Cad

GENERAL OBJECTIVE

At the end of the presentation, students are expected to gain the necessary information regarding Coronary Artery Disease for them to determine the appropriate nursing care management they should provide to those patients having this kind of illness

The students will be able to:  Understand the nature of Coronary Artery

Disease  Distinguishes its clinical manifestations and predisposing factors.  Outline the Anatomy and Physiology of the disease or condition.  Demonstrate the Pathophysiology of the disease.

 Determine the health status of the patient

through: Knowing the past history and present

illnesses of the patient as well as their family health history. Conducting physical examination. Analyzing the laboratory examination done and correlate it to the present condition of the patient.

 Determine the appropriate nursing care

that should be provided to the client.  Understand the different drugs that the client is taking and determine how it will benefit the client as well as the possible adverse effect it may give.  Create a good and therapeutic nursepatient interaction.  Teach the client’s relatives on how to minimize the risk of developing Coronary Artery Disease.

Coronary artery disease (CAD), also called

coronary heart disease, is a condition in which plaque builds up inside the coronary arteries. These arteries supply your heart muscle with oxygen-rich blood. Plaque is made up of fat, cholesterol, calcium, and other substances found in the blood. When plaque builds up in the arteries, the condition is called atherosclerosis. Plaque narrows the arteries and reduces blood flow to your heart muscle. It also makes it more likely that blood clots will form in your arteries. Blood clots can partially or completely block blood flow.

When your coronary arteries are narrowed or

blocked, oxygen-rich blood can't reach your heart muscle and causes it to die. This can cause angina or a heart attack. It can weaken the heart muscle and lead to heart failure and arrhythmias.

Atherosclerosis Coronary heart disease Hardening of the arteries Heart disease Ischemic heart disease Narrowing of the arteries

Starts when certain factors damage the inner

layers of the coronary arteries. These factors include: Smoking High amounts of certain fats and cholesterol in the blood High blood pressure High amounts of sugar in the blood due to insulin resistance or diabetes

 Many factors raise the risk of developing CAD. The

more risk factors you have, the greater chance you have of developing CAD.  Unhealthy blood cholesterol levels  High blood pressure  Smoking  Insulin resistance  Diabetes  Overweight or obesity   Metabolic syndrome  Lack of physical activity  Age  Family history of early heart disease

High levels of a protein called C-reactive

protein (CRP) in the blood may raise the risk for CAD and heart attack. High levels of CRP are proof of inflammation in the body. Other factors also may contribute to CAD. These include: Sleep apnea Stress Alcohol

Angina Shortness of breath Heart Attack Discomfort Irritability Fatigue

The most common symptom of heart attack is

chest pain or discomfort. Most heart attacks involve discomfort in the center of the chest that lasts for more than a few minutes or goes away and comes back. The discomfort can feel like pressure, squeezing, fullness, or pain. It can be mild or severe. Heart attack pain can sometimes feel like indigestion or heartburn. Heart attacks also can cause upper body discomfort in one or both arms, the back, neck, jaw, or stomach. Shortness of breath or fatigue (tiredness) often may occur with or before chest discomfort. Other symptoms of heart attack are nausea (feeling sick to your stomach), vomiting, lightheadedness or fainting, and breaking out in a cold sweat.

Your doctor will diagnose coronary artery

disease (CAD) based on: Your medical and family histories Your risk factors The results of a physical exam and diagnostic tests and procedures

An EKG is a simple test that detects and

records the electrical activity of your heart. An EKG shows how fast your heart is beating and whether it has a regular rhythm. It also shows the strength and timing of electrical signals as they pass through each part of your heart. Certain detect electrical patterns and show signs of a previous or current heart attack.

 During stress testing, you exercise to make your

heart work hard and beat fast while heart tests are performed. If you can't exercise, you're given medicine to speed up your heart rate.  When your heart is beating fast and working hard, it needs more blood and oxygen. Arteries narrowed by plaque can't supply enough oxygenrich blood to meet your heart's needs. A stress test can show possible signs of CAD, such as:  Abnormal changes in your heart rate or blood pressure  Symptoms such as shortness of breath or chest pain  Abnormal changes in your heart rhythm or your heart's electrical activity

During the stress test, if you can't exercise for

as long as what's considered normal for someone your age, it may be a sign that not enough blood is flowing to your heart. But other factors besides CAD can prevent you from exercising long enough (for example, lung diseases, anemia, or poor general fitness). Some stress tests use a radioactive dye, sound waves, positron emission tomography (PET), or cardiac magnetic resonance imaging (MRI) to take pictures of your heart when it's working hard and when it's at rest.

These imaging stress tests can show how well

blood is flowing in the different parts of your heart. They also can show how well your heart pumps blood when it beats.

This test uses sound waves to create a

moving picture of your heart. Echocardiography provides information about the size and shape of your heart and how well your heart chambers and valves are working. The test also can identify areas of poor blood flow to the heart, areas of heart muscle that aren't contracting normally, and previous injury to the heart muscle caused by poor blood flow.

A chest x ray takes a picture of the organs

and structures inside the chest, including your heart, lungs, and blood vessels. A chest x ray can reveal signs of heart failure, as well as lung disorders and other causes of symptoms that aren't due to CAD.

Blood tests check the levels of certain fats,

cholesterol, sugar, and proteins in your blood.. Abnormal levels may show that you have risk factors for CAD.

Treatment for coronary artery disease (CAD)

may include lifestyle changes, medicines, and medical procedures. The goals of treatments are to: Relieve symptoms Reduce risk factors in an effort to slow, stop, or reverse the buildup of plaque Lower the risk of blood clots forming, which can cause a heart attack Widen or bypass clogged arteries Prevent complications of CAD

 Making lifestyle changes can often help prevent or

treat CAD. For some people, these changes may be the only treatment needed:  Follow a heart healthy eating plan to prevent or reduce high blood pressure and high blood cholesterol and to maintain a healthy weight  Increase your physical activity. Check with your doctor first to find out how much and what kinds of activity are safe for you.  Lose weight, if you're overweight or obese.  Quit smoking, if you smoke. Avoid exposure to secondhand smoke.  Learn to cope with and reduce stress.

Decrease the workload on your heart and

relieve CAD symptoms Decrease your chance of having a heart attack or dying suddenly Lower your cholesterol and blood pressure Prevent blood clots Prevent or delay the need for a special procedure (for example, angioplasty or coronary artery bypass grafting(CABG))

Medicines used to treat CAD include

anticoagulants ,aspirin and other antiplatelet medicines, ACE inhibitors, beta blockers, calcium channel blockers, nitroglycerin, glycoprotein and fish oil and other supplements high in omega-3 fatty acids.

Angioplasty opens blocked or narrowed

coronary arteries. During angioplasty, a thin tube with a balloon or other device on the end is threaded through a blood vessel to the narrowed or blocked coronary artery. Once in place, the balloon is inflated to push the plaque outward against the wall of the artery. This widens the artery and restores the flow of blood. It can improve blood flow to your heart, relieve chest pain, and possibly prevent a heart attack.

Arteries or veins from other areas in your

body are used to bypass (that is, go around) your narrowed coronary arteries. CABG can improve blood flow to your heart, relieve chest pain, and possibly prevent a heart attack.

Your doctor may prescribe cardiac

rehabilitation (rehab) for angina or after CABG, angioplasty, or a heart attack. Cardiac rehab, when combined with medicine and surgical treatments, can help you recover faster, feel better, and develop a healthier lifestyle. Almost everyone with CAD can benefit from cardiac rehab. The cardiac rehab team may include doctors, nurses, exercise specialists, physical and occupational therapists, dietitians, and psychologists or other behavioral therapists.

Exercise training. This part helps you learn

how to exercise safely, strengthen your muscles, and improve your stamina. Your exercise plan will be based on your individual abilities, needs, and interests. Education, counseling, and training. This part of rehab helps you understand your heart condition and find ways to reduce your risk for future heart problems. The cardiac rehab team will help you learn how to cope with the stress of adjusting to a new lifestyle and with your fears about the future.

Making lifestyle changes and taking

prescribed medicines are important steps

Dying suddenly from heart problems Having a heart attack and permanently

damaging your heart muscle Damaging your heart because of reduced oxygen supply Having arrhythmias (irregular heartbeats)

 Name: Mrs. J  Address: Gen. Luna Sariaya, Quezon  Date of birth: April 12, 1934  Age: 75  Sex: Female  Nationality: Filipino  Religion: Roman Catholic  Attending Physician: Dr. Obordo

 On August 27, 2009, Mrs. J was supposed to see

her personal physician for her daily check-up. She complained to her physician about the dizzy feeling she experiences lately. The physician advised her for admission to perform some diagnostic tests to know her current health condition.  Patient has a chief complaint of dizziness with a diagnosis of HPN/CAD, frequent PAC’s with LV dysfunction DM II, Dyslipedemia T/C Acute Bronchitis Bronchoestasis Left Base CXR: minimal PTB.

General Health 

The patient

Childhood Illness 

The patient had chicken pox and measles during her childhood.

Immunization

Incomplete immunization. Major



Illnesses/Hospitalization 

She had two hospitalizations prior to admission. The first was on 1961 when she gave birth to her sixth child and the second was on 2005 when she had her mastectomy due to breast cancer.

Current Medications  Aspilet 80mg/tab 1tablet OD after lunch(1PM)  Benazepril 20mg/tab 1 tablet OD(9AM)  Carvedilol 6.25mg/tablet 1 tablet OD(9AM)  Lanoxin 0.125mg OD(9AM)  Furosemide 20mg OD(9Am)  Metformin 500mg BID(8AM-8PM)  Multivitamin plus minerals 500mg OD(9AM)  Pravastatin 20mg ODHS(8PM)  Ranitidine 150mg ODHS(8PM)  Levofloxacin 500mg OD(9AM) for 4 days  Salbutamol 1 neb every eigth hours

Allergies 

No known allergies.

Habits Has regular ballroom dancing session

lasting 2-3 hours Nutritional-Metabolic Pattern  Appetite Patient has a good appetite.

Usual daily menu Her usual daily meal consists of vegetable without sauce. On her middle age, she was fond of eating sweets. She stopped drinking softdrinks 15 years ago. Metabolic Pattern No weight gain nor weight loss.

Elimination Pattern  Bladder The patient empties her bladder 15 times a day.

 Bowel The patient defecates once a day.

Activity Exercise Pattern  Self Care Ability The patient can perform all self care activities.  Oxygenation/Perfusion Not in respiratory distress.

CANCE R

DM

CAD

CA,DM,C AD

Mrs. J

Fath er

Moth er

1st child

2nd child

3rd child

6th child

5th child

4th child

 Skull:  Hair:  Patches of hair loss  Very thin hair  No infection/manifestation

 Eyes:  Skin intact  No discharges  Pinkish conjunctiva  Arcus senilis is present  (Pupil) black-bluish in color, equal in size 2-

3mm in diameter, round and flat  Ears:  Color: same as facial skin  Symmetrical  Mobile, firm and not tender, pinna recoils after it is folded.  No discharges  Normal voice tones not audible.

 Nose:  Color: same as facial skin  No discharges/flaring  Not tender; no lesions  Symmetric and straight  Mouth:  Soft, moist  Ability to purse lips  Uniform, pink color  Smooth, intact dentures  Tongue moves freely  Neck:  Flexible  No palpable lymph nodes

 Chest:  Skin intact, uniform temperature  Chest wall intact, no tenderness, no redness  No nipple discharges  Nails:  Good capillary refill of less than 3 seconds  Intact epidermis  Smooth texture  Musculoskeletal (arms and legs):  No deformities  Coordinated movements  25% normal strength

Your heart is located under the ribcage in the

center of your chest between your right and left lung. It’s shaped like an upside-down pear. Its muscular walls beat, or contract, pumping blood continuously to all parts of your body. The size of your heart can vary depending on your age, size, or the condition of your heart. A normal, healthy, adult heart most often is the size of an average clenched adult fist. Some diseases of the heart can cause it to become larger.

 The heart is the muscle in the lower half of the picture.

The heart has four chambers. The right and left atria (AY-tree-uh) are shown in purple. The right and left ventricles (VEN-trih-kuls) are shown in red.  Connected to the heart are some of the main blood vessels—arteries and veins—that make up your blood circulatory system.  The ventricle on the right side of your heart pumps blood from the heart to your lungs. When you breathe air in, oxygen passes from your lungs through blood vessels where it’s added to your blood. Carbon dioxide, a waste product, is passed from your blood through blood vessels to your lungs and is removed from your body when you breathe air out.  The atrium on the left side of your heart receives oxygen-rich blood from the lungs. The pumping action of your left ventricle sends this oxygen-rich blood through the aorta (a main artery) to the rest of your

 The superior and inferior vena cavae are in blue to the

left of the muscle as you look at the picture. These veins are the largest veins in your body. They carry used (oxygen-poor) blood to the right atrium of your heart. “Used” blood has had its oxygen removed and used by your body’s organs and tissues. The superior vena cava carries used blood from the upper parts of your body, including your head, chest, arms, and neck. The inferior vena cava carries used blood from the lower parts of your body.  The used blood from the vena cavae flows into your heart’s right atrium and then on to the right ventricle. From the right ventricle, the used blood is pumped through the pulmonary (PULL-mun-ary) arteries (in blue in the center of picture) to your lungs. Here, through many small, thin blood vessels called capillaries, your blood picks up oxygen needed by all the areas of your body.  The oxygen-rich blood passes from your lungs back to

Oxygen-rich blood from your lungs passes

through the pulmonary veins (in red to the right of the left atrium in the picture). It enters the left atrium and is pumped into the left ventricle. From the left ventricle, your blood is pumped to the rest of your body through the aorta. Like all of your organs, your heart needs blood rich with oxygen. This oxygen is supplied through the coronary arteries as it’s pumped out of your heart’s left ventricle. Your coronary arteries are located on your heart’s surface at the beginning of the aorta. Your coronary arteries (shown in red in the drawing) carry oxygen-rich blood to all parts of your heart.

 The right and left sides of your heart are divided

by an internal wall of tissue called the septum. The area of the septum that divides the two upper chambers (atria) of your heart is called the atrial or interatrial septum. The area of the septum that divides the two lower chambers (ventricles) of your heart is called the ventricular or interventricular septum.

 The picture shows the inside of your heart and

how it’s divided into four chambers. The two upper chambers of your heart are called atria. The atria receive and collect blood. The two lower chambers of your heart are called ventricles. The ventricles pump blood out of your heart into the circulatory system to other parts of your body.

 The picture shows your heart’s four valves. Shown

counterclockwise in the picture, the valves include the aortic (ay-OR-tik) valve, the tricuspid (triCUSS-pid) valve, the pulmonary valve, and the mitral (MI-trul) valve.

The arrows in the drawing show the direction

that blood flows through your heart. The light blue arrows show that blood enters the right atrium of your heart from the superior and inferior vena cavae. From the right atrium, blood is pumped into the right ventricle. From the right ventricle, blood is pumped to your lungs through the pulmonary arteries. The light red arrows show the oxygen-rich blood coming in from your lungs through the pulmonary veins into your heart’s left atrium. From the left atrium, the blood is pumped into the left ventricle, where it’s pumped to the rest of your body through the aorta.

 For the heart to function properly, your blood

flows in only one direction. Your heart’s valves make this possible. Both of your heart’s ventricles has an “in” (inlet) valve from the atria and an “out” (outlet) valve leading to your arteries. Healthy valves open and close in very exact coordination with the pumping action of your heart’s atria and ventricles. Each valve has a set of flaps called leaflets or cusps, which seal or open the valves. This allows pumped blood to pass through the chambers and into your arteries without backing up or flowing backward.

SVC RA

TV

RV

PV

PA

MV

LA

LUNGS IVC Diffirent systen

Aorta

LV

PV

RISK FACTORS: Smoking, DM, Hypertensio n, Sedentary Lifestyle, Obesity

Family history of CAD (HEREDITY)

CHOLESTE ROL

FOAM CELLS OXIDIZED LDL PLAQUE FORMATION

BLOOD VESSELS ARE BLOCKED

AFFECTS THE SUPPLY OF BLOOD TO THE HEART REDUCES OXYGEN AND NUTRIENTS IN THE HEART AND AFFECTS THE SUPPLY OF OXYGEN TO THE VITAL ORGANS DEATH OF TISSUE WITHIN THESE ORGANS AND THEIR EVENTUAL FAILURE HEART ATTAC K

DEAT H

 The patient was admitted last August 27,

2007 from NS5 under Dra. Obordo attending to the chief complaint of dizziness. The following orders were given: take vital signs every four hours and record, with diet of 1200 calorie, 4 gram of Sodium, low cholesterol diabetic diet divided into three meals and two snacks. The diagnostic procedures that should be done are as follows: Random Blood Sugar thrice a day after meals and midnight (forwarded), 2D echo with Doppler (done), and serum sodium and potassium (forwarded). The attending physician ordered an IV fluid of Plain NSS 1liter x KVO. The medications ordered were Metformin 500grams 1 tablet twice a day, Multivitamin plus minerals 1 tablet once a day and nebulizer with Durament every eight

 At 12PM, a text order from Dra. Obordo to

NOD Nolelily Anne Tan. The order was please refer to Dr. Pureza for cardiac consult.  At 2AM, the patient was seen and examined by Dr. Pureza obtained the following: two days prior to admission, the patient has generalized body numbness with dizziness and BP of 120/70, CAD, with frequent PACS with left ventricle dysfunction, DM type II and dyslipedemia. Dr. Pureza had the following findings:  75 year old, Female, known diabetic for less than one year  On Metformin 500mg twice a day

 Claims to be adhering to her DM diet  Has regular ballroom dancing session lasting

2-3 hours  Negative for episodes of severe angina  Positive for shortness of breath  Negative numbness  Negative HPN  Laboratory: HbA1C=6.10%  FBS=140  RBS=275

 Analysis: DM Type 2, good control  He ordered to continue Metformin

500mg twice a day and continue CBC as ordered.  At 08:05, the AP ordered Ranitidine 150mg one tablet at hours of sleep and may not reinseret IVF.  At 10:45PM, phone order was made by Dra. Obordo to NOD R. Valbuena.  Carry out suggestion of Dra. V. Reyes  On August 28, 2009, the AP ordered to start Isoket 20 mg to NOD.

LABORATORY TEST

RESULT

NORMAL RANGE

INTERPRETAT ION

Cholesterol

152.mg/dL

0-200 mg/dL

Normal

0-150 mg/dL

Normal

Triglycerides

67.mg/dL

Direct HDLC

56.mg/dL

40-60 mg/dL

Normal

ALT

57.U/L

11.-66.U/L

Normal

LABORATORY TEST

RESULT

NORMAL RANGE

INTERPRETATI ON

VDLC

13.mg/dL

0-35 mg/Dl

Normal

LDL

83.mg/dL

0-150 mg/dL

Normal

CHOL/dHDL

2.72mg/dL

<200mg/dL

Normal

Sodium

128.mmol/L

135.0-145.0 mmol/L

Normal

Potassium

5.0mmol/L

3.50-5.50 mmol/L

Normal

LABORATORY TEST

RESULT

NORMAL RANGE

INTERPRETATIO N

RBS (08/28/09) 11:30am

82mg/dL

70-110mg/dL

Normal

5:30am

67mg/dL

70-110mg/dL

12mn

75mg/dL

70-110mg/dL

LOWER:abnormal loss of erythrocytes,lack of needed elements or hormones for erythrocyte production, bone marrow suppresion Normal

5:30pm

133mg/dL

70-110mg/dL

HIGHER: hematuria, trauma to kidney, hemolytic transfusion reaction, UTI, burns sickle cell anemia. Normal

08/27/09 11:30am

91mg/dL

70-110mg/dL

08/25/09

275mg/dL

70-110mg/dL

HIGHER: hematuria, trauma to kidney, hemolytic transfusion reaction, UTI, burns sickle cell anemia.

T est/ Result Color: yellow

Transparency : Slightly turbid

Normal V alues amber yellow

Interpretation normal

clear

Specific gravity:1.015

1.015 – 1.025

normal

Reaction: 6.0

4.5 – 7.5

normal

Sugar : negative

negative

---

Protein: trace

negative

---

T est/ Results

Normal V alues

RBC: 1-2

0-1/HpF

Pus cells: 4-5

0-2/HpF

Interpretation

Epithelial cells: few

few

Normal

Others: Bacteria: few

few

Normal

LABORATORY TEST

RESULT

NORMAL RANGE

INTERPRETATION

Hemoglobin

11.7

M14.0-17.0g/dL F12.0-15.0g/dL

LOWER: blood loss, hemolytic anemia, bone marrow suppression, sickle cell anemia

Hematocrit

35.2

M40-48% F37-45%

LOWER: blood loss, overhydration, dietary deficiency anemia

RBC

3.56

M4 . 6 -5 .1 F 4 - 4 .5 10 ^ 6 /uL

LOWER: abnormal loss of erythrocytes, lack of needed elements or hormones for erythrocyte production, bone marrow suppression

WBC

7.48

5- 10 10^ 3 / uL

MCV

98.9

26-34

Normal

MCH

32.9

26-34

Normal

NORMAL

LABORATORY TEST MCHC

RESULT 33.2

NORMAL RANGE INTERPRETATIO N 31-36g/dL NORMAL

Neutrophils

44.7

55-65

Lymphocytes

43.0

25-35

Monocytes

6.4%

1-6

Eosinophils

5.2%

LOWER: viral diseases

1-5

HIGHER: viral infection , mononucleosis, TB, chronic bacterial infection, lymphocytic leukemia HIGHER: Chronic inflammatory disorders ,TB, protozoan infection, chronic ulcerative colitis

HIGHER: allergic reaction,

LABORATORY TEST

RESULT

NORMAL RANGE

INTERPRETATION

Basophils

0.7%

1-5

LOWER: Acute allergic reaction, corticosteroid, acute infection

Platelet

202

150-400 10^3/uL

NORMAL

LABORATORY TEST FBS

RESULT

NORMAL RANGE INTERPRETATIO N 65-110mg/dL NORMAL

99.4mg/dL

Uric acid

4.4mg/dL

3.0-7.0mg/dL

NORMAL

BUN

41.6mg/dL

10-50mg/dL

NORMAL

Creatinine

1.4mg/dL

M:0.8-1.8mg/dL F:0.6-1.6mg/dL

NORMAL

SGOT/AST

93

Up to 46 U/L

HIGHER: Liver diseases, acute myocardial infarction, anemia

ROENTGENOLOGICAL FINDINGS -Fibroid and hazy densities in the right upper lung -Calcified aortic knob -Heart is slightly enlarged -Res of chest structures unremarkable Remarks: Minimal PTB Act. Undetermined ATHEROMATOUS AORTIC KNOB MICD CARDIOMEGALY. ECG Results: -Normal sinus right with frequent PAC’s -Left atrial abnormality -Poor Rwave phogesnifa V.-V3 -LUH N+ strain or ischemia pattern

Assessme nt Objectives : >pale in appearanc e >irritable >with shortness of breath >cold clammy skin on lower extremitie s >with capillary refill of 4 seconds

Nursin Planni g ng At the end Impaired Diagno of the gas nursing exchange sis

Interventi ons

>Monitore d vital signs and related to interventio cardiac perfusion ns, the rhythm. imbalance client will: >Demonst [as in >Elevated rate altered head of improved blood bed. ventilation flow] as and manifeste >Encourag adequate d by ed oxygenati shortness frequent on of of breath. tissues by position absence of changes shortness and deep of breath. breathing >Participa exercises.

Rational Evaluati es on >To determine patient’s condition.

Goal met. >Patient does not experience shortness of breath. >RR=19 >Seen >To patient promote performin g proper breathing. breathing >Promotes exercises. optimal chest expansion.

>Encourag ed adequate rest and limit activities to within client tolerance.

>Helps limit oxygen needs.

>To >Provided reduce psychologi anxiety. cal support such as active listening. >To treat underlying >Administ condition. ered medication >To as reduce

Goal met. >Patient does not experience shortness of breath. >RR=19 >Seen patient performin g breathing exercises.

Assessment

Diagnosis

Objective: Shortness of breath RR-24 bpm Cardiac rhythm- S1-S2S3 Pale in apperance Cold, clammy skin in lower extremities 4 secs of capillary refill

Risk for decreased cardiac output r/t altered heart rhythm secondary to CAD

Planning

Intervention

After 8 hours of >Monitored vital signs nursing intervention the frequently client will be able to:

Rationale >To determine client’s condition and to note response to intervention

Evaluatio n

Goal partially met Pt. demonstrat ed no >Monitored >To note shortness •Improve cardiac rhythm progressive of breath cardiac output, through condition of RR- 19 and participate auscultation client bpm in activities that and reduce the work >Assessed for >To assess sign participated of poor in activities load of the heart progressive shortness of ventricular that reduce (ex. stress breath function/ work load management impending of heart and balanced cardiac failure such as activity/rest >Placed in >Decreases deep plan) semi- Fowler’s oxygen breathing position consumption exercise. and risk of decompensation .

>Decrease d fluid intake

>To decrease cardiac workload

>Decrease d stimuli and provided quiet environme nt

>To promote adequate rest.

Goal partially met Pt. demonstrated no shortness of breath RR- 19 bpm and participated in activities that reduce work load of heart such as deep breathing exercise.

ASSESSM DIAGNOSI PLANNIN INTERVEN RATIONA EVALUATI ENT S G TION LE ON

“Natatakot ako magpaopera. ” As verbalized by the pt. •Alarmed •Increased tension •Uncooperati ve •Irritability •Increased alertness •V/S: T= 36.4°C RR= 20 bpm PR= 69 bpm BP= 130/70 mmhg

Anxiety related to fear of operatio n.

Within the • 8hr shift, pt. will be able to verbalize sense of safety related to current situation. The pt. will also be able • to demonstrat e understandi ng through use of effective coping behaviors.

Determin • ed client’s age or develop mental level.

Compare • d verbal/no nverbal response s.

Helps in understa nding typical or usual fears experien ced by individua ls. To note congruen cies or misinterp retation of environm ent.

•

•

Stayed • with the client or make arrange ments to have someon e else be there. Discuss • ed client’s percepti on /fearful feelings. Listen/a ctivelisten to client’s

Providin • g client with usual/de • sired support persons can diminish feelings of fear. Promote s atmosph ere of caring and permits explanat ion/corr ection of misperc

GOAL NOT MET Pt. was not able to verbaliz e sense of safety related to current situation .

•

•

Provided • opportuni ty for questions and answer honestly. Managed • environm ental factors such as loud noises, harsh lighting, changing person’s location without knowledg e of family, unfamilia

r

Enhances • sense of trust and nurseclient relations hip. This can cause exacerba te stress especiall y to very • young or to older individual s.

Pt. was not also able to demonstr ate understa nding through use of effective coping behaviors . Pt. was still uncooper ative. She doesn’t want to participat e with any discussio ns

Diagnosis

Planning

Intervention

Rationale

After 8 hours of nursing intervention the client will be able to: -verbalize understanding of disease process, therapeutic regimen and rationale for actions and prevention.

>Determined client’s ability and barriers to learning. >Provided information relevant only to the situation. >Provided positive reinforcement >Stated objectives clearly in learner’s terms >Determined client’s method of accessing information >Used short, simple sentences and concepts >Provided active role for client in the learning process.

>Individual may not be physically, emotionally or mentally capable at this time. >To prevent overload. >Can encourage continuation of efforts. >To meet learner’s needs >To facilitate learning.

Assessment Subjective: “maayos naman pakiramdam ko hindi ko na kailangan na magpaopera pa” as verbalized by the patient Objective: inappropriate behavior verbalized false concepts regarding health condition irritable

Knowledge deficit regarding to treatment related to unfamiliarity with information resources

Evaluatio n Goal partially met.

Pt. verbalized to restrict salt intake and follow some health teachings such as >To facilitate exercising effective learning. regularly. >Promotes sense of control over the situation and is means for determining that client is using new information.

DRUG’S NAME

ASPILET

ACTION •

•OD after lunch •80mg. 1tab

• •

INDICATION

Reduction • of inflamma tion • Reduction of fever Decrease incidence of transient ischemic attacks and MI

Mild pain to moderate pain Fever

SIDE EFFECTS •Hearing loss dyspepsia, heartburn, nausea, abdominal pain, anorexia, anemia, increase bleeding time, allergic reaction.

NURSE’S RESPONSIBLITIES 







 





Assess pt. with asthma and allergies. Pain: assess pain and elimination of movement. Fever: assess fever and note associated signs (diaphoresis, tachycardia, malaise, chills) Use lowest effective dose for shortest period of time. Administer after meals or with food Do not crush or chew enteric coated tablet Advice to report tinnitus, bleeding of the gum, bruising, or fever lasting for 3days Caution patient

DRUG’S NAME BENAZEPRIL (Lotensin) Angiotensin – converting enzyme (ACE) inhibitor Antihypertensive •20mg. OD

ACTION •

•

Lowering of blood pressure in hypertensiv e patient. Decrease developme nt of overt heart failure.

INDICATION

SIDE EFFECTS

NURSE’S RESPONSIBLITIES

•Management of hypertension

•Dizziness, fatigue, headache, insomnia weakness, cough, hypotension tachycardia, taste disturbance, nausea, rashes diarrhea

 Hypertension: monitor blood pressure and pulse frequently during initial dose and periodically during therapy.  Monitor frequency of prescription refill to determine adherence.  Instruct patient to take medication as directed  Instruct patient to change position slowly to minimize hypotension  Caution patient to avoid driving and other activities

DRUG’S NAME CARVEDILOL Antihypertensive Beta-blocker •6.25mg. OD

ACTION •

•

Decreased heart rate and blood pressure. Improved cardiac output, slowing of the progressio n of CHF and decreased risk of death.

INDICATION •

•

For hypertensio n Left ventricular dysfunction after myocardial infarction

SIDE EFFECTS

NURSE’S RESPONSIBLITIES

•Dizziness, fatigue, weakness, anxiety, drowsiness, nervousness, blurred vision, bronchospasm, wheezing, diarrhea, constipation, decreased libido, itching, rashes, hyper/hypoglyc emia, bradycardia, CHF

 Monitor blood pressure and pulse frequently during therapy  Assist patient from supine position  Caution from sudden movement  Monitor intake and output ratios and daily weight  Assess patient routinely for evidence of fluid overload  Administer with food  Caution to avoid driving or activities that

DRUG’S NAME DIGOXIN (Lanoxin) •0.125mg OD

ACTION

•Increase cardiac output and slowing of the heart rate.

INDICATION

SIDE EFFECTS

NURSE’S RESPONSIBLITIES

 Monitor apical •Treatment •Fatigue, pulse for 1full of CHF headache, min. before bradycardia administering. , anorexia,  Monitor blood vomiting, pressure diarrhea, periodically in burred patient vision, receiving IV thrombocyt digoxin. openia

 Instruct pt. to take medication as directed  In IV administration check for redness or infiltration and sloughing

DRUG’S NAME •LEVOFLOXACIN (Levox)

Anti-bacterial agent

•500mg OD x 4days

ACTION

INDICATION

• Acute •It works bacterial by killing worsenin the g of bacteria chronic that cause bronchitis the infection.

SIDE EFFECTS

NURSE’S RESPONSIBLITIES

•Anemia,  Closely thrombocy monitor topenia, blood anxiety, glucose depression , tremors,  Assess patient for convulsion s, epistaxis signs of phlebitis, tremors, pancreatiti anxiety or s, blurred depression vision,  Check IV hyper/hyp insertion site oglyce  Assess for allergic symptoms  Administer

DRUG’S NAME FUROSEMIDE Diuretics •20mg OD

ACTION •Inhibits the reabsorption of sodium and chloride

INDICATION

SIDE EFFECTS

•Hypertensio •Dizziness, n headache, nervousness, hypotension, nausea, dyspepsia, vomiting, excessive urination, dehydration, hypokalemia, blood dyacrasia, hyperglycemi a, muscle cramps, rashes

NURSE’S RESPONSIBLITIES  Assess fluid status during therapy  Monitor blood pressure and pulse during administration  Assess pt. using digoxin for anorexia, nausea, vomiting, muscle cramps, paresthesia, confusion  Administer medication in the morning  O not administer discolored solution or tablet  Advice diabetic pt. to monitor blood glucose

DRUG’S NAME METFORMIN

ACTION •

Anti-diabetic 500mg. BID

•

•

•

Maintena nce of blood glucose Decrease s hepatic glucose productio n Increases sensitivit y to insulin Decrease s intestinal glucose absorptio n

INDICATION

SIDE EFFECTS

•Managemen •Abdominal t of type II bloating, DM diarrhea, nausea, vomiting, hypoglycemi a, lactic acidosis

NURSE’S RESPONSIBLITIES

 Observe for signs and symptoms of hypoglycemic reaction when combined with oral sulfonylurea.  Metformin should be temporarily discontinue in pt. requiring surgery  Explain to pt. metformin controls hyperglycemia and does not

DRUG’S NAME

ACTION

INDICATION

Multi Vit  Used in  Serves as compone the + nt of preventio minerals enzyme n and systems treatmen that 500mg. OD t of catalyze vitamin numerous deficienci varied es and as metabolic various reaction metaboli c disorder

SIDE EFFECTS

NURSE’S RESPONSIBLITIES

Rashes, heartburn , abdomina l cramps

 Assess pt. for signs of vitamin deficiency before and periodically throughout therapy  Assess nutritional status through 24hr diet recall  Determine frequency of consumption of vitamin rich foods  Encourage pt.

DRUG’S NAME

ACTION

INDICATION

Pravastatin  Adjunct  Lowering the total (pravachol) to and LDL dietary Lipid lowering cholester therapy agent ol in the  Increase manage 20mg HDL and ment of ODHS decrease primary s VLDL hyperch cholester olesterol ol and emia triglyceride and s mixed dyslipedi mias

SIDE EFFECTS

Dizziness, headache, weakness, abdominal cramps, nausea dyspepsia, rashes, pancreatitis , blurred vision

NURSE’S RESPONSIBLITIES

 Obtain dietary history, especially with regards to fat consumption  Avoid large amount of grapefruit juice during therapy  Instruct to take drug as directed, not to skip dose and don’t

DRUG’S NAME

ACTION

INDICATION

 Short  Healing Ranitidin treatment and e of acute preventio duodenal n of ulcers Histamine H2 ulcers antagonists and  Decrease benign d 150mg. qHS gastric symptom ulcer s of  Managem gastro ent of esophage GERD al reflux  Treatmen  Decrease t and s preventio secretion n of of gastric heartburn acid , acid indigestio n, and

SIDE EFFECTS

NURSE’S RESPONSIBLITIES

 Assess for Confusion, dizziness, epigastric and drowsiness, abdominal pain headache, and frank to black tongue, occult blood in dark stool, the stool, constipation, emesis, or anemia, pain in IM site, epigastric altered taste aspirate  Administer with meals or immediately afterward and at bedtime to prolong effect  Shake oral suspension before administration

DRUG’S NAME

ACTION

Salbutamol  Control Bronchodilator

1neb q8º

INDICATION

 Decrease and d prevent intracelul reversible ar airway calcium obstructio relaxes n caused sooth by muscle asthma or airway  Relaxatio COPD n of airway smooth muscle with subseque nt bronchodi lator

SIDE EFFECTS

NURSE’S RESPONSIBLITIES

Nervousnes s restlessness, tremors, chest pain, palpitation, hypertension , nausea, hypokalemia vomiting

 Assess lung sound, pulse and blood pressure before administrati on and during peak of medication  Monitor pulmonary function test  Observe for paradox

DRUG’S NAME

Isoket Anti anginal 10mg. OD

ACTION

• Control and prevent anginal attacks

INDICATION

 Treatmen t and preventio n of anginal pectoris attack

SIDE EFFECTS

NURSE’S RESPONSIBLITIES

Monitor Headache, blood pressure postural before and hypotension after , dry rashes treatment



Assess for very low blood pressure and acute circulatory failure Caution patient for sudden movement to

Aspilet 80mg/tab 1tablet OD after

lunch(1PM) Benazepril 20mg/tab 1 tablet OD(9AM) Carvedilol 6.25mg/tablet 1 tablet OD(9AM) Lanoxin 0.125mg OD(9AM) Furosemide 20mg OD(9Am) Metformin 500mg BID(8AM-8PM) Multivitamin plus minerals 500mg OD(9AM) Pravastatin 20mg ODHS(8PM) 

Provide an environment which is:  non stressful  unpolluted  safe surroundings

Conform to a personal exercise program

which should comply with the abilities of the patient. Relatable signs and symptoms that must be reported to a healthcare professional Disruption in cerebral circulation can result in motor sensory deficits, client shall report the following: dizziness changes in sensation of motor control in arms or legs numbness in face

visual changes/loss of vision temporary loss of memory ulcers or darkened spots on skin; arterial

stenosis and decreased tissue perfusion interferes with healing process of skin ulcers. Monitor peripheral circulation (pulses,

sensation, skin color) Report changes immediately, loss of sensation occurs first with accompanying ischemic pain followed by a decrease ion motor function.

Stop smoking. Avoid drinking alcohol. Avoid stressful activities. Limit cholesterol intake. Restrict eating sweet food. Eat a balanced nutritious diet. Exercise regularly.

Follow up check up after one

week discharge.

Diet Maintain a low salt, low

cholesterol diabetic diet.

Thank You