiratory rate, blood pressure and oxygen saturation. To monitor clients condition Laboratory examination Hematology Complete Blood Count -Include hemoglobin and hematocrit measurements, erythrocyte (RBC) count, Red Blood Cell (RBC) and a differential white cell count. Arterial blood gas measurements to assess the need for supplemental oxygen. Chest x-ray To check the abnormalities and complication inside the body. Gives information about the location and extent of community acquired pneumonia. Non-Pharmacotherapy Assessment of the skin and nail bed to determine the severity of hypoxia. Chest physiotherapy Placed in semi-fowlers position to promote expansion of lungs.

Monitored vital signs every hour- temperature, pulse rate, respiratory rate, blood pressure, oxygen saturation.

Complete blood count done.

ABG analysis done.

Chest x-ray APL (AnteriorPosterior and Lateral) done.

Non-Pharmacotherapy Checked capillary refill Oxygen saturation checked

Placed in moderate high-back rest.

129 Pharmacotherapy Pharmacotherapy

130

X. DISCHARGE PLANNING
M-MEDICATION Encourage patient for a strict compliance to medications and to take medications as directed to attain therapeutic effects. Instruct patient and the significant other to keep a list of medications with their respective dosage and frequency of intake to prevent medical errors. Inform patient regarding side effects of medications to allay patient anxiety if said effects manifest. Encourage patient to discuss with health care provider the concerns regarding medications. Instruct patient to take home medications: 1. Metoprolol 50mg (Neobloc), tab, once a day before breakfast (6:00am) 2. Candesartan 8mg (Candez), tab, once a day (8:00am) 3. Amiodarone HCl 20mg (Cordarone), 1 tab, once a day (8:00am) 4. Isosorbide 30mg (Imdur), tab, once a day, after breakfast (8:00am) 5. Aspirin 80mg (aspilet), 1 tab, once a day (1:00pm) 6. Clopidogrel 75mg (Platexa), 1 tab, once a day, after dinner (8:00pm) 7. Atorvastatin 40mg (Lipitor), tab, once a day (8:00pm) 8. Essentiale Forte, 1 tab, once a day, at bedtime (8:00pm) 9. Omeprazole 40mg, 1 cap, once a day 10.Targecef 200mg, 1 cap, two times a day (8:00am & 6:00pm) E-EXERCISE Teach patient and his Significant other to perform passive and active ROM exercises with slow progressions in frequency to prevent muscle straining. Instruct the patient and the SO for adequate rest periods in between exercises to prevent straining.

131

Instruct patient to start on easy to moderate exercises first, rest frequently, and build up strength until hard exercises are tolerated.

T-TREATMENT Instruct patient and the SO to seek medical advice and immediately treat infections or other complications. Explain to patient the necessary treatment and lifestyle changes. Discuss to patient and the SO, the purpose of treatments to be done and continued at home and continue monitoring blood pressure.

H-HEALTH TEACHING Provide patient and the SO written and verbal information regarding the following: a) Explain the indication of prescribed medications, their actions, dosages, contraindication and side effects. b) Immediate notification of physician for presence of adverse reactions in medicines and home care complication. c) Compliance to follow up examination. d) Instruct patient about the importance of proper nutrition and increase in fluid intake to improve general well being and condition. e) Strict medication compliance. O-OUT PATIENT; FOLLOW-UP VISIT Assert importance of the follow up visits to physician. Instruct the patient and the family to report to the physician if any recurrence or severity of symptoms, any adverse effects of the medication and any development of complication. Promote the use of the communitys available resources such as carrying out regular visits to the nearest health center for continuing monitoring of the clients over all status. If there are things that are unclear, instruct patient and the SO to refer to physician. 132

D-DIET Encourage low fat and low sodium diet to prevent further complications that would develop from his disease condition. Encouraged eating variety of foods to acquire a balanced diet.

S-SPIRITUALITY Encourage SO to contact the family pastor to provide spiritual guidance. Participate in religious ceremonies together with the family can be a form of family bonding and can strengthen the family internally.

XI. PROGNOSIS

133

Myocardial infarction is a major cause of death and disability worldwide. Coronary atherosclerosis is a chronic disease with stable and unstable periods. During unstable periods with activated inflammation in the vascular wall, patients may develop a myocardial infarction. It may be a minor event in a lifelong chronic disease, it may even go undetected, but it may also be a major catastrophic event leading to sudden death or severe hemodynamic deterioration. A myocardial infarction may be the first manifestation of coronary artery disease, or it may occur, repeatedly, in patients with established disease. Information on myocardial infarction attack rates can provide useful data regarding the burden of coronary artery disease within and across populations, especially if standardized data are collected in a manner that demonstrates the distinction between incident and recurrent events. CRITERIA: Good Poor A. Response of the patient regarding the presence of the pain after its management B. Physiologic response of the body to disease process C. Relief of symptoms associated with the disease condition D. Performance of the daily living of the patient during confinement (e.g. eating, toileting, dressing, etc.) E. Compliance of the patient to the medication and/ or therapy F. Adequacy of rest periods and sleep G. Consumption of the patient with nutrition H. Patients significant others behavior regarding the health teaching given by the health caregiver and the physician I. Attitude towards the condition J. Duration of Illness K. Precipitating Factor L. Nature of Problems

134

 CALCULATIONS:

M. Predisposing Factors N. Family Support O. Level of Consciousness

Formula: amount # of (good/poor) x 100 = % (Percentile) 15 Amount of: Good =10 Poor = 5 INTERPRETATION: The patient is more likely to have a Good prognosis because the patient and significant other are very cooperative and compliant to the medication regimen. Full Family support is observed during the 1st assessment day and continued to be observed upon follow-up assessment last August 3, 2011. In addition, according to Harvard Health Publications, about 15% of patients who suffer a heart attack die before they reach a hospital, and another 15% die after they arrive. Among the remaining 70% who survive hospitalization, about 4% (1 in 25) will die within the first year after discharge. However, this risk is not the same for all age groups. Percentile 66.7% 33.3 %

XII. CONCLUSION
The proponents of this case study have gathered all relevant details regarding the case herein about a 51 year-old male diagnosed with Cardiopulmonary Arrest secondary to Acute Coronary Syndrome Myocardial

135

Infarction

secondary

to

Chronic

Hypertensive

Cardiovascular

Disorder

secondary to Hyperlipidemia secondary to Community Acquired Pneumonia High Risk and admitted at Maria Reyna-Xavier University Hospital. The health care team involved in the case provided, in conjunction to the medical treatments, overall nursing management set to alleviate the clients condition and support the patients over all well being. The necessary health teachings were also given to the patient and his SO in order to assist the patient to full recovery. Implementation of relevant and effective nursing interventions to relieve signs and symptoms were strictly observed so as to prevent or at least reduce the risks of complications. From what the group can surmise however, the limitations on the effectiveness of the provided nursing interventions rest on the grounds of the presence of irreversible and inalterable factors such as advanced age and preexisting medical conditions. With this subsequent information, the persons involved in this study have realized the significance of this case, its management and its overall impact on affected clients. In line with this, the proponents worked hand in hand with each other to help convey what has been researched and planned about the case.

XIII.

RECOMMENDATION

In nursing practice, we recommend student nurses to regularly check and monitor closely patients vital signs especially those with advanced age

136

and are diagnosed with other medical conditions which may aggravate the disease condition, observe for signs and symptoms of Myocardial Infarction, and over all condition of the patient and prompt adherence to safety precautions. Also follow up patients medication supply for prompt timing of administration. It is recommended for the healthcare team to: Collaborate with the client and the family to establish client-centered goals directed toward promoting and restoring the clients optimum state of health, preventing illness and providing rehabilitation. Support client and the familys decisions regarding care. Promote an environment conducive for maintenance or restoration of the clients ability to carry out activities of daily living. Provide for continuity of care in the management of the disease. Demonstrate caring behaviors in providing nursing care. Assist other personnel to develop skills in providing nursing care. Manage an environment that promotes clients self-esteem, dignity, safety, and comfort. Student nurses and other health care providers should further read books regarding Myocardial Infarction, update about the disease and incorporate it with desired plan of care. This is to prevent patients with Myocardial Infarction from developing severe complications, preserve patients health and promote wellness.

XIV. APPENDIX

Appendix A. DOCTORS ORDERS

137

1) Maria Reyna- Xavier University Hospital PHYSICIANS NOTES (SOAP) 6:00 PM Avista given Mg 80mg/1tab-4tabs Clopidogrel 75g/tab- 4tabs Hgb 10mg/dl 120/70 mmHg ORDERS >Cefuroxime dobutamine drip: D5W 250cc+2caps dobutamine drip @ 30cc/hr > Mg 80/tab 1tab OD PO >Clopidogrel 75g/tab 1tab OD >Lipitor 80g/tab 1tab OD @ HS >Captopril 25g/tab tab OD (hold if BP 90/60mmHg) >Lactulose 20g OD ( hold if bowel 2x/day) >I&O q shift >v/s q hour, include O2 sat >Moderate back rest >NVS q >Refer accordingly Dr. Apodeo ------ ----- ------- -- ----- -->attach Px to mech vent TV-500 AV mode RR-16/min FiO2 100% > Save serum pls - - - - - - - - - - - - - - - - - - - - - -- -- -- - - -> Turn Px side to side q2 >Oral hygiene w/ bactidol solution Swab over oral cavity > Salbutamol nebulization 1neb q8 >Omeprazole 40g IVT OD - - - - - - - - - - - - - - - - - -- - - - - - - - - - -> Dopamine to 25cc/hr To maintain BP 100/60 mmHg -------------- ---------------> Start Cordeme drip; D5W 250cc+ 900g Cordeme for 24hrs - - - - - - -- - - -- - - - - - - - - - - - - - - - - -> add 30 mcg KCl to mainline IVF @ 10cc/hr > Kalium Durule 1tab TID > Nacl 1tab TID ------------------------------- > Dopamine to 15cc/hr

2006 HPN, UBP- 120/80, UBP180/100 Neobloc 100g tab OD

8: 15pm 9: 10pm 140/90 mmHG 9: 24pm

9: 30pm k-3 0/90 16

138

> Dobutamine drip to 20cc/hr >Pls. recheck BP after 30mins

7:00pm

7/9/11 140 100 115 16 Dopa 2:1 15cc/hr Dobu 2:1 20cc/hr MTC drip 10cc/hr Amiodarone 11cc/hr

(-) edema Pulse: R PTA- +2 DPA- +2 L +2 +2

7/10/11 1:20am

Interventional Cardiology > Thank you for the referral >Patient seen and examined. Impression: Cardiopulmonary Arrest 2 to Ventricular Arrhythmia 2 to Acute Coronary Syndrome, Massive wall St elevation Myocardial Infarction CHVD-Chronic Hypertensive Cardiovascular Disease Hyperlipidemia > Additional diagnosis: 2Decho w/ doppler once stable Ca, Mg, Albumin FBS, Lipid profile > Hold Isoket drip please > Start Vastarel 35mg 1tab BID/NGT >Hold Captopril for now until further orders >Continue ASA 80mg 1tab OD PO Clopidogrel 75mg 1tab OD pm Lipitor 80mg 1tab OD HS Fondapaenex 2.5mg SQ OD Lactulose 20ml OD HS >Continue Kalium durule 1tab TID >Start Essentiale forte 1tab TID > Dobutamine drip to 15cc/hr and downtitrate by 3cc/hr q 15minutes then discontinue but to maintain SBP between 100-110 > Continue Amiodarone drip (900mg/day) to run in 24hrs. but to hold for HR 65bpm >Start Sucralfate 1gm 1tab q6h/NGT >Start Diazepam 5mg 1tab OD HS >Start Nacl 1tab TID/NGT > Dobutamine drip to 8cc/hr then to continue if BP 100/60mmHg > FiO2 to 80%, then 60% @ 12noon

139

6: 20am 120/90 7/ml 99% @100% FiO2 Dobutamine 1 1:00am Mg 1.7 130/100 Off Dopamine Off Dobutamine 12 :00nn 170/100 79 16 Awake, conscious, follows command Do Anixtra I-1,046 U-1000

>Recheck O2 sat after 30mins >shift omeprazole IV to 40g/cap 1cap OD >Repeat Na, K >Dulcet 1tab q6 for pain -- - - - - - - - - - - - - - - - - - - - - - - - - - - - > FiO2 60% now, 450ml TV > Shift Vastarel 35mg to 20mg 1tab TID/NGT >Rpt ECG 12L - - - - - - - - - -- - - - - - - - - - - - - - - - - - --Interventional Cardiology > For repeat serum K and Na tomorrow am >Start Candesartan 8mg tab OD after breakfast, hold for BP 90 > Amiodarone drip to consume then discontinue (10pm) > Start Amiodarone 200mg 1tab TID starting at 9pm, hold for HR 65bpm > Lipitor to 80mg tab OD HS > Start Imdur 30mg tab OD after dinner, hold for BP 90 > will fllow-up patent --------------------------- --> Start 1500 kcal in 900cc H2O CHO 60%, CHON 20% fat 20% in 6 div feedings - - - - - - - - - - - - - - - - - - - - - - - - - -- - -> revise Diazepam to 5mg OD t HS to PRN for restlessness FiO2 to 40% Start Cefepime1gm IV q12 ANST( ) 1tab OD/NGT > PCM 500mg 1tab PRN for temp 38C >FBS lipid profile-error > D/C HGT monitoring > pls. include K+ >Rpt ECG 12L tom - ----- - - - - - - - - - - - - - - - - - - - - - - - - - > Prob: Hematuria and Hematoma

12:00nn

1:00pm

4:o opm 7/11/11 7:50am May3 first MI 110/80 I II52 HR 86 U 630 Afebrile FiO2 40%

140

11:30am BP=100/60 pain

awake (-) chest

(w/ minimal pain throat O2 sat=98% at 40% FiO2 c/c= Clear breath sounds Na= 134 (128) K= 3.9 (3.0) FBS= 125mg/dl (Stress- induced hyperglycemia) 4:15pm

9:30pm 120/90 89 18 K=3.9 __=73 Ff Dopa/Dobu 1: 00pm

7/12/11 1:00pm BP-130/90 Weaning tolerated PR-72/min (-) SOB// Chest pain RR-21/min O2 sat= 100% at 50PM TPS C/L= Clear breath sounds

> Hold ASA, Clopidogrel >Will update Dr.Pena > Hold Nacl tab >IVF rate to 10gtts/min to consume >IVF to ff: PNSS 1L at 10gtts/min >OF to 1800 kcal/day in 1200 Ca volume in 6 divided meals, low fat diet >Rpt Serum Na, K in am >APs updated - - - - - - - - - - - - - - - - - - - -- - - - - - - - - -> Resume Aspirin and Clopidogrel as previously ordered to start in am > Shift Anixtra in am to Clexane0.4cc SC OD ----------------------------- Wean Px for MV turned standby at 7am T-piece 61/___ MV 15min 30 30min 30 1hr 30 2hr if tolerated may be extubated - - - - - - - - - - - - - - - - - - - -- - - - - -- - - -Interventional Cardiology >Give last 3 doses of Kalium Durule then discontinue > Lipitor to 40mg tab OD HS > shift Anixtra to Clexane 0.4cc SQ OD >Resume ASA 80mg 1tab OD after ___ >Start Metoprolol 50mg tab OD, hold for BP 90 or HR 60 > Amiodarone to 2oomg 1tab BID, hold for HR 65 > Noted Dr. Pena for weaning tomorrow > Please watcth-out for SOB, tachycardia, cyanosis and chest pain -----------------------------> extubate pt. now >APs updated-done >Ok for extubation >Ok for extubation Post Extubation order > Suction secretions now then PRN > High back rest

141

1:05pm

>O2 inhalation at 5lpm nasal cannula >pls. give Dolcet 1tab/NGT now > Will update APs-done >Ok to remove NGT >may start soft diet

1:30pm 5: 50pm >Ok to proguninal diet > IVF to ff: PNSS 1L at 10gtts/min > O2 inhalation at 2lpm nasal cannula > Ok for trans-out to private room > Shift Anixtra to Tergecef 200mg 1tab BID >Rpt CKMB > for 2D echo w/ colon flow Doppler studies in am > Hold Clexane and Aspirin >Pls. include BUN, urea to previously extracted blood > Start w/ Hemostan 500mg IV q8h > May not reinsert FBC > Pls. elevate if there is bladder distention of unable to void > Pls. refer if still w/ hematoma > For profile, repeat CBC UO CBC, > no new order >Rpt ECG 12L now

1:40pm 2:00pm 4:00pm

5:50pm 9:00pm BP-110/100 HR- 74 RR-22 99% O2 sa @ 2L/min 5:20pm 110/100 mmHg 300cc 71 no rales 20 Cough w/ hemoptysis 92% O2 sat @ 2L/m Able to void w/o FBC

4: 48pm 10:50am 7/13/11 100/80 71 18 Awake, conscious, coherent (-)angina (-) SOB (-)hematuria 6: Interventional Cardiology > Amiodarone to 200mg 1tab OD, hold or HR 65bpm >Resume ASA 80mg (Aspelt Ec) 1tab after > Give last 3 dose of Hemostan then discontinue >Cardiovascular wise, no objection if for transout to a private room tomorrow am > May have bedside commode

142

40pm 120/80 I 2020 O2 sat 98% O 2630 Still w/ cough (-)wales, (-)wheeze (-)hematuria 1:00pm

> O2 1LPM >Revise diet to low salt, low fat

> Hold Hemostan > Shift Vastarel to Vastarel MR 35mg BID 7/14/11 Trans-out orders > pls. transfer to room of choice under the service of Dr. G/Dr. P >informed consent >Diet: Soft low fat, low salt diet Labs to ff-up: Rpt Na,K, SGPT in Am >IVF: PNSS 1L at 10gtts/min >Meds: 1. Cefuroxime (Tergecef) 200mg 1tab BID 2. Levofloxacin(Levox) 750mg 1tab OD 3. Salbutamol 1neb q8H 4. Candesartan 8mg tab OD, hold for SBP 90 mmHg 5. Metoprolol 50mg tab BID 6. Amiodarone 200mg 1tab OD 7. BMN(imdur) 30mg tab OD 8. Trimetagdine (Vastarel MR) 35mg 1tab BID 9. ASA 80mg (aspelet EC) 1tab OD PO 10.Clopidogrel (Platexan) 75 mg 1tab OD PO 11.Atorvastatin (Lipitor) 40mg tab OD HS 12.Omeprazole 40mg 1cap OD ___ 13.Sucralfate 1gm 1tab q6H, 30 mins pior meals 14.Phosphatidyl 1cap TID 15.Lactulose (Movelax) 20ml OD HS >CBR w/o TP > pls. provide bedside commode >Monitor vs qH and record

1:00pm

Da y 2Da y 4-5PRN

143

BID

>I&O q shift >Pls. refer recurrence of chest pain/ SOB or any unusualities >Pls. refer accordingly >Will flup APs-done > Salbutamol nebulization PRN

4:30pm (-)chest pain (-)SOB 110/90 70 20 8:00pm 100/60 66 18 (-)angina (-)SOB (-) S3 (-)S4 (-)edema

> IVF to follow PNSS 1L at 10gtts/min Interventional Cardiology > Hold Sucralfate starting tomorrow >Will follow-up patient

Summary of meds: 1. Cefixime (Tergecef) 200mg tab BID 2. Levofloxacin (Levox) 750mg tab OD 3. Candesartan 8mg tab, 1tab BID, hold if BP 90/60 4. Metoprolol 50mg tab BID 5. Amiodarone 200mg tab OD 6. ISMN (Imdur) 30mg tab, tab OD, hold for SBP 90 mmHg 7. Aspirin (Aspilet Ec) 80mg tab OD PO lunch 8. Clopidogrel (Platexan) 75mg tab OD PO 9. Atorvastatin (Lipitor) 40mg tab, tab OD HS 10.Omeprazole 40mg cap OD breakfast 11.Essentiale forte 1 tab BID 12.Lactulose (Movelax) 20cc OD HS 13.Salbutamol neb PRN

144

7/15/11 4:00am I-2660 pain O-1560 (-) chest

> IVF: TF PNSS 1L to run at 1ogtts/min >May go home if consulted w/ dr. G > Home meds 1. Losartan(Candesartan) 8mg tab, 1tab BID 2. Metoprolol 50g tab, tab BID 3. Amiodarone 200mg tab, 1tab OD 4. ISMN(imdur) 30mg tab, tab OD 5. Aspirin (aspilet Ec) 80mg tab, 1tab OD 6. Clopidogrel (Platexan) 75mg tab, 1tab OD 7. Atorvastatin (Lipitor) 40mg tab, tab OD at HS 8. Essentiale forte tab, 1tab BID 9. Omeprazole 40mg cap, 1cap OD BF x2 >follow-up July 29, 2011

6: 30am (-)SOB (-)chest pain I-2280 O-1380 100/70 76 20 4am 130/80 74 18 Na=136 K=3.7 11: 45am 7/16/11 >MGH >Home meds: 1. Levofloxacin (levox) 750mg tab 1tab OD x2 mornings 2. Tergecef 200mg cap,1cap BID x3 more days

Interventional Cardiology > Candesartan to 8mg 1tab BID, hold for BP 90/60 > Essentiale to 1tab BID > Discontinue O2 inhalation >May have bedside commode >Will follow-up patient >For repeat 12lead ECG >Decrease vs monitoring to q4

145

2) Polymedic Hospital

Date/ Time 7/9/11 2:45pm 70/50

Progress notes BPHR

Doctors Orders (S-O-A-P) >IVF: D5W 500ml x KVO Anixtra 2.5g SQ OD 7:20pm Dobutamine drip (2 amp)+200 D5W Start Dopamine drip. D5W 250 >refer to Dr.G > Start Midazolam drip 90cc D5W+10mg midazolam in solvent to run 10cc/hr >10cc Midazolam drip then regulate at 10cc/hr > midazolam drip to 20cc/hr >midazolam 1mg IVT now

-98 ECG-Sinus Tach

2:50 pm 2:55 pm 110/80 (+) chest pain

> Midazolam drip to 10cc/hr >Intubate Px now > Dobutamine drip to 15cc/hr

Bp-80/50 HR-96 7/9/11 3:00pm BP-0 HR-0 RR-0 3:15 pm O2 sat 0 V tach 3:16pm HR-253 3:30 pm

> CPR > intubate patient > ambubag w/ 10cpm >D5W 500cc @10cc/hr > Give Diazepam 5mg IVT now > Isordil 5mg SL now-error >Defibrillate 200J300360J 2x >Cordarone amp IVT now >Isordil 5mg SL now

146

BP-180/100 HR-122 O2 sat 94% 3:37 pm Px still restless 4:00 pm Still extremely restless BP-150/80 HR-120 4:40 pm BP-100/80 HR-112 O2 sat 98% 5:0 0pm BP-70/50 Px extubated due to restlessness 5:5 0pm BP-60/40 HR-106 O2 sat 98% Asleep

> Diazepam 5mg IVT now >Diazepam 5mg IVT now >Cordarone amp IVT now >Morphine 2mg IVT now > Cordarone drip 2 amps cordarone in 250 D5W @32cc/hr > Isoket drip 10mg Isoket in 90cc D5W @10cc/hr >Midazolam 5mg IVT now > Hold Isolet & Cordarone drip >Dobutamine drip to 30cc/hr >Dopamine drip to 30cc/hr > Hold Midazolam drip TV-500 FiO2 100% ABG 1hr after having+MV > Resume Midazolam drip > Resume Isolet drip @ 10cc/hr >refer to MRH

5:5 5pm (+)Restlessness 110/80 6:0 0pm 130/80

147

DATE AND TIME 7/9/11 8:55PM

FOCUS

NURSES NOTES

Admission Standard

> received from ER drowsy on continous ambubagging; follows commands, conscious, coherent; with normal power on both upper and lower extremities > ushered safely to bed > vital signs taken and recorded

Altered Cardiac Rhythm

>

hooked

to

cardiac

monitor

on

sinus

tachycardia (-) PAC, (-) PVC, kept monitored for arrythmias

Ineffective Airway Clearance

> with ET @ 20cm lip level to vent with TV=500, RR=16, FiO2=100% AC mode > placed on moderate high back rest >secretion suctioned every hour and when necessary with moderate blood streak ETA and oral > with ongoing Dopamine, Dobutamine,

Isoket, Cordarone drip > due medications given > seen and examined by Dr. Pea with

148

orders carried out > on NPO except meds > with NGT F14 in placed NGT standard > with FBC in placed attached to urobag > kept watched for unusualities > routine ICU care done > needs attended > endorsed

7/10/11 10PM

> received awake on bed; conscious and coherent; with GCS score of 15/15; with spontaneous eye opening; responsive to painful stimuli; with pupil size of 3mm on both eyes; briskly reactive to light and accommodation; with normal power on both upper and lower extremities > with initial vital signs taken and recorded: BP=140/90 mmHg, HR=88bpm, Temp=35.8 degrees Celsius > hooked to cardiac monitor on sinus

rhythm, (+) tachycardia at times; (-) PAC; (+) PVC occasional > with ET @ 20 cm lip level attached to mechanical ventilator with the ff set-up: TV=500, RR=16, FiO2=100% on AC mode > suction secretions every hour and PRN; with moderate brownish ETA and brownish

149

oral secretions > turn to sides every 2 hours; back tapping rendered; placed on moderate high back rest > due nebulisations given; oral care done > with O2 sat monitoring saturating well at 98-99% > with NGT for due PO meds given; intake measured and recorded > standard followed > with ongoing IVF of D5W 1L @ 10cc/hr; with D5W250 + 2 amps Dopamine @ 8cc/hr; IVF standard with D5W250 + 2 amps Dobutamine @ 1cc/hr > with D5W250 + 6 amps Cordarone @ 11cc/hr > patent and infusing well at left arm > due IVTT meds given > standard followed FBC standard > with foley catheter attached to urine bag draining well to yellow color urine; output measured and recorded > standard followed HGT standard > with HGT monitoring every 6 hours with result relayed to Dr. Aperocho without orders > standard followed

150

General Notes

> routine ICU care rendered > morning care rendered > still for FBS, Lipid profile; AFB x 2 takings > I&O measured and recorded > kept monitored for any unusualities > needs attended > endorsed

7/10/11 6AM > received awake on bed, conscious, nods head when asked ample questions, verbalized needs by pointing and giving signals; with GCS monitoring with GCS score of 15/15, pupils 3mm in size, briskly reactive, with normal power on all extremities > vital signs taken and recorded > hooked to cardiac monitor on sinus rhythm (-) PAC, (-) PVCs noted > kept monitored for arrythmias Ineffective Airway Clearance > with ET @ 20 cm lip level attached to mechanical ventilator with the following set up: TV=500, RR=16, FiO2=80%, AC mode > suctioned secretions with moderate

brownish ETA and abundant blood tinged OS > due nebulizations given, oral care done, turned to sides at intervals, back tapping done, back kept dry, placed on moderate

151

high back rest > on continuous O2 sat monitoring,

saturating well at 99-100% > with NGT for due PO meds. Due meds NGT standard given with strict aspiration precaution. Intake measured and recorded. Standard followed. (-) BM noted FBC standard > with FBC attached to urobag draining to a dark yellow urine. Output measured and recorded. Standard followed. 12NN DM standard/HGT standard > with HGT monitoring every 6 hours while on NPO. HGT result relayed to Dr. Flores ICU ROD. No insulin coverage given > standard followed IVF standard > with venoclysis of D5W250 + 900 mg Cordarone @ 11cc/hr and D5W 1L @ 10cc/hr + 30 mEq KCl infusing well at left arm > intake measured and recorded. Standard followed > seen and examined by Dr. Pea with new orders carried out > routine ICU care rendered > needs attended, monitored for unusualities > endorsed 7/10/11 2PM > received awake on bed, conscious and coherent, able to follow commands, able to

152

verbalize needs, with GCS monitoring with score of 15/15, with pupil size of 3mm both pupils briskly reactive to light and accommodation, with normal power on all extremities noted > vital signs taken and recorded, BP=120/80 mmHg, HR=78bpm, on vent, O2 Sat=99%, Febrile=38.2 for fever > hooked to cardiac monitor on sinus degrees Celsius, Dr. Flores informed, Paracetamol 500 mg tab given PRN

rhythm, (-) PACs, (+) PVCs in isolated episodes > kept watched for any arrhythmias Ineffective Airway Clearance > with ET @ 22 cm lip level attached to mechanical ventilator with the following set up: TV=450, RR=16, FiO2=40%, on AC mode > due nebulisation given > suctioned secretions PRN and every 12 hours with moderate brownish ETA and abundant whitish with blood streaks oral seretions > turn to sides at intervals, gentle back tapping done, oral care done > placed on moderate high back rest > NGT standard on continuous O2 Sat monitoring

saturating well @ 99% > with NGT for of 200cc every 4 hours and

153

due PO meds given > patency checked, (-) BM noted > intake and output monitored and recorded > standard followed > with IVF of D5W250 cc + 900mg

IVF standard

Cordarone @ 11cc/hr (hold for HR 65 bpm) > with IVF #1 D5W 1L @ 10 cc/hr + 30 mEq KCl FBC standard > due IVTT meds given > standard followed > with FBC attached to urobag draining well to a yellow colored urine > output monitored and recorded DM Standard > standard followed > with HGT monitoring every 6 hours with result of 158 mg/dL, with no coverage given General Notes by Dr. Flores > standard followed > routine ICU care done > kept watched for any unusualities 10PM > still for CBC, Na+ K+, FBS, Lipid profile in AM and X-ray > intake and output measured and recorded 7/10/11 10PM > needs attended

154

> endorsed to night NOD

>

received

asleep

on

bed,

arousable,

conscious and coherent, able to express needs and complaints, with 3mm size on both pupils, briskly reactive to light, with normal power on all extremities > initial vital signs taken and recorded as follows: BP=110/80 mmHg, HR=85 bpm, RR=on vent, O2 sat=98% > hooked to cardiac monitor on sinus rhythm Ineffective Airway Clearance (-) PVCs (-) PACs, monitored for any arrhythmias > with ET @ 20cm lip level attached to mechanical mode > secretions suctioned with abundant pale yellow ETA and minimal to moderate pinkish OS > turned to sides every 2 hours, due Impaired Skin Integrity nebulisation given, gentle chest tapping rendered, placed on moderate high back rest > on continuous O2 saturation monitoring NGT standard saturating @ 95-99% > with burns with at chest at area after ventilator with the following settings: TV=450, RR=16cpm, FiO2=40%, AC

defibrillation,

wound

tongue

inflammation noted

155

> oral care done > with NGT for OF ad medications > on fasting and still for FBS, Lipid profile, due 7/11/2011 8AM IVF standard > patency checked and maintained > enteral intake measured and recorded > standard followed > with ongoing venoclysis of D5W 1L + 30 mEq KCl infusing well via infusion pump > IV site (-) infiltration (-) phlebitis FBC Standard > parenteral intake measured and recorded > due IVTT meds given > standard followed HGT Standard > with FBC attached to urobag draining well to a yellow colored urine > urine output measured and recorded 7/11/11 6AM > standard followed > with HGT monitoring every 6 hours, HGT results relayed to Dr. Flores without coverage > standard followed > routine ICU care rendered > endorsed

6AM

>

received

asleep

on

bed,

arousable, 156

conscious and coherent, on GCS monitoring every hour, with GCS score of 15/15, with spontaneous eye opening, both pupils 3mm size, briskly reactive to light, with normal power on both upper and lower extremities Ineffective Airway Clearance > initial vital signs taken and recorded, BP=120/90 mmHg, HR=78 bpm, and O2 saturation of 98% and afebrile > with ET @ 20cm lip level attached to mechanical mode > suctioned secretions every hour/PRN with copious brown/blood streaked ETA and moderate abundant blood tinged OS > due nebulizations give, turned to sides every 2 hours, back tapping done, placed on moderate high back rest and continuous O2 sat monitoring saturating well at 98-100%, NGT standard oral care done > hooked to cardiac monitor with NSR, (-) PAC, (-) PVC, and monitored for any arrhythmias IVF standard > with NGT on left nostril for OF and due PO meds, in place, (-) NGT drainage > intake measured and recorded. Standard followed FBC Standard > with ongoing IVF of D5W 1L @ 10cc/hr + 30 mEq KCl, infusing well via infusion pump ventilator with the following settings: TV=450, RR=16cpm, FiO2=40%, AC

157

> parenteral intake measured and recorded. Standard followed. 2PM > with FBC attached to urobag with a dark yellow colored urine, draining well 7/11/11 2PM > urine output measured and recorded > standard followed > routine ICU care rendered > for repeat sodium and K+ tomorrow morning 7/12/11 > endorsed

>

received

asleep

on

bed,

arousable,

conscious and coherent, on GCS monitoring every hour, with GCS score of 15/15, with spontaneous eye opening, both pupils 3mm size, briskly reactive to light > with normal power on both upper and lower extremities > initial vital signs taken and recorded: Ineffective Airway Clearance BP=110/80 mmHg, HR=76 bpm, and O2 saturation of 98% and afebrile > hooked to cardiac monitor on sinus rhythm (-) PVCs (-) PACs, monitored for any arrhythmias > with ET @ 20cm lip level attached to mechanical ventilator with the following settings: TV=450, RR=16, FiO2=40%, AC

158

mode > secretions suctioned with abundant pale yellow ETA and moderate to abundant blood NGT standard tinged OS > due nebulizations given, turned to sides every 2 hours, back tapping done, placed on moderate high back rest and continous O2 sat monitored saturating well @ 98-100%, IVF standard oral care done > with NGT on left nostril for OF and due PO meds, in place, (-) NGT drainage FBC standard > intake measured and recorded standard followed > with ongoing IVF of D5W 1L @ 10cc/hr + 30 mEq KCl, infusing well via infusion pump, 10PM standard followed > with FBC attached to urobag with

hematuria noted, draining well 7/11/11 10PM > urine output measured and recorded > standard followed > routine ICU care rendered > needs attended > kept monitored for any unusualities > endorsed to night NOD

>

received

asleep

on

bed,

arousable,

159

conscious and coherent, on GCS monitoring every hour, with GCS score of 15/15, with spontaneous eye opening, with pupil size of 3mm on both eyes, briskly reactive to light and accomodation, with normal power on both upper and lower extremities Ineffective Airway Clearance > initial vital signs taken and recorded as follows: BP=100/70 mmHg, HR=76 bpm, and O2 saturation of 98% and afebrile > hooked to cardiac monitor on sinus rhythm (-) PVCs, (-) PACs, monitored for any unusualities > with ET @ 20cm lip level attached to mechanical mode NGT Standard > secretions suctioned with abundant pale yellow ETA and moderate blood tinged OS > due nebulizations given, turned to sides every 2 hours, back tapping done, placed on IVF Standard moderate high back rest and continous O2 sat monitored saturating well @ 98-100%, FBC Standard oral care done > with NGT on left nostril for OF and due PO meds, in place, (-) NGT drainage > intake measured and recorded standard 6AM followed > with ongoing IVF of PNSS 1L @ 10cc/hr infusing well via infusion pump standard 7/12/11 160 ventilator with the following settings: TV=450, RR=16, FiO2=40%, AC

6AM

followed > with FBC attached to urobag with

hematuria noted, draining well > urine output measured and recorded > standard followed > routine ICU care done/rendered > kept watched for any unusualities > endorsed

> received awake, lying on bed, conscious and coherent, on GCS monitoring every hour with a score of 15, with spontaneous eye 7: 05AM Ineffective Airway Clearance opening, both pupils equally reactive to light and accommodation measuring 3mm, with normal power on both upper and lower extremities > initial vital signs taken and recorded: BP=130/100 mmHg, HR=75 bpm, and O2 sat - 99%, afebrile > hooked cardiac monitor on sinus rhythm (-) PVCs, monitored closely for any arrhythmias > with ET tube in place @ 20cm lip level attached to mechanical ventilator with the following settings: TV=450, RR=16, FiO2=40%, on AC mode > weaning started on T-piece @ 6LPM for 15 min- tolerated, hooked back to mech vent for

161

30

min,

on

T-piece

for

30

minutes

tolerated, hooked back to mech vent for 30 min, on T-piece again for 1 hr- tolerated, hooked back to mech vent for 30 min, on Tpiece for 2 hours tolerated well > secretions suctioned PRN with moderate whitish ETA, and clear, blood tinged oral NGT standard secretions breathing extubation IVF standard > turned to sides every 2 hours, due nebulizations saturation given, chest physiotherapy monitored, done, maintained n high back rest, O2 continuously saturating well @ 98-99% 1:15PM FBC standard > with patent NGT in place > intake measured and recorded > NGT standard followed > with ongoing IVF of #2 PNSS 1L @ 680 cc level, infusing well over left arm via infusion pump set to drop standard followed > with FBC in place attached to urobag draining in a tea-colored urine, oliguria noted as output is only 150cc for the entire shift, referred to Dr. Rosales, output recorded, FBC standard followed 7/12/11 2PM > extubation done by Dr. Rosales after oral and ET secretions were suctioned, oral care @ 10 gtts/min, IVF in copious in amount, taught for exercises preparation

1:25PM

162

rendered, O2 inhalation delivered via nasal cannula @ 5LPM saturating well @ 99%, kept monitored for unusualities none noted > NGT removed per doctors order, patient watcher and dietary department informed of dietary changes > vital signs monitored every hour > routine ICU care rendered > kept monitored for any unusualities

>

received to

awake time

sitting and

on

bed on

on GCS

moderate high back rest, conscious and oriented Altered Breathing Pattern place, monitoring every hour with score of 15, with spontaneous eye opening both pupils at 3mm in diameter equally round, reactive to light accommodation, with normal power on both upper and lower extremities, with initial vital signs taken and recorded - afebrile > hooked to cardiac monitor on normal sinus rhythm, (-) PVCs, (-) PACs, monitored for any IVF standard arrhythmias > on O2 inhalation @ 5LPM via nasal cannula, (+) productive cough able to expectorate phlegm with moderate yellowish to whitish secretions, able to turn to sides on his own, with due nebulization given > gentle back and chest tapping done, O2 4PM sat monitored with saturation of ,

163

maintained in moderate high back rest FBC standard > with ongoing IVF infusion of #2 PNSS 1L @ 360cc level @ left arm via infusion pump set to run at 10gtts/min patent and infusing 5:50PM General Notes well, with due IVTT meds given, IVF standard followed > in soft diet, fed with strict aspiration precaution, due PO meds given, intake measured and recorded > with foley bag catheter attached to urobag draining well to a tea colored urine, output measured recorded, FBC standard followed 8:30P M > seen and examined by Dr. Gamolo with orders carried out, O2 inhalation was decreased to 2LPM in nasal cannula, shifted Axera to Tergecef 200mg 1 tab BID 10PM > for repeat CKMB > seen and examined by Dr. Pea with 7/13/11 10PM orders carried out > (+) tea colored urine, (+) hematuria, seen by Dr. Pea > hold Clexane and Aspirin temporarily as per doctors order > for 2D Echo with color flow Doppler studies in AM 7/13/11, for BUN and Crea, Hemostan 500mg IVTT started > foley catheter accidentally removed by patient Dr. Aperocho informed

164

> needs attended > endorsed

> received awake on bed, on moderate high back rest, conscious and coherent. On GCS monitoring every hour with score of 15, with spontaneous eye opening both pupils at Ineffective Airway Clearance 3mm in diameter equally round reactive to light accommodation, with normal power on both upper and lower extremities, with initial vital signs taken and recorded- afebrile > hooked to cardiac monitor on normal sinus rhythm, (-) PAC, (-) PVC > BP and HR kept monitored and watched for any unusualities > (+) productive cough able to expectorate phlegm, with large amount of bloody oral secretions, ROD informed with new orders > placed on high back rest; kept back dry and comfortable > due nebulisation given back tapping done, 7/13/11 6AM General Notes kept monitored for shortness of breath and O2 desaturation > IVF due and transferred to right hand, with IVF #3 PNSS 1L regulated at 10gtts/min infusing well > due IVTT meds given

IVF standard

165

7AM

> IVF standard followed > intake and output measured and recorded > routine ICU care rendered > kept observed > endorsed to AM NOD

> received awake on bed, conscious and coherent; not in respiratory distress; on GCS monitoring every hour with a score of 15/15; with both pupils 3mm in diameter, both briskly reactive to light and accommodation; Altered Breathing Pattern with normal motor response on all extremities > initial vital signs taken and recorded: BP=110/80 Sat=99% > hooked to cardiac monitor on sinus rhythm (-) PVCs (-) PACs noted Soft Diet > kept monitored for arrhythmias and mmHg, HR=70, RR=22, O2

referred accordingly > with O2 inhalation @ 2LPM via nasal cannula (+) productive cough with yellow phlegm with blood streaks noted able to expectorate >turned to sides every 2 hours; placed on moderate high back rest; kept back dry at all times; oxygen saturation monitored and

166

recorded > served and consumed of share with good appetite > (+) throat pain upon swallowing as claimed IVF standard > strict aspiration precaution > due oral medications given > intake measured and recorded 10:50AM General Notes >(-) BM noted during shift > voids per urinal with amber colored urine kept monitored for hematuria and referred accordingly > output measured and recorded > with ongoing IVF of PNSS 1L @ 10gtts/min infusing well at right arm due meds given 7/13/11 2PM > patent and without signs of phlebitis or infiltration > standard followed > on complete bed rest maintained > with inflamed tongue noted resolving oral care with Bactidol oral swab done > with burns first degree on anterior chest after defibrillation > ushered to heart station for 2D Echo woth CFDs and ushered back to ICU once done follow up result

167

> routine ICU care rendered Ineffective Airway Clearance > needs attended > endorsed to PM NOD

>received awake on bed, conscious and coherent, initial vital signs taken and recorded afebrile >hooked to cardiac monitor on sinus rhythm with ST elevation, (-) PAC, (-) POCS noted, kept closely monitored 10PM IVF Standard >(+) inflamed trachea, (+) productive cough able to expectorate pleghm, able to turn to sides, with due medications q8 given, with 7/13/11 10PM O2 inhalation @ 2L/min via nasal cannula, (-) SOB noted, O2 sat monitored, saturating well @ 99%, placed on moderate high back rest >on soft diet, served and consumed share with good appetite, fed with aspiration precautions, intake measured and recorded >voids per urinal urine output measured and recorded >with on-going venoclysis @ right arm

patent and infusing well, with due IVTT meds given, IVF Standard followed >seen and examined by Dr. Gamolo >routine ICU care done

168

>observed for any unsualities >endorsed Altered Breathing Pattern

>received awake; conscious and coherent, responsive to all forms of stimuli; able to verbalize needs; with normal power on all extremities >v/s taken and recorded >hooked to cardiac monitor sinus rhythm; (-) PACS, (-) PVCS >kept monitored abnormalities >with O2 inhalation @2L/min via nasal and observed for any

cannula saturating well >(+)productive cough able to expectorate whitish pleghm IVF Standard 6AM >on MHBR and kept back dry and

comfortable >able to turn to sides @ intervals >on continence, O2 sat monitoring and kept observed for respiratory distress >on soft diet >due P.O. meds given >voids per urinal and may use bedside commode

7/14/11 6AM

169

>with IVF @ right arm infusing well >due IV meds given >standard followed >I and O measured and recorded >routine care rendered >kept observed >endorsed

Altered Breathing Pattern

>received awake, conscious and coherent; Diet able to verbalize needs >vital signs taken and recorded >hooked to cardiac monitor on sinus rhythm (-)PAC, (-)PVC; kept monitored for arrhythmias IVF Standard >with O2 inhalation @1L/min cannula >placed on moderate high back rest; able to turn to sides General Notes 2PM >oral care done; due nebulization given; with productive cough noted able to expectorate pale 7/14/11 2PM Post transfer Assessment yellow sputum; oxygen saturation monitored saturating @ 98-99% >on soft, low salt, low Fat diet; ate share and consumed with good appetite; aspiration precaution strictly observed via nasal

170

>voids per urinal >Intake and output measured and recorded Health Teaching: Stress Reduction 7/14/11 11PM >with ongoing venoclysis @ right arm,

patent and infusing well (-) infiltration noted; standard followed >For trans-out to Private room today >kepy watched for unsualities >routine ICU care done

7/15/11 8AM Health Teaching: Complete Bed rest

>needs attended >transported to Station 2 per stretcher wit h BP- 120/80mmHg, HR- 73bpm, RR- 17cpm, O2 sat- 98% >endorse to Station 2

7/15/11 9PM Body Weakness

D: received from ICU per stretcher, with IVF of #4 PNSS 1L @ 10 gtts/min A: ushered to patient room of choice,

instructed patient and watcher to be on complete bed rest without toilet privileges, vital signs taken and recorded, kept watched for any unusualities

7/15/11

Health Teaching: Complete Bed rest without toilet privilege with bedside commode

A: Discussed on different ways to minimize/ prevent stress in order to prevent recurrence of chest pain R: Stated understanding of the health

171

teaching

A: instruct patient to have complete bed rest and to use bedside commode in case of urge to defecate to avoid stress that may lead to other complications Health Teaching: Amiodarone R: Patient stated understanding of the

7/15/11 8AM

instruction given

D: received on bed with ongoing IVF of PNSS 1L @ 450cc level regulated @ 10gtts/min; infusing well on the right arm with initial vital sign of BP 110/80 T- 36.5 PR- 75bpm RR- 22 cpm 12NN Health Teaching: Compliance to Medication A: placed on bed comfortably with proper postioning, head of bed elevated, maintained to moderate high back rst R: Arang-arang na ako paminaw as

verbalized by the patient

A: instructed to remain at bed at all times 7/15/11 4PM Health Teaching and to use bedside commode for defecation. Explained the importance of the plan, to maintain adequate rest and to refrain from strenuous activities which may cause further complications R: verbalized understanding willingness to participate of plan and

172

Health Teaching: Medication Compliance 7/16/11 10PM

A: any information given to patients and patients watcher particularly the drug usage, action and side effects R: verbalized understanding of the given information

D: explained and instructed patient and patients watcher the importance of complying in the therapy, administering the prescribed medications with the right dosage Health Teaching and timing and possible adverse effects R: Patient and watcher verbalized

7/17/11 10AM

understanding of the given information

D>received on bed with ongoing PNSS 1L 500cc level regulated @ 10gtts/min with 7/17/11 9PM initial vital signs of BP- 120 T-36 RR-19cpm PR-80bpm Health Teaching: Balanced Nutriton A>patient instructed about the importance of medication regimen, diet modification, regular exercise, adequate rest period R>patient verbalized understanding of health 7/18/11 8AM Health Teaching: Proper Diet A: reinstructed patient about taking the medications at home with the proper dosage, proper timing and to continue medications in teaching imparted

173

specific span of time especially antibiotics to achieve therapeutic effect of the prescribed medications R: verbalized understanding of plan and willingness to cooperate

A:

encouraged

adequate

rest

upon

discharged to avoid stress and occurrence of condition R: verbalized understanding DISCHARGED A: Discussion given about balanced nutrition and its importance in relation to current condition R: verbalized understanding to instruction given

A: instruct patient to eat proper duo of fat and salt to avoid other complications R: patient stated understanding to instruction given

A: home medications given >how meds instructed with emphasis on timing >refer to discharge plan

174

R: client verbalized on understanding of the given discharge plan

XV. BIBLIOGRAPHY

Black, Joyce M., et.al. Medical- Surgical Nursing: Clinical Management for Positive Outcomes. Singapore: Saunders Elsevier, 2008. 8th edition. Vol.1&2. Cuevas, Frances Prescilla L.ed. Public Health Nursing in the Philippines. Philippines: National
th

League

of

Philippine

Government

Nurses,

Incorporated, 2007. 10 ed.

175

Doenges, Marilynn E., et.al. Nurses Pocket Guide Diagnoses, Prioritized Interventions and Rationales. Philadelphia: F.A. Davis Company, 2008. 11th edition. Doenges, Marilynn E., et.al. Nursing Care Plans, Guidelines for Individualizing Patient Care. Thailand: F.A. Davis Company, 2002. 6th edition. Karch, Amy M. 2009 Lippincotts Nursing Drug Guide. London: Lippincott William and Wilkins, 2009. Porth, Carol Mattson. Pathophysiology: Concepts of Altered Health States. Philadelphia: Lippincott William & Wilkins, 2005. 7th edition. Rosto, Elizabeth ed. Pathophysiology: Made Incredibly Easy!. Philippines: Lippincott Williams & Wilkins, 2009. 4th edition. Smeltzer, Suzanne C.,et.al. Brunner and Suddarths Textbook of MedicalSurgical Nursing. New York: Lippincott Williams & Wilkins, 2004. 10th edition. Vol. 1&2 Udan, Josie Q. Medical-Surgical Nursing: Concepts and Clinical Application. Philippines: Guiani Prints House, 2002. 1st edition. Weber, Janet R. Nurses Handbook of Health Assessment. Philadelphia: Lippincott Williams & Wilkins, 2008. 6th edition.

176