mMYOCARDIAL INFARCTION




V Myocardial infarction (MI) or acute myocardial
infarction (AMI), commonly known as a heart attack is
the interruption of blood supply to part of the heart,
causing some heart cells to die. This is most
commonly due to occlusion (blockage) of a coronary
artery following the rupture of a vulerable
atherosclerotic plague, which is an unstable collection
of lipids(fatty acids) and white blood
cells(especiallymacrophages) in the wall of an artery.
The resulting ischemia(restriction in blood supply)
andoxygen shortage, if left untreated for a sufficient
period of time, can cause damage or death (infarction)
of heart muscle tissue (myocardium).
V The researchers decided to choose this case because
they wanted to acquire more knowledge about
Myocardial infarction. They wanted to use the
knowledge that they have acquired in promoting
awareness to the people especially to the poor that
they should seek for medical care in order to prevent
the development and progression of complications
related to HPN. The researchers also wanted to focus
on preventive measures. Complications may occur
and the researchers would not want that to happen, so
they will focus more on information campaign as part
of primary prevention of health.
V This study will help the nursing profession by
providing information about the proper
management and care for hypertensive patient. It
will also educate the people, especially those with
hypertension and vulnerable individuals to seek
medical care in order to prevent such illnesses. It
will increase awareness about the importance of
having a healthy lifestyle and recommended food
preferences.
V This study will discuss the background of
myocardial infarction and its signs and symptoms
and the proper nursing care management of the
medical condition will also be tackled.
V However, this study will help a lot in the duties
in the area of nurses.
 


V NAME: A.M.A.
V ADDRESS: Near Globe Tower, Turbina, Calamba City,
Laguna, Philippines
V SEX: FEMALE
V CIVIL STATUS: Widowed
V BIRTHDATE: November 12, 1937
V BIRTH PLACE: Calamba City, Laguna
V AGE: 72y0m11d
V NATIONALITY: Filipino
V OCCUPATION: Retired
V ADMISSION DATE: November 23, 2009
V ADMISSION TIME: 04:34 pm
V The patient was admitted at Calamba Medical
Center last November 23, 2009 due to the
complaint of vomiting.
V Few hours prior to admission the patient was
experiencing epigastric pain with associated
vomiting
V
V When the patient experiences CVA, the patient
takes herbal medicine.
V The family has a history of high blood pressure
and diabetes.
 §§§ 
§
§ 


  


§ 

1. Size, shape Inspection Rounded Normocephalic Normal findings states
(normocephalic Symmetrical no signs of abilities
and Palpation and symmetrical, shape
symmetry of with frontal,
the skull. parietal, and
occipital
prominences);
Smooth skull
contour
2. Presence Palpation Smooth, uniform Plain and smooth Normal findings states
consistence; when palpated no signs of
of nodules, Inspection absence of nodules abnormalities
masses and or masses
depressions.
3. Facial Inspection Symmetric or All movements are The face has no
slightly well procured movement disabilities
features. Palpation asymmetric facial
features;
palpebral fissure
equal in size;
symmetric
nasolabial
4. Presence Inspection No edema and Eyes are not Normal findings states
hollowness exopthalmic and
of edema no signs of edema no signs of disabilities
and
hollowness in
the eye.
§

ely istrite Hir is t i  
Hir lss e t i
1.
eess f Is ecti  c
ers t e
rt , t erere sis f
lti  le scl;  ir l ss


t ic  ess
r M y e t ic  r
t iess f t i
ir. 

2. ext re Is ecti Sil y; resiliet ir Oily ir Oily  ir e t
 iliess i ility t clese
lti  
 ir r erly

er t e
scl .  ifecti   sis f lesis r l fiis sttes
3. resece Is ecti   
 sis f
f ifecti ifestti  scl
l ti  r lities

ifesttis.

§

Syetric r 
e ets r l fiis sttes
1. Fcil Is ecti All 
re ls ell 
 sis f
sli tly
fet res,  sy  etric f ci l rc re  r lities
sy etry f fet res;
fcil  le r l fiss res
eq  l i size;

e ets. sy etric 
 s l il fl s
 



§

1. air Inspection Symmetrical and in Clean and evenly Normal findings states
line with each
distribution, other; maybe distributed no signs of
alignment, black, brown or abnormalities
skin quality blond depending
on race; evenly
and distributed
movement.

 
1. Evenness of Inspection Evenly distributed; Equally distributed Normal findings states
turned outward
distribution Palpation and turned no signs of
and direction outward eyelashes abnormalities
of curl.

!"
1. Surface Inspection Upper eyelids cover No signs of Normal findings states
the small portion of
characteristics the iris, cornea, and discharge and no signs of
and position. sclera when eyes discoloration, able abnormalities
(in relation to are open; eyelids to close eyes,
meet completely
cornea, when the eyes are blinking normally
ability to closed; symmetrical
blink and
frequency of
blinking)
 #$%#&'!(
1. Color, Inspection Pinkish or red in Smooth in texture Normal findings states
color; with
texture and Palapation presence of small no signs of
the presence capillaries; moist; abnormalities
of lesions in no foreign bodies;
no ulcers
the bulbar
conjunctiva.
2. Color, Inspection Pinkish or red in Pinkish in color and Normal findings states
color; with
texture and Palpation presence of small no lesions no signs of
the presence capillaries; moist; abnormalities
of lesions in no foreign bodies;
no ulcers
the
palpebral
conjunctiva.

&
1. Color and Inspection White in color; Sclera is yellowish in Abnormal. Yellowish
clear; no yellowish
Clarity discoloration; color sclera due to lack of
some capillaries nutrition
maybe visible
#
1. Clarity and Inspection No irregularities Clear and smooth Normal findings states
on the surface;
texture looks smooth; in texture no signs of
clear or abnormalities
transparent
!
1. Shape and Inspection Anterior chamber Transparent Normal findings states
is transparent; no
color noted visible anterior chamber no signs of
materials; color abnormalities
depends on the
person·s race

%)!
Inspection Color depends on upil size is 3mm Normal findings states
1. Color, the person·s race;
size ranges from no signs of
shape and 3-7 mm, and are
e
abnormalities
symmetry of  ual in size;
size. e ually round

2. Light Inspection Constrict Capable of light Normal findings states

briskly/sluggishly
reaction and when light is reaction (constricts no signs of
accommodat directed to the when there is abnormalities
ion. eye, both directly light)
and consensual
!%§&%!'
1. Near vision Inspection Able to read Incapable of Abnormal. Due to
newsprint
reading new sprint aging

*&!+#"
1. Palpability Palpation No edema or No tenderness Normal findings states
tenderness over
and lacrimal gland no signs of
tenderness of abnormalities
lacrimal
gland.

,'&%
%&

1. Eye Inspection Both eyes oves in unison

coordinated,
alignment move in unison, Normal findings states
and with parallel no signs of
coordianatio alignment abnormalities
n.
!%!"

1. Peripheral Inspection When looking Cannot see objects Abnormal. Due to

straight ahead,
and Visual client can see in the periphery aging and lack of
Fields. objects in the nutrition
periphery

§ 
§§%!&
1. Color, Inspection Color same as Same color as Normal findings states
facial skin;
symmetry of symmetrical; facial skin, tip of no signs of
size, and auricle aligned auricle aligned at abnormalities
position. with outer the outer canthus
canthus of eye,
about 10 degrees of the eye
from vertical

2. Texture, Palpation , firm, and not Smooth in texture, Normal findings states
tender; pinna
elasticity and recoils after it is no tenderness no signs of
areas of folded abnormalities
tenderness

!#-§&%!''

1. Client·s Inspection Normal voice Cannot hear Abnormal. Due to

tones audible
response to normal volume aging
normal voice tones
tones.
 

1. Any Inspection Symmetric and Symmetrically no Normal findings states
straight; no
deviations in discharge or discharge no signs of
shape, size or flaring; Uniform abnormalities
color and color
flaring or
discharge
from the
nares.
2. Nasal Inspection Nasal septum Nasal septum Normal findings states
Palpation intact and in
septum midline intact and in no signs of
(between midline abnormalities
the nasal
chambers)
Inspection Air moves freely 
3. Patency of an breathe Normal findings states
as the client
both nasal breathes through normally no signs of
cavities. the nares abnormalities

4. Palpation Not tender; no No tenderness nor Normal findings states

lesions
Tenderness, lesions no signs of
masses, and abnormalities
displacement
s of bone
and
cartilage


1. Inspection Not tender No pain when Normal findings states
Idantification palpated no signs of
of sinuses abnormalities
and for
tenderness.


§!)
1. Symmetry Inspection Uniform pink Pale in color,has Abnormal. Due to
Palpation color; soft, moist,
of contour, smooth texture; the capability to aging
color and symmetry of purse lips
texture. contour; ability to
purse lips
%&&
%&
1. Color, Inspection Uniform pink Pink color Normal findings states
color; moist,
moisture, smooth, soft, no signs of
texture and glistening, and abnormalities
the presence elastic texture
of lesions.
'
1. Color, Inspection 32 adult teeth; The patient have Abnormal. Related to
smooth, white,
number and shiny tooth dentures upper dental carries and
condition enamel; smooth, and lower area infrequently tooth
and presence intact dentures Some areas are brushing
of dentures. black and
yellowish
 %+
1. Color and Inspection Pink gums; no Pink gums; has no Normal findings states
retraction
condition. visible retraction no signs of
abnormalities

#-%./' 
%'
1. Color and Inspection Pink color; moist; Pink and moist Normal findings states
slightly rough;
texture of thin whitish Tongue moves no signs of
the mouth coating; moves freely and no pain abnormalities
floor and freely; no felt
tenderness
frenulum.
2. Position, Inspection Central position; Located and Normal findings states
pink color;
color and smooth tongue positioned in the no signs of
texture, base with center abnormalities
movement prominent veins
and the base
of the
tongue.
3. Any Palpation Smooth with no No tenderness Normal findings states
Inspection palpable nodules,
nodules, lumps, or no signs of
lumps or excoriated areas abnormalities
excoriated
area.
'#"(%
1. Color, Inspection Light pink, No presence of Normal findings states
Palpation smooth, soft
shape, palate; lighter exostoses (bony no signs of
texture and pink hard palate growth) abnormalities
presence of , more irregular
texture
bony
promnences.
2. Position of Inspection Positioned in No damage on 5th Normal findings states
midline of soft
the uvula palate and 10th cranial no signs of
and mobility nerve abnormalities
(while
examining
the palates)
 ) #,#"#!
1. Color and Inspection Pink and smooth No swollen or Normal findings states
posterior wall
Texture. inflamed no signs of
abnormalities

2. Size, color Inspection Pink and smooth; No presence of Normal findings states
no discharge; of
and normal size discharge; pinkish no signs of
discharge of abnormalities
the tonsils.
3. Gag Reflex Inspection Present The patient has no Abnormal. Due to
gag reflex stroke she experienced
before
0 §0
§§#'! ,
1. Breathing Inspection Quiet, rhythmic, effortless Normal findings states
and effortless
Patterns. respirations no signs of
abnormalities

2. Palpation Skin intact; as an intact skin; Normal findings states

uniform has equal warmth
Temperature temperature; on both sides. No no signs of
, tenderness, chest wall intact; masses. abnormalities
masses. no tenderness; no
masses

3. Anterior Auscultation Bronchovesicular Bronchovesicular Normal findings states

and vesicular and vesicular
thorax, breath sounds breath sounds no signs of
auscultation. heard abnormalities
'! ,
1. Shape, Inspection Anteroposterior as a Normal findings states
Palpation to transverse anteroposterior to
symmetry diameter in ratio transverse no signs of
and 1:2; Chest diameter ratio of abnormalities
comparison symmetric 1:2, elliptical in
shape and
of the symmetrical chest
anteroposteri
or thorax to
transverse
diameter.
2. Spinal Inspection Spine vertically as a vertical Normal findings states
aligned alignment
alignment. no signs of
abnormalities

3. Palpation Skin intact; No masses nor Normal findings states

uniform tenderness; has
Temperature temperature; equal warmth on no signs of
, tenderness, chest wall intact; each side abnormalities
masses. no tenderness; no
masses
4. Posterior Auscultation Vesicular and Vesicular and Normal findings states
bronchovesicular bronchovesicular
thorax, breath sounds breath sounds no signs of
auscultation. heard abnormalities
0§  §§
§§'!& Auscultation No pulsations No presence of Normal findings states
reeves
#" no signs of
%+#!& abnormalities
§
 Auscultation No pulsations; no Normal active of Normal findings states
lift or heave right ventricle
!&%)!" no signs of
§ abnormalities

§)!& Auscultation Pulsations visible No lifts Normal findings states

in 50% of adults
§ and palpable in no signs of
most P I in fifth abnormalities
LICS at or medial
to CL
 Auscultation Aortic pulsations as pulsations Normal findings states

)!-'!& no signs of
§ abnormalities
0§  § 



1. Carotid Palpation Symmetric pulse Symmetric pulse Normal findings states

volumes; full
artery pulsations, volumes no signs of
palpation. thrusting quality; abnormalities
quality remains
same when the
client breathes,
turns head, and
changes from
sitting to supine
position; elastic
arterial wall

0§0§

1. Axillary, Inspection No tenderness, No masses and Normal findings states
masses, or nodules
subclavicular nodules no signs of
and abnormalities
supraclavicul
ar lymph
nodes.
0§


1. Skin Inspection Unblemished skin; Not uniform in Abnormal. Due to aging
uniform color
Integrity. color and no lesions

2. Abdominal Inspection Flat, as a concave Normal findings states

rounded(convex),
Contour. or abdomen. no signs of
scaphoid(concave) abnormalities
3. Inspection No evidence of There is no Normal findings states
enlargement of
Enlargement liver or spleen enlargement of the no signs of
of liver or liver or spleen abnormalities
spleen.
4. Symmetry Inspection Symmetric contour as a symmetrical Normal findings states
of contour. abdominal contour no signs of
abnormalities
5. Abdominal Inspection Symmetric as no blood Normal findings states
movements
movements caused by vessels visible no signs of
associated respiration; visible abnormalities
with peristalsis in very
respirations, lean people; aortic
pulsations in thin
peristalsis or persons at
aortic epigastric area
pulsations.
6. Vascular Inspection No visible vascular
pattern
patterns.
0
 

§

§
%&
1. !uscle size Inspection Proportionate to The muscle is Normal findings states
the body; even in
and both sides proportionate to no signs of
comparison the body; even in abnormalities
on the other both sides
side.
2. Inspection No fasciculation No presence of Normal findings states
and tremors
Fasciculation tremors on the no signs of
and tremors patient abnormalities
in the
muscles.
3. !uscle Palpation Even and firm The muscles of the Normal findings states
muscle tone
Tonicity patient is normally no signs of
firm abnormalities

4. !uscle Palpation "as equal The muscle Abnormal. Due to mild

muscular strength
Strength on both sides strength of the stroke
right side is not
equal to the
muscle strength of
the left side
*!#'

1. Joint Inspection No swelling, no There is no

warmth, no
swelling. redness, no pain, presence of Normal findings states
no crepitus swelling on the no signs of
patients joint, no abnormalities
pain
0 Inspection, No swelling, no The patient have abnormal
Palpation warmth, no

0

 redness, no pain. edema I her both

 feet, no pain and
tenderness
 §#!#"
'- +!#"!#- §&'%!#"!#-
#')''!#

#'''%
Š Level of Alert
# Alert
# Normal
Consciousness riented riented to person Normal
#
Š rientation Coherent Coherent Normal
Š Language Test Able to remember Able to state what are the things Normal
Š Recall that happened to her past

#!(
Š CN$I Able to smell and recognize stimuli Able to identify scent of the Normal
( lfactory) 20/20 alcohol Abnormal
$ $
Š CN II ( ptic) (+)E &; lateral upward and Cannot read in near vision Normal
Š CN downward; pupils react to light Normal
$ III, IV, VI Pupils react to light. There is
( cculomotor, Able to feel and clearly identify constriction and eyes are able to Normal
Trochlear, stimulus, with bilateral facial move in unison Abnormal
Abducens) sensation Able to feel my finger on her face Normal
Š CN V (+)corneal reflex facial symmetry while covering her eyes Normal
(Trigeminal) Able to hear clearly, can maintain Facial symmetry Normal
Š CN VII (Facial) balance Cannot hear normal volume tone
Š CN VIII (+)gag reflex, uvula at the center Able to swallow and able to
(Vestibulocochl Able to shrug shoulders against identify the taste of the food
ear) resistance and able to turn head Can shrug shoulders against
Š CN IX, X aside against resistance resistance and can turn head side
(Glossopharyn Able to move tongue from side to to side
geal, Vaus) side Able to protrude tongue and
Š CN XI move side to side
(Accessory)
Š CN XII
( %ypoglossal)
V The researchers utilized Gordon¶s Typology in
assessing the patterns of functioning of our patient
in her life. How does she manage, and takes care
of herself based on the eleven patterns.
 =
   
=
 


 


does not drink any alcoholic beverages

either doesn¶t use cigarettes
 

  
 
 

she eats atleast 3x a day

took general volume of liquid
wear dentures
able to eat and swallow foods.
 



No presence of pain when urinating

she defecates every other day
does not have UTI
 

  

doesn¶t involve in any household chores

can shower and washes hair independently
  
   

highest educational attainment is elementary
she is widowed
She doesn¶t have any difficulty when it comes to communicating.
She stops studying because of financial problem.
She can read and right properly.
She can talk properly.
She is aware of the people and happenings around her.
She can express her feelings appropriately.

 

  
usual sleep pattern 8-9 hours
Her usual wake-up time is 11 am.
She doesn¶t have any difficulty when it comes to sleeping.
She feels that her sleep and rest is adequate.
does not used sleep medications

   

Vison:She has eyeglasses but doesnt¶s wear it
due to old age.
She doesnt need it in doing her Activities
of Daily Living
Hearing:She doenst wear hearing aid.
No difficulty in hearing
Smell: No difficulty in smelling
Touch: No difficulty in sense of touch
Taste: No difficulty in her sense of taste.
    



-got married at the age of 42

-no siblings


   

menstrual history:
age of menarche: approximately
14 years old
Nullipara
  

 
shares confidence and problems with her husband before.
Whenever she has problems, she automatically relies to God for help.
 h
   
She is Roman Catholic
she can¶t attend mass every Sunday
due to old age
have belief in life.
 =
=   =


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KK.12.34 +'- (120-150)g/L 130
=emoglobin (0.37-0.47) 0.38
=ematocrit (5-10 x 10^9/L) 14.0
WBC (4-4.5x10^12/L) 4.3
RBC
!//#'! %#' 0.55-0.65 0.88
Segmenters 0.25-0.35 0.12
Lymphocytes 150-400x100^9/L 221
Platelet Count
"#"!& 80-96 88.4
'CV 27-31 30
'C= 32-36% 34
C=C
 !" # ' (.47-4.64 uIV/ml)EIA .204
TS= (1.45-3.48 pg/ml)EIA .91
FT3 (0.71-1.85 ng/dl)EIA .84
FT$
KK.15.34 !' 163 (0-16 U/L) 1
CK B
!' 163 (0.52-1.25 mg/dl) 0.9
Creatinine (137-145 mmol/L) 138
Sodium (3.6-5 mmol/L) 2.9
Potassium (0-16 u/L) 5
CK B
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IV. Pathophysiology
& Schematic Diagram
In an MI, an area of the myocardium is permanently destroyed; a condition in which the blood supply to
the heart muscle is partially or completely blocked. The heart muscle needs a constant supply of oxygen-
rich blood. The coronary arteries, which branch off the aorta just after it leaves the heart, deliver this
blood. MI is usually caused by the reduced blood flow in a coronary artery of an atherosclerotic plaque
and subsequent occlusion of the artery by a thrombus. Coronary artery disease can block blood flow,
causing chest pain. In unstable angina and acute MI are considered to be the same process but different
appoints along a continuum. specifically coronary atherosclerosis (literally ùhardening of the arteries,
which involves fatty deposits in the artery walls and may progress to narrowing and even blockage of
blood flow in the artery., As an atheroma grows, it may bulge into the artery, narrowing the interior
(lumen) of the artery and partially blocking blood flow. With time, calcium accumulates in the atheroma.
As an atheroma blocks more and more of a coronary artery, An atheroma, even one that is not blocking
very much blood flow, may rupture suddenly. The rupture of an atheroma often triggers the formation of
a blood clot (thrombus), the supply of oxygen-rich blood to the heart muscle (myocardium) can become
inadequate. The blood supply is more likely to be inadequate during exertion, when the heart muscle
requires more blood. An inadequate blood supply to the heart muscle (from any cause) is called
myocardial ischemia. If the heart does not receive enough blood, it can no longer contract and pump
blood normally. Other causes of MI include vasospasm, (sudden constriction or narrowing) of a
coronary artery, decreased oxygen supply (e.g. from acute blood loss, anemia, or low blood pressure),
and increased demand for oxygen (e.g. rapid heart rate, thyrotoxicosis, or ingestion of cocaine). In each
case, a profound imbalance exists between myocardial oxygen supply and demand. The area of
infarction develops over minutes to hours. As the cells are deprived of oxygen, ischemia develop, cellular
injury occurs,, and the lack of oxygen results in infarction, or the death of cells. The area of the heart
muscle supplied by the blocked artery dies.
V In Myocardial Infarction,
inadequate coronary
blood flow rapidly results
in myocardial ischemia in
the affected area. The
location and extent of the
infarct determine the
effects on cardiac
function. Ischemia
depresses cardiac
function and triggers
autonomic nervous
system responses that
exacerbate the
imbalance between
myocardial oxygen
supply and demand.
Persistent ischemia
results in tissue necrosis
and scar tissue
formation, with
permanent loss of
myocardial contractility in
the affected area.
Cardiogenic shock may
develop because of
inadequate CO from
decreased myocardial
contractility and pumping
capacity.
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 Inhibits platelet Ther. class. Reduction of Contraindicated in: Incidence of adverse ‡ Assess patient for
aggregation by antiplatelet atherosclerotic ‡ =ypersensitivity reactions similar to symptoms of stroke,
irreversibly agents events ( I, stroke, ‡ Pathologic that of aspirin peripheral vascular
inhibiting the vascular death) in bleeding (peptic CNS: depression, disease, or I
binding of ATP to Pharm. class. patients at risk for ulcer, intracranial dizziness, fatigue, periodically during
platelet receptors platelet such events hemorrhage) headache. therapy
aggregation including recent I, ‡ Lactation ‡ onitor patient
inhibitors acute coronary Use Cautiously in: EENT: epistaxis. for signs of
syndrome (unstable ‡ Patients at risk for thrombotic
angina/non²Q- bleeding (trauma, Resp: cough, dyspnea. thrombocytic
wave I), stroke, or surgery, or other purpura
peripheral vascular pathologic CV: chest pain, edema, (thrombocytopenia,
disease conditions) hypertension. microangiopathic
‡ =istory of GI hemolytic anemia,
bleeding/ulcer GI: GI BLEEDING, neurologic findings,
disease abdominal pain, renal dysfunction,
‡ Severe hepatic diarrhea, dyspepsia, fever). ay rarely
impairment gastritis. occur, even after
short exposure (<2
Derm: pruritus, wk). Requires
Clopidogrel purpura, rash. prompt treatment
Trade Name(s)
‡ Plavix =emat: BLEEDING,
(
NEUTR PENIA,
T=R ( (B TIC
T=R ( ( (
B CYT PENI
C PURPURA.

etabolic:
hypercholesterolemia.

S: arthralgia, back
pain.

isc: fever,
hypersensitivity
reactions.
 Binds to an Ther. class. ‡ Contraindicated CNS: dizziness, ‡ Assess patient
enzyme on antiulcer GERD/maintena in: drowsiness, routinely for
gastric parietal agents nce of healing in ‡ fatigue, headache, epigastric or
cells in the erosive =ypersensitivity weakness. abdominal pain
presence of Pharm. class. esophagitis ‡ etabolic and frank or
acidic gastric proton pump ‡ Duodenal alkalosis and CV: chest pain. occult blood in
p=, preventing inhibitors ulcers (with or hypocalcemia the stool, emesis,
the final without anti- (Zegerid only) GI: abdominal or gastric
transport of infectives for Use Cautiously pain, acid aspirate
hydrogen ions =elicobacter in: regurgitation, Lab Test
into the gastric pylori ) ‡ Liver disease constipation, Considerations
lumen ‡ Short term (dose reduction diarrhea, ‡ onitor CBC
treatment of may be flatulence, nausea, with differential
active benign necessary) vomiting. periodically
gastric ulcer ‡ Geri: Increased during therapy
‡ Pathologic risk of hip Derm: itching, » ay cause l
ëmeprazole hypersecretory fractures in rash. AST, ALT,
conditions, patients using alkaline
including high-doses for > 1 isc: allergic phosphatase,
Zollinger-Ellison year reactions. and bilirubin
syndrome ‡ Bartter's » ay cause
‡ Reduction of syndrome, serum gastrin
risk of GI hypokalemia, concentrations
bleeding in and respiratory to l during first
critically ill alkalosis 1²2 wk of
patients (Zegerid only) therapy. Levels
‡ ëTC: ‡ ëB: Lactation: return to normal
=eartburn Pedi: Pregnancy, after
occurring lactation, or discontinuation
Btwice/wk children <1 yr of omeprazole
(safety not » onitor INR
established) and
prothrombin
time in patients
taking warfarin
 ‡ Increases water Ther. class. Treatment of Contraindicated in: GI: belching, cramps, ‡ Assess patient for
content and laxatives chronic constipation Patients on low- distention, flatulence, abdominal
softens the stool in adults and galactose diets diarrhea. distention, presence
‡ Lowers the p= of Pharm. class. geriatric patients of bowel sounds, and
the colon, which osmotics ‡ Adjunct in the Use Cautiously in: Endo: hyperglycemia normal pattern of
inhibits the management of ‡ Diabetes mellitus (diabetic patients). bowel function
diffusion of portal-systemic ‡ Excessive or » Assess color,
ammonia from the (hepatic) prolonged use (may consistency, and
colon into the encephalopathy lead to dependence) amount of stool
blood, thereby (PSE) ‡ ëB: Lactation: produced
reducing blood Pedi: Safety not PSE
ammonia levels. established ‡ Assess mental
Therapeutic status (orientation,
Effect(s): level of
‡ Relief of consciousness) before
constipation and periodically
‡ Decreased blood throughout course of
ammonia levels therapy
with improved Lab Test
mental status in Considerations
Lactulose PSE ‡ ± blood ammonia
concentrations by
25²50%
» ay cause l blood
glucose levels in
diabetic patients
» onitor serum
electrolytes
periodically when
used chronically.
ay cause diarrhea
with resulting
hypokalemia and
hypernatremia
 
§

. §§
 §    § §   
 

  

*Do not connect flexible plastic

containers of intravenous solutions in
series, i.e., do not piggyback
connections. Such use could result in
air embolism due to residual air
being drawn from one container
before administration of the fluid
*=ypovolemia from a secondary container is
*=eat-related completed.
emergencies *Pressurizing intravenous solutions
0.9 Sodium
*Freshwater contained in flexible plastic
Chloride 1000ml Isotonic *C=F
drowning containers to increase flow rates can
Plain NSS 1L
*Diabetic result in air embolism if the residual
ketoacidosis(D air in the container is not fully
KA) evacuated prior to administration.
*Use of a vented intravenous
administration set with the vent in
the open position could result in air
embolism. Vented intravenous
administration sets with the vent in
the open position should not be used
with flexible plastic contain.
 §


 §  § 

  § §

§§ 



7
Subjective: Activity After 8 hours of 1. monitor heart rate, rhythm, 1. changes in V/S assist with After 8 hours of nursing
´medyo hirap intolerance r/t nursing intervention, respirations and blood monitoring physiologic intervention:
siya sa paghinga generalized the patient will be pressure for abnormalities. responses to increase in
at nasakit ang ulo weakness as able to: Notify physician of significant activity A. the patient
niyaµ as manifested by changes in V/S 2. alleviation of factors that tolerated activity
verbalized by the alterations in A. tolerate activity 2. identify causative factors are known to create without excessive
patient·s niece. blood pressure without excessive leading to intolerance of intolerance can assist with dyspnea and had been
ëbjective: with activity and dyspnea and will be activity development of an activity able to utilize
(+) dyspnea dyspnea able to utilize 3. encourage patient to assist level program breathing techniques
(+) headache breathing techniques with planning activities, with 3. to help give the patient a and energy
(+) vomiting and energy rest periods as necessary feeling of self- worth and conservation
(+)peri- oral conservation 4.instruct patient in energy well- being techniques effectively.
cyanosis techniques effectively conservation techniques 4. to decrease energy Goal was met.
(+) R sided body B. increase and 5. turn patient sideways at expenditures and fatigue B. the patient
weakness achieve desired least every 2 hours, and prn. 5. to improve respiratory increased and
V/S: activity level, 6. instruct patient in isometric function and prevent skin achieved desired
BP- 180/120 progressively, with no and breathing exercise breakdown activity level,
mm=g intolerance symptoms 7. provide patient/ family 6. to improve breathing progressively, with no
PR- 81 bpm noted, such as with exercise regimen, with and to increase activity level intolerance symptoms
RR- 28 breaths/ respiratory written instructions 7. to promote self- worth noted, such as
min compromise


7 and involves patient and his respiratory
T- 36.5 C 1. assist patient with family with self- care compromise. Goal was
ambulation, as ordered, with 1. to gradually increase the met.
progressive increases as body to compensate for the
patient·s tolerance permits increase in overload
 § §
7 1. provides continued
1. refer to cardiac support/additional
rehabilitation program, if any supervision and
participation in recovery
and wellness process
§


 §  § 

  § §

§§ 

Subjective: Risk for Within 8 hours of 


7 1. to determine if After 8 hours of
´nagsusuka decreased nursing 1. auscultate BP. Compare hypertension is due to nursing intervention:
akoµ as cardiac output intervention, the both arms and obtain common problems or if it A. the patient
verbalized by related to patient will be lying, sitting, and standing related to a much more maintained
the patient changes in able to: pressures when able serious complication hemodynamic
ëbjective: electrical A. maintain 2. monitor V/S 2. decreased cardiac stability such as the
(+) nausea conduction hemodynamic 3. note response to activity output results to blood pressure. Goal
(+) vomiting stability such as and promote rest irregularities that may was met.
(+) slight the blood pressure appropriately require further evaluation/ B. the patient
dyspnea B. report 4. provide small, easily monitoring reported decreased
V/S: decreased episodes digested meals. Limit 3. to avoid overexertion episodes of dyspnea,
BP- 130/90 of dyspnea, angina caffeine intake that can compromise angina. Goal was
PR- 104 bpm 5. have emergency myocardial function met.
RR- 20 breaths/ equipment/ medications 4. to avoid increase and
min available stimulation of myocardial
T- 36 C  § §
7 workload resulting to
1. administer supplemental increased heart rate
oxygen, as indicated 5. to provide immediate
2. maintain IV/ =ep- Lock life- saving therapies when
access as indicated cardiac arrest suddenly
3. monitor serial ECGs, occurs
chest x-ray and laboratory 1. to reduce ischemia and
data dysrhythmias
4. administer medications 2. to administer emergency
as indicated drugs upon persistent lethal
dysrhythmias or chest pain
3. to provide information
regarding progression/
resolution of infarction
4. to avoid potential
complications and have
appropriate management
§


 §  § 

  § §

§§ 

Subjective: Risk for Within 8 hours of 1. note patient·s age, 1. to provide information After 8 hours of
´ nagsusuka deficient fluid nursing intervention, current level of hydration, regarding ability to tolerate nursing
akoµ as volume related the patient will be and consciousness fluctuations in fluid level and intervention:
verbalized by to vomiting able to: 2. monitor I/ë balance risk for creating or failing to A. the patient
the patient A. avoid fluid 3. Weigh patient and respond to problem avoided fluid
ëbjective: volume deficiency compare with recent 2. to ensure accurate picture volume deficiency .
(+) slurred B. reduce, or if weight history of fluid status Goal was met.
speech noted possible, alleviate 4. assess skin turgor/ oral 3. to determine trends with B. the patient·s
(+) nausea vomiting mucous membranes fluid status vomiting was
(+) vomiting 5.monitor V/S 4. to check for any alleviated. Goal
- Poor skin 6. encourage oral intake of manifestation of possible was met.
turgor fluids dehydration
V/S: 7. provide supplemental 5. BP and heart/ respiratory
BP- 130/90 fluids, as indicated rate often increase initially
PR- 104 BP 1. reinforce need for when either fluid deficit or
RR- 20 breaths/ adequate rest excess is present
min 2. administer medications 6. to avoid deficiency in fluid
T- 36 C as indicated volume
7. fluids may be given in this
manner if patient is unable
to take oral fluid, is NPë for
procedures, or when rapid
fluid resuscitation is required
1. to limit adverse effects of
vomiting
2. to avoid potential
complications and have
appropriate management
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