TABLE OF CONTENT Introduction------------------------------------------------------------------- 1 Objectives---------------------------------------------------------------------- 2 Scope and limitation---------------------------------------------------------3 Theoretical Framework----------------------------------------------------- 4 Nursing History Biographical Data------------------------------------------------5 Reasons for

seeking health Care----------------------------6 History of the present illness----------------------------------6 Past Medical History--------------------------------------------6 Family History----------------------------------------------------7

Gordons Functional Pattern-----------------------------------------------7 Physical examination----------------------------------------------------10 Anatomy and Physiology------------------------------------------------15 Pathophysiology Book based---------------------------------------------------------16 Client based--------------------------------------------------------18 Diagnostic Examination------------------------------------------------------20 Drug Study-----------------------------------------------------------------------26 Nursing Care Plan----------------------------------------------------------50 Medical- Surgical Management----------------------------------------58 Health Teaching------------------------------------------------------------59 Bibliography------------------------------------------------------------------61

Acute myocardial infarction refers to the process by which areas of myocardial cells in the heart are permanently destroyed. MI is caused by reduced blood flow in a coronary artery due to atherosclerosis and a complete occlusion of an artery by an embolism or thrombus. Other causes of an MI include vasospasm (a sudden constriction or narrowing) of a coronary artery, decreased oxygen supply (from acute blood loss, anemia, or low blood pressure) and increased demand for oxygen (from rapid heart rate, thyrotoxicosis or ingestion of cocaine). In each case, a profound imbalance exists between myocardial oxygen supply and demand. The risk factors are diabetes; elevated homocysteine, Creactive protein and fibrinogen levels; excessive alcohol consumption; family history of heart disease; high-fat, highcarbohydrate diet; hypertension; and obesity. The signs and symptoms are uncomfortable pressure, squeezing burning, severe persistent pain of fullness in the center of the chest lasting for 15 to 30 minnutes; pain radiating to the shoulders, neck, arm or jaw or pain in the back between the shoulder blades; lightheadedness or fainting; sweating; nausea; shortness of breath and anxiety or a feeling of impending doom.

The diagnostic tests that are conducted to patients with MI are Electrocardiography which helps determine which area of the heart and which coronary arteries are involved, Echocardiography which may show ventricular wall motion ventricular wall motion abnormalities and may detect septal or papillary muscle rupture, Transesophageal echocardiography may reveal areas of decreased heart muscle wall movement and Chest x-rays may show leftsided heart failure, cardiomegaly or other cardiac causes of dyspnea and chest pain. The treatments given to patient with MI are supplemental oxygen that is used to increase oxygen supply to the heart, Nitroglycerin is ordered to relieve for chest pain, Morphine is prescribed to relieve pain, Aspirin is used to inhibit platelet aggregation, Low-cholesterol, low-sodium, low-fat, high-fiber diet is ordered.

General Objective: The purpose of this case presentation is to broaden our knowledge, enhance related nursing skills by rendering quality health nursing service to a patient with Acute Myocardial Infarction. This also intends to help patient promote health and medical understanding of such condition through the application of the nursing skills. Specific Objective: To know the nursing history, personal data and all the pertinent information that would help to recognize the etiology of the disease. To assess carefully the patient that will further identify the clinical manifestation of the disease. To illustrate the anatomy, physiology and pathophysiology of the affected organ. To clearly identify the suitable nursing diagnosis that is appropriate for the patient To provide a client a nursing care plan and health teaching to assure for patients total health wellness during his hospitalization up to the time he was discharge. To evaluate the efficiency of each nursing intervention done and reassess goals they were not met specific to the patients care.

This study concentrates and limits to a patient who is identified having an acute myocardial Infarction. This case study focused onn how we could help the patient lessen his difficulty on his condition. On our Third Rotation we handle the patient for 2 days in 2 consecutive weeks. At the Jose Reyes Memorial Medical Center in the Male medical Ward on the cardio Unit together with the assistance of our C. I Mrs. Minda Emerciana, Rn, Man We did some Intervention such as monitoring of vital signs and Intake and output. Administration of medications, we also assessed the client by general inspection, auscultation and palpitation. We were able also to interview the patient but he cant remember some vital information that would complete the case. Health Teaching was also provide like, Low salt, low fat, low cholesterol diet. We choose this study due to our curiosity to the present condition of the patient which can greatly help in developing our nursing skills and knowledge as we are in this nursing profession.

Sister Calixta Roy defined her theory of Adaptation Model as process and outcome whereby thinking and feeling persons as individuals or in groups,use conscious awareness and choice to create human and environmental integration. As an open living system,the person receives inputs or stimulifrom both the environment and the self.The adaptation level is determined by the combined effect of the focal,contextual and residual stimuli.Adaptation occurs when the person responds positively to environmental changes.This adaptive rsponse promotes the integrity of the person,which leads to health.Ineffective response to stimuli leads to the disruption of the integrity of the person. In relation to to our case,our patient was diagnosed of having Acute Myocardial Infarction(internal stimuli).This underlying disease process flows into a controll process where patient presents physiologic function by adapting some manifestations of the disease process such as chest pain,shortness of breathing,fatigue and dizziness which felt by the patient.

Through this manifestations occur in our patient,he was able to use Roy's coping mechanisms,the regulator and cognator.Physiologic function of the patient is to responds automatically to chemical coping process made by mechanical actions of drug regimens being rendered to ively,as an output. him.In relation with cognator,patient's ability to adapt to different interventions is considered as coping mechanism by which his perceptual information processing,learning,judgment and emotion are developed.Accepting those necessary interventions increased his faith to believe that his condition,if not totally healed,atleast lessen through minimizing some precipitating factors including smoking as part of his lifestyle.Significant others are also important for the patient to cope up and minimize anxiety. With Roy's model,patient is capable to adapt and responds effect

Patients Profile: Name: Patient FM Age: 73 years old Gender: Male Date of birth: 02-02-1937 Birth Place: Panggasinan Occupation: Retired Technician at PNR Address: Tondo, Manila Date of Admission: January 14, 2011 Diagnosis: Acute Myocardial Infarction Reason of seeking health Care: Chest pain and difficulty of breathing History of the present illness Few minutes prior to admission patient feels severe chest pain and difficulty of breathing while he was watching T.V. Thus, the patient was brought immediately to the hospital .

Past Medical History Patient was 30 years old patient when he went to the clinic due to headache and being tired all the time and was diagnosed with hypertension. Medication was given but he cant remember what kind of medicine it was. Last 2004, 30 days prior to admission patient experience blurring of vision and diagnose with cataract. Patient underwent a cataract surgery removal and after one day the procedure was done, he was being discharge. 2 months prior to his first admission, patient had chronic chest pain with no association symptoms noted. He just took Isordil 5 mg. SL PRN for pain which offered temporary relief. Recurrence of chest pain was noted hour s prior to admission last March 31, 2010; when he was awaken by sudden onset of chect pain associated with cold clammy skin, diaphoresis, body weakness and epigastric pain. Consult and subsequently admitted. He was diagnose with CAD, ACS, Anterior wall ischemia non Infarction. Treatment and management were given. Medications were ASA, clopidogrel, metropolol, captopril, ISMN, ISDN. With patients condition progress. He was discharged April 11, 2010. Patient doesnt have any allergies to drugs and foods.

Family History His parents are the only known person who was diagnosed with hypertension.

The heart is a muscular pump that contains four chambers: right atrium, left atrium, right ventricle and left ventricle. The two small atria make up the top of the heart, and the two large ventricles make up the bottom of the heart. The right atrium pumps blood to the right ventricle, and the left atrium pumps blood to the left ventricle. A wall, called the septum, separates the right atrium and right ventricle, from the left atrium and left ventricle. Blood flows through the heart in the following manner: The right atrium receives oxygen-poor blood from the body, and then pumps the blood through the tricuspid valve and into the right ventricle. The right ventricle pumps the blood through the pulmonic valve and to the lungs, where it picks up more oxygen. The left atrium receives the oxygen-rich blood from the lungs, and then pumps the blood through the mitral valve and into the left ventricle. The left ventricle pumps blood through the aortic valve and to the rest of the body. The blood supplies oxygen to the body and the cycle starts again.

Change in condition of Plaque in the coronary artery

Activation of Platelets

Formation of Thrombus

Occlusion/ reduction of blood flow

Coronary blood supply by the artery

Ischemia of tissue in region supplied by the artery

Myocardial cell death

Altered Repolarization of the myocardium

Release of lysosomal enzymes

Decreased contractility

Myocardial Irritability

Anerobic Glycosis

Elevated ST Segment T wave Inversion

Elevated CKMB, Elevated troponin, Elevated Lactate

ANGINA

Arrhythmias

Lactic Acid Producti on

Stimulation of the sympathetic Nervous

Decreased Left Ventricular Failure

Increased Heart Rate

Increased O2 needs

Increased Afterload

Increased Preload

Decreased cardiac Output

Vasoconstriction

Increased Venous Pressure

Decreased ventricular Ejection Fraction

Increased Pulmonary capillary Pressure

Predisposing factor: Gender(M) Age(73) Diet(high calorie diet) Life style( chronic smoking for 42 years)

Precipitating factor: hypertension

Injuries endothelial lining of blood vessel (arteries)

Deposition of fats on the arterial wall Atheroma plaque formation Narrowing of arterial lumen (ischemia of the tissue chest pain)

Sluggish blood flow (increase blood viscosity) Thrombus formation Total occlusion of blood flow Myocardial infarction Myocardial cell death (necrosis)

Decrease blood supply to SA node

Decreased contractility

Anaerobic glycolosis

Altered repolarization of the myocardia ECG test result: ST segment elevation T wave inversion Troponin I/T, and Lactic Acid

Heart arrythmia

Increase work demand to heart

Tachycardia

Pattern
Health Perception

Before Hospitalization
y

During Hospitalization
Patient stated that health is one of the most essential needs of human being to prolong life. He complies on the medication given to him and become aware of the factors influencing his condition.

Analysis
 Due to patients illness, his health perception and health management had changed

Patient used to ignore y what he feels when experiencing mild sickness. He doesnt visit the doctor for check-up. When he was 16 years old he started using tobacco and consumed 20 sticks per day. He also drinks alcohol beverages occasionally. Fifteen years ago, he used to stop these vices . At the age of 30, he was diagnosed of hypertension but failed to comply with the medication due to financial problems.

Nutritional Metabolic

Elimination

He has a fair y appetite and eats anything. Patient usually eats three times a day. He was fun of eating fish, vegetables, meats and pork. He usually consumes three cups of rice and drinks 5 glasses of water a day. He urinates 5-6 y times a day and defecates every other day. The patient has a yellowish color of urine and soft brown stool.

Patient eats three y times a day but restricted of eating foods which are high of sodium and fats. He drinks 5-6 glasses of water a day.

The patient understands the importance of nutritional balance and had followed the doctors advice about the food the patient must avoid eating.

He urinates 4-5 times a day and defecates every three days; Patient has yellowish urine and soft brown stool.

Patient is doesnt have any problems on his elimination pattern.

Activity/Exercise

Patient usually jogs y for about 30 minutes to 1 hour every morning. For the past few years the patient got easily tired and feels chest pain while doing heavy work or even exercising fatigability and chest pain was relieved by rest .however, Chest pain worsen, until he feels the pain even at rest. He sleeps 9pm and y wakes up at 5 am in the morning. He takes naps on and off during afternoon .For the past few days, he felt chest pain, shortness of breathing and it made him awaken.

Patient is on complete y bed rest. He easily gets tired. And sometimes in pain even at rest

The patient cannot perform the things he used to do. He is on complete bed rest to minimize the occurrence of the chest pain.

Sleep and Rest Pattern

He sleeps on and off. The y patient usually 6-7 hours a day. He feels mild chest pain. Sometimes he was awakening by the noise, uncomfortable environment and the need to take the medication at midnight.

Disturbance and his condition is the factor that hinders his sleep.

Pattern

Before Hospitalization

During Hospitalization

Analysis

Cognitive/Percept y ual

He is high school y graduate. Patient cant read far object and able to hear sounds clearly. He can smell and able to taste food. He can comprehend on things easily.

Role/Relationship

He lives with his spouse and 3 kids.

Patient doesnt y have any problem in vision and able to hear sounds clearly. He can cooperate and follow instructions done by the health care provider. The patient still remember the vital events on his life.. They always visit y him by his friends, family and relatives. They have their schedule in taking care of him here in the hospital. He has good relationship with his relatives.

He is well oriented.

He has good relationship with his family. They have good family ties.

Pattern Coping/Stress Tolerance

Before Hospitalization
y

During Hospitalization

Analysis

When the patient y feels exhausted and stress, he went out with his friends.

The patient stated that he y feels stressed at the hospital, to lessen the burden he talks to his wife and listen to what his wife could advice. Eventhough he cannot attend on mass every Sunday, he prays at night. He statedthat God created us for certain purposed. He knows that God is the greatest healer of all. .

Patient was able to cope up despite of his condition.

Value/Belief
y He is a Roman y Catholic, he used to attend mass on Sunday. He believes that God is always there to guide and protect us. He also believe in some superstitious.

Patient has strong faith on God. He became more devoted since he was hospitalized..

Body Part General Appearance

Skin

Actual Findings The client appearance of height (172cm) and weight (75kg) is according to the body. Clients skin is brown in color. Clean and well groomed, no body and breathe odor. Client is conscious and coherent. Cooperative, able to follow instructions. The client has difficulty of breathing with a respiratory rate of 29bpm. Clients blood pressure is 150/100. Client is in pain; scale is 7 and nonradiating. Fair complexion, absence of scar and lesions. Less firm and sag Skull is symmetrical, smooth, nontender and without masses or depression.

Analysis Deviation from normal. The client is weak in appearance because he is having difficulty in breathing due to chest pain. Administer pain reliever and Position the patient in semi fowlers position, this will help him to breath and administer oxygen inhalation if needed.

Skull

Lesser firmed and sagging of skin may be indicated due to age. No deviation from normal.

Body Part Scalp Hair Face

Eyes

Actual Findings Scalp is white, intact and without lesions or masses. Hair is evenly distributed, thick, no sores, lice, nits. Smooth in texture and shiny. Face is oval. No edema, disproportionate structures or involuntary movements. -Eyes can move smoothly and able to look straight and symmetrical to each other. -Round cornea, black color, white sclera. -nearsighted

Analysis No deviation from normal. No deviation from normal. No deviation from normal. Deviation from normal; patient Cant see far letters or words. This indicates myopia due to age. No deviation from normal.

Eyebrows

Eyelids Conjunctiva

Hair evenly distributed with skin intact, symmetrically aligned with equal movement. Skin intact, no discharge, no discoloration. No deviation from Lids able to close symmetrically. normal. Shiny, smooth and pink No deviation from normal.

Body Part
Nose

Actual Findings

Analysis

Eternal Nares Internal Nares Septum Ears

Located symmetrically in the midline of the face No deviation from normal. and without swelling, bleeding lesions and masses. No tenderness and mass. No deviation from normal. No discharges. Patent, clean with presence of cilia. No deviation from normal. Septum is located midline. The ears match the flesh color of the rest of the body and positioned centrally proportion of the head. There are no foreign bodies, redness, drainage, deformities, nodules or lesions. The lips and membranes are pink in color and with no evidence of inflammation or lesion. Have no bleeding or swelling. White teeth. Upper teeth: 14 Lower teeth: 15 Total: 29 The dorsum of the tongue is pink, moist, rough and without lesion. The tongue is symmetrical and moves freely. No deviation from normal. No deviation from normal.

Lips Gums Teeth

No deviation from normal. No deviation from normal. Deviation from normal the patient has incomplete teeth can be also due to his age. -Promote good oral hygiene No deviation from normal.

Tongue

Body Part

Actual Findings

Analysis

Buccal mucosa The buccal mucosa is moist, smooth and free of lesion. Tonsils Pink in color, smooth and no discharge. Neck Able to move from side to side, freely movable. Posterior Uniform in color, scapula is Thorax symmetrically aligned. Spine are vertically aligned and no deformities. Full and symmetrical chest expansion upon palpation. Anterior Uniform in color, clavicles is Thorax symmetrically aligned. No deformities.

No deviation from normal. No deviation from normal. No deviation from normal. No deviation from normal.

No deviation from normal.

Body Part

Actual Findings

Analysis

Abdomen

Inspection: -uniform in color -flat rounded contour -no evidence of enlargement of liver or spleen symmetric movement caused by respirations -no visible of vascular pattern Auscultation: -absence of arterial bruits Percussion: gas bowels liver -audible bowel sounds -absence of friction rub -tympanic over the stomach and -dullness especially over the

No deviation from normal.

Lungs Heart Upper Extremities

Palpation: -no tenderness and relax abdomen with smooth consistent tension No crackles, gurgle or wheeze sounds heard No murmur sounds heard No gross deformities are apparent. All muscles and joints have active range of motion, with no pain. Shape is normal, with no swelling and tenderness. Bilateral muscle tone, texture and strength are equal. No involuntary contraction or twitching is detectable. Bilateral pulses are equally strong.

No deviation from normal. No deviation from normal No deviation from normal.

Body Part

Actual Findings

Analysis

Hands

There are five fingers in each hand. Able to do move. Phlebitis is present on the right hand.

Nails

The nails have oink cast. The capillary is normal its color returns within 2 3 seconds. Lower No gross deformities are apparent. All muscles and Extremities joints have active range of motion, with no pain. Shape is normal, with no swelling and tenderness. Bilateral muscle tone, texture and strength are equal. No involuntary contraction or twitching is detectable. Bilateral pulses are equally strong. Legs The knees are symmetrical with each other. The patient can stand alone.

Deviation from normal. The right hand of the patient has phlebitis because of the IV line was not patent. -Apply cold compress on the right hand to reduce the swelling. No deviation from normal. No deviation from normal.

No deviation from normal.

HEMATOLOGY REPORT:
Result Reference range 110-160 Analysis (NORMAL) Hemoglobin which transports oxygen is the main component of red blood cells. Low Hgb concentration may indicate anemia, recent hemorrhage, or fluid retention, which can cause hemodilution; elevated Hgb suggest hemoconcentration from polycythemia or dehydration (NORMAL) Hematocrit is the ratio between th RBC and the plasma. In Anemia, Hgb and Hct are low. (NORMAL) Increased RBCs suggest inadequate tissue oxygenation. Hypoxia stimulates renal secretion of erythropoietin. This stimulates the bone marrow to increase the RBC production (polycythemia) 118 g/L

Hemoglobin

Hematocrit

0.383

0.370-0.540

RBC count

4.17 10^12/L

3.50-5.50

Result
MCV MCH MCHC RDW-CV 91.8 fL 28.3 pg 30.8 g/dL 14.0 %

Reference range
80.0-100.0 27.0-34.0 32.0-36.0 11.0-16.0

Analysis
(NORMAL)It is measurement of the rate at which RBCs settle out of anti coagulated blood in an hour. Erythrocytes Indices MCV- increased are macrocytic anemia, decreased are microcytic anemia MCH- increased are macrocytic anemia, below than 27 are hypochromic anemia, and below 15 are microcytic anemia MCHC- increased are severe dehydration, xerocytosis, cold agglutin disease, hereditary sphenocytosis, and intravascular hemolysis; and decreased are chronic blood loss, anemia, microcytic anemia, iron anemia, severe and immediate overhydration, thalassemia and sideroblastic anemia.

Result

Reference range

Analysis

WBC Count Neutrophils Lymphocytes Basophils Monocytes Eosinophils

7.94 10^9/L 78.9% 21.1% 0.4% 9.0% 9.7%

4.00-10.00 50.0-70.0 20-40 0.0-1.0 3.0-8.0 0.5-5.0

Platelet MPV

132 10^9/L 10.0 fL

100-300 6.5-12.0

(NORMAL) increased WBCs may indicate infectious heart disease and Myocardial Infarction. WBC count elevate due to inflammatory process associated with the damaged heart muscles. (NORMAL) (NORMAL)

Result Prothrombin time 15.3 sec

Reference Range 11.3-15.3

Analysis (NORMAL) It measures the time required for clotting to occur after thromboplastin and calcium are added to decalcified plasma

PT control PT INR PT% activity APTT

13.3 sec 1.20 75.30% 90.0 sec 70-100 28-37 (NORMAL) (ABNORMAL) It is most specific test to evaluate effectiveness of heparin. Therapeutic range is 2-2.5 times the normal APTT. Abnormal APTT indicates that the client has a low clotting factor.

APTT control

31.8 sec

Clinical Chemistry
Result 108.22 umol/L Analysis Reference range Adult- 45It is the most cardiac specific 104 enzyme. It is an accurate indicator of myocardial damage. Lack oxygen to the muscle for 30-60 minutes causes the release of intracellular enzymes. Heart muscle damage can be assessed by evaluation. 135-145 (NORMAL)Serum electrolytes affect the cardiac contractility 3.6-5.5 (NORMAL) Serum electrolytes affect the cardiac contractility. (ABNORMAL) Best indication of myocardial infarction. Elevated result indicates MI.

Creatinine

Na+ K+ Troponin I

137.20 mmol/L 3.83 mmol/L Positive

Cholesterol Triglycerides HDL

7.55 mmol/L 2.82 mmol/L 0.98 mmol/L

0-5.20 0-1.70 > 1.55

LDL

6.20 mmol/L

1.724.63

(ABNORMAL) Below HDL levels are accompanied by elevation of LDL levels. It is valuable in detecting silent MI. (ABNORMAL) Below HDL levels are accompanied by elevation of LDL levels. It is valuable in detecting silent MI.

Parameter LV ID (ED) LV ID (ES) Vol. (ED) Vol. (ES) SV CO EF FS

Value 60 33 53 37 16 0.97 42 11

Normal Paramet Value Normal er RV ID (11-19mm) (3350mm) RVOT 24 (35mm) (1731mm) MI 38 (26-36mm) LA DIA (ED) MI AORTIC (ED) Ml/beat 1. Diame 42 (21-36mm) ter L/min 1. Orifice (15-20mm) (4-13mm) (551. Amplit 83%) ude 28-44 PULMONARY ARTERY

Parameter Value Normal Paramet er

VCF 0.44 (0.881.554s) AV annulu s

Value

Normal

ET

25 MVANNUL US TV ANNULUS

33

mm

EPSS IVST IVSS IVSA LV PWT LV PWS

8 17 18

(40mm) 6-11mm

33

mm

15 17

1. Diamet er 5-8mm Perica rdium (7-11mm) LV MASS LV MASS index

26

mm mm

240 129

VALUE

m/sec

mmHg

cm2

Regurgitati on

Mitral 0.41/0.61 0.67/1.48 Tricuspid 1.42/0.53 0.72/1.14 Aortic 0.74/0.94 2.21/3.58 Pulmonic 0.70 1.96 135 QP/QS= PAT = (NV: > 100ms)

E/A ratio Deceleration time IVRT

148 155

Pulmonary vein a wave Pulmonary systolic flow Pulmonary diastolic flow S/D ratio

25 49 43

1.1-1.5 160-240 msec < 89msec (>40 years old) < 25cm/sec (m/sec) (m/sec)

LVOT= 25

RV=33

RA=25

Interpretation

Eccentric left ventricular hypertrophy with segmental wall motion abnormalities A kinetic left ventricle anterior wall from apex to base hypokinetic posterior and inferior wall from apex to base. Right ventricle is normal in diameter with good wall motion and contractility. Left atrium is dilated with evidence of thrombus, right atrium is normal in dimension with evidence of thrombus

The anterior and posterior mitral valve leaflets are normal in thickness and motion. The annulus is normal. The anterior and septal tricuspid valve leaflets are normal in thickness and motion. The annulus is normal The right coronary cusp, non-coronary cusp and left coronary cusp of the aortic valve leaflets are normal in thickness and motion. The annulus is normal. The pulmonic valve is normal in dimension The main pulmonary artery and aortic root are normal in dimension. The pericardium is normal.

Conclusion: Eccentric left ventricular hypertrophy with segmental wall abnormalities Dilated left atrium with evidence of thrombus CHEST X-RAY Result: There are prominent hilar vascular markings. Likewise there are reticulonodular densited noted on the right lower lobe with slight thickening of the right minor fissure. The heart is enlarged. The aorta is tortuous and calcified Diaphragm and sinus are intact Bony thorax is unremarkable.

Impression Right minor fissural thickening Atherosclerotic Vascular Disease ECG RESULT: ST segment elevation T wave inversion ECG ANALYSIS: ECG is the first diagnostic test done when cardiovascular disorder is suspected. ST segment: ( represents the plateau phase of the action potential, end of ventricular depolarization. ST segment elevation: elevation of the ST segment heralds a pattern of injury and usually occur as an initial change in acute MI. T wave: (ventricular repolarization, should not exceed 5mm amplitude. Non stimulation of heart muscles: T Wave inversion: may occur as the MI evolves. The T wave will return to the upright position after the MI resolves

Name of Mechanism of Drug action captop Inhibits ACE, ril preventing conversion of angiotensin I to angiotensin II, a potent vasoconstrictor. Less angiotensin II decreases peripheral arterial resistance, decreasing aldosterone secretion, which reduces sodium and water retention and lowers blood pressure.

Dosag e 25 mg/tab OD

Contraindic ations Hypertensi Contraindi on cated in patients hypersensitiv Diabetic e to drug or Nephropathy other ACE inhibitor. Indications Heart failure Use cautiously in patients with impaired renal function or serious autoimmune disease, especially systemic lupos erythematosu s,

Adverse Reaction CNS: dizziness, fainting, headache, malaise, fatigue, fever. CV: tachycardia, hypotension, angina pectoris. GI: abdominal pain, anorexia, constipation, diarrhea, dry mouth, dysgeusia, nausea and vomiting.

Nursing Alert Monitor patients blood pressure and pulse rate frequently. ALERT: Elderly patients may be more sensitive to drugs hypotensive effects. Assess patients for signs of angioedema .

Left ventricular dysfunction after acute MI.

Mechanis m of action (continued Has a higher ) antifactorXa-toantifactor-IIa activity ratio than heparin.

Contraindications

Adverse Reaction

Nursing Alert

and in those who have been exposed to other drugs that affect WBC counts or immune response.

RESPIRATO Drug causes the most RY: dry, frequent occurrence of persistent, cough, compared with nonproductive other ACE inhibitors. cough, In patients with impaired dyspnea. renal function or collagen SKIN: vascular disease, monitor urticarial rash, WBC and differential maculopopular counts before starting rash, pruritus, treatments, every 2 weeks dyspnea. for the first 3 months of therapy, and periodically OTHERS: thereafter. angioedema.

Name of Drug

Mechanism of action

Dosage

Indications

Contraindic ations

Adverse Reaction

Nursing Alert

Enoxa A lowparin molecularsodium weight heparin derivative that accelerates formation of antithrombin IIIthrombin complex and deactivates thrombin, preventing conversion of fibrinogen to fibrin.

0.6 ml/ IV now , then S.C. Q12h.

To prevent ischemic c omplication s of unstable angina and non STelevation MI with oral aspirin therapy. to prevent pulmonary embolism.

Contrain dicated In patients hypersensiti ve to drug, heparin, or pork products; in those with active major bleeding; an in those with thrombocyt openia and anti-platelet antibodies in presence of drug.

CV; edema, peripheral edema.

the vascular access sheath for instrument CNS: ation fever, pain. should SKIN: remain in irritation place for pain, 6to 8 hours ematoma, after a and dose; give erythema at next dose injection no sooner site, rash, than 6 to 8 urticuria. hours after OTHERS: sheath angioedema removal. Monitor , anaphylaxis. vital signs.

Contraindications

Nursing Alert

(CONTINU Use cautiously in ED) patients with history of heparin

Never give I.M. ALERT: Dont try to expel the air bubble fron the 30- or 40-prefilled syringes. This may lead to loss of drug and an incorrect dose. With patient lying down ,give by deep subcutaneous injection , alternating doses between left and right

induced thrombocytopenia, aneurisms, cerebrovascular hemorrhage, spinal or epidural punctures(as with anesthesia) Uncontrolled hypertension, or threatened abortion. Use cautiously in elderly patients and in those with conditions that place them at increased risk of hemorrhage, such as bacterial endocarditis, congenital or acquired beeeding disorders, ulcer disease, angiodysplastic GI disease, hemorrhagic stroke, or recent spinal, eye, brain surgery.

Contraindications

Nursing Alert anterolateral and posterolateral abdominal walls. Dont massage after subcutaneous injection. Watch for signs of bleeding at site and keep record. Avoid I.M. injection of other drugs to prevent or minimize hematoma. Monitor platelet counts regularly. Patients with normal coagulation wont need close monitoring of PT or PTT. Regularly inspect pt. for bleeding gums, bruises on arms or legs, petechiae, nosebleeds, melena, tarry stools, hematuria, heamtemesis

(CONTIN UED)

Use cautiously in patients with prosthetic heart valves, with regional or lumbar block anesthesia, blood dyscrasias, recent childbirth, pericaritis or pericardial effusion, renal insufficiency, or severe CNS trauma.

action
diazepam A 5 mg/ benzodiazepin tab BID e that probably potentiates the affects of GABA, and suppresses the spread of seizure activity. Anxiety Acute alcohol Before Endoscopic withdrawal Muscle Spasm Preoperative sedation Cardioversio n Adjust treatment for seizure disorder. CV: Contraindica CV collapse , ted bradycadia, In patients hypotension hypersensitive CNS: to drug or soy drowsiness, protein; in dysartria, patients slurred speech, experiencing shock, coma,or tremor, transient amnesia, acute alcohol intoxication(par fatigue, ataxia, headache, ental form) insomia, minor changes in EEG patthern. EENT: diplopia, blurred vision, nystagmus. . Use Diastat rectsl gel to treat no more than five episodes per month and no more than one episode every 5 days because tolerance may develop. When using oral solution, dilute dose just before giving Monitor elderly patients for dizziness, ataxia, mental status changes.

Contraindications

Adverse Reaction

Nursing Alert

(CONTIN UED)

Diastat rectal gel is contraindicated in pt. with acute angle-closure glaucoma.

GI: nausea, constipation, diarrhea with rectal form. GU: incontinence, urine retention.

Patients are at in increased risk for falls. ALERT: Use of this drug may lead to abuse and addiction. Dont withdraw drug abruptly after long-term use; Withdrawal ymptoms may occur.

Use cautiously in patients with liver or renal RESPIRATORY: impairment, depression, Respiratory or chronic open-angle glaucoma. Use cautiously depression, apnea. in elderly and debilitated OTHERS: patients. Pain., phlebitis, at injection site, altered libido, physical or physocological dependence.

Name of Drug

Mechanism of action

Dosage

Indications

Contraindic ations

Adverse Reaction

Nursing Alert

lactulo se

produces 3 cc an osmotic CDC effect in colon; resulting distention promotes peristalsis. Also decreases ammonia, probably as a result of bacterial degradation, which lowers the pH of colon contents.

Constipa tion To prevent an treat encephalop athy, including hepatic pre -coma and coma in patients with severe hepatic disease.

Contrain dicated in patients on a low galactose diet Use cautiously in patients with diabetes mellitus.

GI: Abdominal cramps, belching, diarrhea, flatulence, gaseous distention, nausea, vomiting.

To minimize sweet taste, dilute with water of fruit juice or give with food.

Nursing Alert

(CONTIN UED)

prepare enema (not commercially available) by adding 20 g (300 ml) to700 ml of water or normal saline solution. The diluted solution is given as retention enema for 30 to 60 minutes. Use a rectal balloon. If enema isnt retained for at least 30 minutes. Repeat dose.

Name of Mechanism Dosage Drug of action isosorbi Thought 5mg / de dinitrate to reduce tab 5L cardiac Q5mins x oxygen # doses demand by PRN decreasing chest preload and pain. after-load. Drug may also increase blood flow through the collateral coronary vessels.

Indications Acute anginal attacks (S.L. isosorbide dinitrate only); to prevent situations that may cause anginal attacks.

Contraindic ations Contraindi cated in patients with hypersensitivi ty or idiosyncrasy to nitrates and in those with severe hypotension, angle-closure glaucoma, increased intracranial pressure, shock, or acute MI with lower left ventricular filling pressure.

Adverse Reaction CV: Orthostatic hypotension, tachycardia, palpitation, ankle edema, flushing, fainting. CNS: headache, dizziness, weakness.

Nursing Alert To prevent tolerance, a nitrate-free interval of 10 to 14 hours per day is recommend ed. The regimen for isosorbide mono-nitrate

GI: nausea, . vomiting. EENT: S.L. burning SKIN: cutaneous va sodilation.

Contraindication s

Nursing Alert

Use cautiously in patients with blood volume depletion (such as from diuretic therapy) or mild hypotension.

( 1 tablet on awakening with the second dose in 7 hours, or 1 extended release tablet daily) is intended to minimize nitrate tolerance by providing a substantial nitrate-free interval. Monitor blood pressure and intensity and duration of drug response. Drug may cause headaches, especially at beginning of therapy. Dosage may be reduced temporarily, but tolerance usually develops. Treat headache with aspirin or acetaminophen

Name of Drug

Mechani sm of action

Dosage

Indication s

Contraindi Adverse cations Reaction

Nursing Alert

Alorvast 80mg/ta Antihyperl Inhibits atin b OD ipidemic HMGCoA reductas e,the enzyme that catalyzes the first step in the cholester ol synthesis pathways ,resulting in a decrease in serum Cholester ol

For reduction of risk of MI and stroke in patient w/ type 2 diabetes and those with multiple risk factors for CAD

>Contraind icated with allergy to Atovastatin ,fungal byproducts ,active hepatic disease or unexplaine d and persistent elevation of transamina se levels >pregnanc y and lactation

>CNS: Ensure headache,a that sthenia patient is >GI: not flatulence,a pregnant bdomi nal and hs pain,cramp appropriat s,cvonstipat e ion,nausea, contracept dyspepsia, ives heartburn available and liver during failure therapy. >Respirator y: sinusitis,ph aryngitis >

Name of Drug
Metoprolol

Mechani sm of action
50g/tab BID

Dosage

Indications

Contraindic ations

Adverse Reaction
Transient effects

Nursing Alert
> Take several BP readings close to the end of a 12 h dosing interval to evaluate adequacy of dosage for patients with hypertension, particularly in patients on twice daily doses. Some patients require doses 3 times a day to maintain satisfactory control.

> Blocks the action of the sympathetic nervous system, a portion of the involuntary nervous system, by blocking beta receptors on sympathetic nerves. Since the sympathetic nervous system is responsible for increasing the rate with which the heart beats, by blocking the action of these nerves metoprolol reduces the heart rate and is useful in treating abnormally rapid heart rhythms.

>Essential hypertension,Tach ycardia,Coronary heart disease (preventi on of angina attacks) >Secondary prevention after a myocardial infarction >Treatment of heart failure.

>Hypertension and Angina ,Hypersen sitivity ,Sick-sinus syndrome ,Pheoc hromocytoma ,My ocardial Infarction

include dizziness, drowsiness, fatigue, diarrhea, unusual dreams, ataxia, trouble sleeping, depression, and vision problems. It may also reduce blood flow to the hands and feet, causing them to feel numb and cold; smoking may worsen this effect. Serious side effects which are advised to be reported immediately include, but are not limited to, symptoms

Name of Drug

Dosage

Adverse Reaction

Nursing Alert

(CONTIN > educes the force of UED) contraction of heart

of bradycardia (a very slow heartbeat (less than 50 bpm)), persistent symptoms of dizziness, muscle and thereby fainting and unusual fatigue, bluish lowers blood pressure. discoloration of the fingers and By reducing the heart toes, numbness/tingling/swelling of rate and the force of the hands or feet, sexual muscle contraction, dysfunction, erectile metoprolol reduces the dysfunction (impotence), hair loss, need for oxygen by heart mental/mood changes, muscle. Since heart pain depression, trouble breathing, (angina pectoris) occurs cough, dyslipidemia, and increased thirst. Other highly when oxygen demand of unlikely symptoms include easy the heart muscle exceeds bruising or bleeding, persistent the supply of oxygen, sore throat or fever, yellowing skin metoprolol, by reducing or eyes, stomach pain, dark urine, the demand for oxygen, and persistent nausea. Symptoms is helpful in treating heart of an allergic reaction include: rash, itching, swelling, and severe pain. dizziness. Taking it with alcohol might cause mild body rashes and therefore is not recommended

> Observe hypertensive patients with CHF closely for impending heart failure: Dyspnea on exertion, orthopnea, night cough, edema, distended neck veins. > Monitor I&O, daily weight; auscultate daily for pulmonary rales.

Name of Drug Aspirin

Mechanism of action Thought to produce analgesia by blocking generalizatio n of pain impulses, probably by inhibiting prostaglandin synthesis in the CNS or the synthesis or action of other substances that sensitize pain receptors to mechanical or chemical stimulation.

Dosag Indications e 80g  Rheumato tablet id arthritis, OD osteoarthri tis, or other polyarthriti s or inflammat ory conditions .  Juvenile rheumatoi d arthritis  Mild pain or fever  Preventio n of thrombosi s

Contraindic ations Contraindicat ed in patients hypersensitivi ty to drug and in those with NSAIDinduced sensitivity reactions, G6PD deficiency, or bleeding disorders, such as hemophilia, Von Willebrands disease, or telangiectasi a

Adverse Nursing Alert Reaction  EENT:  Monitor tinnitus, patient for hearing hypersens loss itivity  GI: reactions nausea, such as GI anaphylax distress, is or occult asthma. bleeding,  For inflammat dyspepsia ory , GI condition, bleeding rheumatic  Hematolo fever and gic: thrombosi leucopeni s, aspirin a, administer thrombocy d on topenia, schedule prolonged rather bleeding than PRN. time

Name of Drug

Mechanism of action

Indications

Nursing Alert

(CONTIN UED)

Its thought to relieve fever by central action in the hypothalamic heat regulating center. Exert its antiinflammatory effect by inhibiting prostaglandin synthesis; also may inhibit the synthesis or action of other medications of the inflammatory response. In low doses, aspirin also appears to impede clotting by blocking prostaglandin synthesis, which prevents formation of the platelet-aggregating substance, thromboxane A2

 Hepatic: hepatitis  Monitor elderly patients  Skin: rash, closely because they bruising, urticaria may be more susceptible to aspirins  Other: toxic effect. angioedema,  During prolonged hypersensitivity therapy, hematocrit, reactions, Reyes hemoglobin, PT, INR, syndrome and renal function  Reduction of risk of should be assessed MI in patients with periodically. previous MI or  ALERT: dont confuse unstable angina Aspirin with Asendin or  Kawasaki Afrin syndrome (mucocutaneous lymph syndrome)  Acute rheumatic fever

Name of Mechanism Drug of action Isosorbide Not Mononitrat completely e unknown. Thought to reduce cardiac oxygen demand by decreasing preload and afterload. Drug also may increase blood flow through the collateral coronary vessels.

Dosag e 60 mg/table t tablet OD

Contraindic ations Acute anginal Contraindicat attacks (S.L. ed in patients an chewable with tablets of hypersensitivi Isosorbide ty or Dinitrate idiosyncracy only), to nitrates and in those prophylaxis in situations with severe likely to caue hypotension, angle-closure anginal glaucoma, attacks increased intracranial pressure, shock, or acute MI with low left ventricular filling pressure. Indications

Adverse Nursing Reaction Alert  CNS:  Monitor HeadachE, blood dizziness, pressur weakness e and  CV: intensit orthostatic y and hypotension, duration tachycardia, of drug palpitations, respons ankle e edema,  Use cautiou fainting, sly in flushing patients  EENT: S.L. with burning blood  GI: Nausea volume and vomiting  Skin: depletio cutaneous n vasodilation rash

Name of Drug

Mechanism of action

Dosage

Indications

Nursing Alert

 (such as from diuretic therapy) or mild hypotension  To prevent development tolerance, a nitrate- free interval of 8-12 hours per day is recommended. The regimen for ISMN (one tablet upon awakening with the second dose in 7 hours, or one extended- release tablet daily) is intended to minimize nitrate tolerance by providing a substantial nitrate- free interval.  Drug may cause headaches, especially at beginning of therapy. Dosage may be reduced temporarily, but tolerance usually develops. Treat headache with aspirin or acetaminophen.  ALERT: dont confuse Isordil with Isuprel or Inderal

Name of Drug

Mechanism of action

Dosage

Indications

Contraindic ations

Adverse Reaction

Nursing Alert

lactulo se

produces 3 cc an osmotic CDC effect in colon; resulting distention promotes peristalsis. Also decreases ammonia, probably as a result of bacterial degradation, which lowers the pH of colon contents.

Constipat ion To prevent an treat encephalop athy, including hepatic precoma and coma in patients with severe hepatic disease.

Contraind icated in patients on a low galactose diet

GI: Abdominal cramps, belching, diarrhea, flatulence, gaseous Use distention, cautiously in nausea, patients with vomiting. diabetes mellitus.

To minimize sweet taste, dilute with water of fruit juice or give with food. prep are enema (not commerciall y available) by adding 20 g (300 ml) to700 ml of water or normal saline solution..

Name of Drug

Mechanism of action

Dosage

Indications

Contraindic ations

Adverse Reaction

Nursing Alert

The diluted solution is given as retention enema for 30 to 60 minutes. Use a rectal balloon. If enema isnt retained for at least 30 minutes. Repeat dose

Name of Drug
Morphine

Mechanism of action
Relieves pain by stimulating opiate receptors in CNS; also causes respiratory depression, peripheral vasodilation, inhibition of intestinal peristalsis, sphincter of Oddi spasm, stimulation of chemoreceptors that cause vomiting and increased bladder tone.

Dosage

Indications

Contraindic ations
Hypersensitivity to opiates; upper airway obstruction; acute asthma; diarrhea caused by poisoning or toxins.

Adverse Reaction
Cardiovascular Hypotension; orthostatic hypotension; bradycardia; tachycardia; palpitations. CNS Lightheadedness; dizziness; drowsiness; sedation; euphoria; dysphoria; delirium; disorientation; incoordination. Dermatologic Sweating; pruritus; urticaria. EENT Blurred vision; miosis.

Nursing Alert
Instruct patient to take oral preparations with food or juice if GI upset occurs.
y yTell

2 mg I.V Q15mins in pain

Relief of moderate to severe acute and chronic pain; relief of pain in patients who require opioid analgesics for more than a few days (sustainedrelease only); management of pain not responsive to nonnarcotic analgesics;

Immediaterelease oral solution Respiratory insufficiency; severe CNS depression; heart failure secondary to chronic lung disease; cardiac arrhythmias; increased intracranial or cerebrospinal pressure; head injuries; brain tumor;.

patient not to crush or chew controlledrelease tablets.

yExplain

that full effectiveness of drug may not occur for 30 to 60 min after administration.

Name of Drug

Indications

Contraindic ations

Adverse Reaction

Nursing Alert
y

dyspnea associated with acute left ventricular failure and pulmonary edema; preoperative sedation; adjunct to anesthesia; analgesia during labor..

acute alcoholism; delirium tremens; convulsive disorders; after biliary tract surgery; suspected surgical abdomen; surgical anastomosi s;

GI Nausea; vomiting; constipation; abdominal pain. Genitourinary Urinary retention or hesitancy. Respiratory Respiratory depression; apnea; respiratory arrest; laryngospasm; depression of cough reflex.

Emphasize that drug is more effective if taken regularly to prevent pain rather than to treat pain after it occurs. If patient is to receive patient-controlled analgesia (PCA), instruct on use of PCA pump. Explain that physical dependency may occur with long-term therapy and that dosage will be tapered slowly before stopping to prevent withdrawal symptoms (nausea, vomiting, cramps, fever, faintness, anorexia).

Name of Drug

Contraindicati ons idiosyncrasy to the drug; concomitantly with MAOIs or within 14 days of such treatment

Adverse Reaction Miscellaneous Tolerance; psychological and physical dependence with chronic use; pain at injection site; local irritation and induration following subcutaneous use.

Nursing Alert
y

Encourage patient to turn, cough and breathe deeply every 2 h to prevent atelectasis. Advise patient to consult with health care provider if excessive sedation occurs or if pain relief is inadequate. Inform patient that drug may cause constipation. Stool softener, fiber laxative, increased fluid intake and bulk in diet may help alleviate problem. Caution patient to avoid sudden position changes to prevent orthostatic hypotension. Instruct patient to avoid intake of alcoholic beverages and other CNS depressants. Advise patient that drug may cause drowsiness, dizziness or blurred vision and to use caution while driving or performing other tasks requiring mental alertness.

Administer Drug Therapy: Captopril 25 mg/tab OD Enoxaparin sodium 0.6 ml/ IV now , then S.C. Q12h. Diazepam 5 mg/ tab BID Lactulose 3 cc CDC isosorbide dinitrate 5mg / tab 5L Q5mins x # doses PRN chest pain. Alorvastatin 80mg/tab OD Metoprolol 50g/tab BID Aspirin 80g tablet OD Isosorbide Mononitrate 60 mg/tablet tablet OD Morphine 2 mg IV in pain Procedure: ECG monitoring Echocardiogram Test Clinical Chemistry CBC

NURSING CARE PLAN

ASSESS MENT Subjectiv e cues: Naninikip ang dibdib ko as verbalize d by the patient. It is felt upon work or even at rest, with

DIAGNO SIS Acute pain related to Ischemia of myocardi al tissue as evidence d by: Verbal reports , restlessn ess, diaphore sis.

PLANNIN INTERVEN G TION ShortDependent term : goal: 1.Administe After 15- r O2 30 2Liter/minut minutes of e via nasal nursing cannula as interventio indicated n the 2.Administe patient will r morphine demonstra 2mg IV as te use of ordered by relaxation the technique physician s, reduced Independe tension, nt relaxed manner, ease of movement .

RATIONALE 1.Increase amount of oxygen available for myocardial uptake and thereby may relieve discomfort associated with tissue ischemia 2.Although intravenous Morphine is the usual drug if choice, other injectable narcotics may use in acute phase/recurrent chest pain unrelieved by nitroglycerin to reduce severe pain, provide sedation

EVALUATION 1. Tachypnea is started to resolve and patient is less anxious at this time 2. Client appears to be cooperative in taking medication. 3. Patient started to listen relaxing music 4. Patient was sitting on bed appears more comfortable with the help of non

ASSESS DIAGNOSIS MENT

PLANNING

INTERVENTION

RATIONALE

EVALUATI ON

sharp, severe, steady subster nal pain and a scale of 7 out of 10 that last more than 15 minutes .

scientific Explanation/ Inference Unpleasant sensory and emotional experience arising from actual or potential tissue damage or describe in terms of such damage (internationa l association for the

After 1-2 hrs of nursing intervention the patient will verbalize relief/ control pain within appropriate time frame for administere d medications

3. Provide quit environment, calm activities, and comfort measures approach patient calmly and confidently. 4. Position the patient into semi-fowlers position and assist or instruct in deep slow breathing, visualization, guided imagery. 5. Check Vital Signs before and after narcotic medications

3. Decreases external stimuli which may aggravate anxiety and cardiac strain limit, coping abilities and adjustment to current situation. 4. Helpful in decreasing perception of response to pain, provides sense of having some control over the situation, increase positive attitude.

5. Client BP slightly decrease s because of relaxatio n techniqu es.

Cues

Nursing Diagnosis

Nursing Intervention 6. Evaluate and document client's response to medicine and assist in transitioning or altering drug regimen, based on individual needs and protocols. 7. Encourage adequate rest periods.

Rationale

Evaluation

Objective cues: BP: 150/100 mmHg RR: 29 cpm PR: 108 bpm Restlessn ess, sleep disturbanc e, diaphoresi s Lab result: ECG= S-T elevated

Study of pain); sudden or slow onset of any intensity from mild to severe with any anticipated or predictable end and a duration of less than six months.

5. Hypotension/ respiratory depression can occur as a result of narcotic administration. These problems may increase myocardial damage in presence of ventricular insufficiency. 6. Increasing or decreasing dosage stepped program (switching from injection to oral route increased time span as pain lessens) helps in self management of pain. 7. To prevent fatigue.

6. Client states that the pain on her chest started to diminished 7. Client was now lying on bed and is sleeping effectively.

Nursing Diagnosis Subjective: Anxiety Natatakot related to ako sa threat of pwedeng death as mangyari sa evidence by akin as increase in verbalized respiratory by the rate, client restlessness Objective: , facial o Vital tension and Sign tense taken appearance

Cues

Planning Short Term Goal: After 1-2 hours of nursing intervention the client will be able to verbalize absence or decrease in subjective distress Long term Goal After 1 day of nursing intervention the client will be Able to identify and demonstrate techniques to control anxiety.

Nursing Intervention Independent 1.Observe clients facial tension 2. Identify and acknowledge patients perception of threat or situation. Encourage expression of and do not deny feelings of anger, grief, sadness or fear 3.Use therapeutic touch and healing touch techniques like back rub

Rationale Helps client to identify what is reality-based. (Nurse s pocket guide by: Doenges pg. 91) Coping with the pain and emotional trauma of MI is difficult. Patient may fear of death and anxious about immediate environment.

Evaluation After 2 hours the client facial tension changed into calm. The patient started expressing his feelings freely The clients stated he feels better. Patient started to listen relaxing music The patient appears calm.

Cues

Nursing Diagnosis

Nursing Intervention

Rationale

BP: 150/100 mmHg RR: 29 cpm PR: 108 bpm o Restle ssness o Facial tensio n o Tense Appe aranc e o Mild anxiet

Inference A vague uneasy feeling of discomfort or dread accompanied by an automatic response (the source often non specific or unknown to the individual); a feeling of apprehension caused by anticipation of

4. Provide clients with a means to listen to music of their choice and audiotapes.

Ongoing anxiety (related to concerns about impact of heart attack on future lifestyle, matters left untended unresolved and effects of illness on family) may be present in varying degrees for some Provide quiet time and maybe manifested by places and symptoms of depression encourage clients Various techniques that involve to listen for 20 intention to heal, laying on hands, minutes. cleaning the energy field Collaborative surrounding the body and transfer Administer of healing energy from the Diazepam 5mg/tab environment through the healer to BID prescribed by the subject can relieve anxiety the doctor.

Cues

Nursing Diagnosis

Planning

Nursing Interventi on

Rationale

Evalu ation

It is an alerting signal that warms of impending danger and enables the individual to take measure to deal with threat. Reference Ladwig, G.B. Guide to Nursing Diagnosis page 183

Immediately and 1 hour after listening to music for 2o minutes in quiet environment is reduction in heart rate, respiratory rate and myocardial angina demand were significantly greater in the experimental group of client with MI than in the control of the group To lessen nervousness and irritation. (Ackley, B.J., Ladwig, G.B., Nursing Diagnosis Handbook page 187

Cues
Subjective: Madalas akong mahilo as verbalized by the client Objective: o Lab Test: ECG Result (ST Elevated and T wave inversion )

Nursing Planning Diagnosis

Risk for Decreased Cardiac Output related to altered heart rate or rhythm as manifested by ECG Result (ST Elevated and T wave inversion ) and PR = 108 bpm. Short Term Goal: After 8 hours of nursing intervention the client will have no elevation in blood pressure above normal limits and will maintain blood pressure within acceptable limits. Long term Goal After 1-2 days of nursing intervention the client will be maintain normal cardiac rhythm with adequate cardiac output

Nursing Intervention
Independent 1. Position the client in upright or semi fowler s position 2. Support the client in using pursed lip and controlled breathing technique 3. Monitor intake and output, if the client is acute ill, measure hourly urine output and note decreases in output

Rationale
Facilitate lung expansion. Pursed lip breathing result in increased use of intercostals muscles, decreased respiratory rate, increased tidal volume and improve oxygen saturation Decreased cardiac output result in decreased perfusion of the kidney with resulting decreased urine output Caffeine is a cardiac stimulant and may adversely affect cardiac function.

Evaluation
Client lying on bed with head slightly elevated and now in comfortable position Patient performed pursed lip and deep breathing techniques in times of pain. The patient was cooperative and able to mentioned his intake and output Patient was no longer drink caffeine, cola and chocolate. The patient was being cooperative with the health care provider

Cues

Nursing Diagnosis

Nursing Intervention

Rationale

Evaluation

o Vital Sign taken BP: 150/100mmHg RR: 29 cpm PR:108 bpm o Accessory Muscle use in breathing o Fatigue o Restlessnes s o Tachypnea

Inference 1. Encourage Inadequate blood patient purified by the to decrease heart to meet intake of metabolic demand caffeine, cola of the body. and Reference chocolate. Ackley, B.J., 2. Monitor ECG Ladwig, G.B., for Nursing Diagnosis dysrrhythmias, Handbook 7th conduction Edition page 266 defects and for heart rate

Decrease in cardiac output may result in changes in cardiac perfusion causing dysrhythmias. (Ackley, B.J., Ladwig, G.B., Nursing Diagnosis Handbook 7th Edition page 268)

Promote compliance with the prescribed medication regimen and other treatment measure, thoroughly explain dosages and therapy. Inform the patient of the drugs adverse reactions, and advise him to watch for and report sign and symptoms of toxicity. Review dietary restrictions with the patient. If he must follow a low-sodium diet, low-fat, or low- cholesterol diet, provide a list of foods to avoid. Ask the dietitian to speak the patient and family. Advise patient to eat high fiber diet to avoid constipation Encourage the patient to participate in a cardiac rehabilitation exercise program. The physician and the exercise physiologist should determine the level of exercise and then discuss it with the patient and secure his agreement to a stepped-care program.

Counsel the patient to resume sexual activity progressively. He may need to take nitroglycerin before sexual intercourse to prevent chest pain from the increased activity. Advise the patient about appropriate responses to new or recurrent symptoms. Advise the patient to report typical or atypical chest pain. Post MI syndrome may develop, producing chest pain that must be differentiated from a recurrent MI, pulmonary infarction, and heart failure.

Stress the need to stop smoking. If necessary, refer the patient to a support group. Explain to the patient that physical activity is restricted initially after an MI, to decrease the workload of the heart. However, complete bed rest is contraindicated. Tell him to plan his daily activities so that he alternates light and heavy tasks and rests between them.

(Nursing 2003: Drug Handbook 23rd Edition published by Lippincott Williams and Wilkins) (Diseases: A Nursing Process Approach to Excellent Care 4th Edition published by Lippincott Williams and Wilkins) (Patient Teaching: Reference Manual published by Springhouse) Frizzell, J.P. (2000). Handbook of Pathophysiology, Springhouse, PA: Springhouse Josie Quiambao Udan, RN, MAN. Fundamentals of Nursing 2nd edition Doris Smith Suddarth, RN BSNE MSN, The Lippincott manual of nursing Practice Fifth Edition Kozier, Fundamentals of Nursing Pearson, Medical Surgical Nursing 4th edition Volume 2 Reference: Brunner and Suddarths, Textbook of Medical- Surgical Nursing, Suzanne C. Smeltzer and Brenda G. Bare 9th Edition, Volume 1, ) Handbook of med surg Nsg. 3rd published by springhouse