Micu Case Study Presentation

PHILIPPINES COLLEGES of HEALTH & SCIENCES

AFPMC V. Luna General Hospital Medical Intensive Care Unit (MICU) NMC 204 (2 008 - 2009)

CASE STUDY:

MYOCARDIAL INFARCTION GROUP D1 BELTRAN, JHON MARC MARIANO, RYAN TADIFA, JOLEEN

MR. EPHRAIM MIRAFUENTES Clinical Instructor

I. Introduction An intensive care unit (ICU), also sometimes known as a critical care unit or an intensive therapy department is a special ward found inside most hospitals. It provides intensive care (treatment and monitoring) for people who are in a critically ill or unstable condition. Patients in ICUs need constant medical support to keep their body functions going. They may not be able to breathe on their own, and may have multiple organ failure, so medical equipment takes the place of these functions while they recover.There are several circumstances in which a person may be admitted to intensive care, for example, following surgery, or after an accident or severe illness. ICU beds are a very expensive and limited resource because they provide specialized monitoring equipment, a high degree of medical expertise and constant access to highly trained nurses (usually one nurse for each bed). Being in an ICU can be a daunting experience both for the patient and his or her friends and family. The healthcare professionals in ICUs understand this and are there to help and support both patients and their families during their time in intensive care.

Myocardial infarction (MI) is the irreversible necrosis of heart muscle secondary to prolonged ischemia. This usually results from an imbalance of oxygen supply and demand. The appearance of cardiac enzymes in the circulation generally indicates myocardial necrosis. MI is considered, more appropriately, part of a spectrum referred to an acute coronary syndromes (ACSs), which also includes unstable angina and non–ST-elevation MI (NSTEMI). Patients with ischemic discomfort may or may not have STsegment elevation. Most of those with ST-segment elevation will develop Q waves. Those without ST elevations will ultimately be diagnosed with unstable angina or NSTEMI based on the presence of cardiac enzymes. MI may lead to impairment of systolic function or diastolic function and to increased predisposition to arrhythmias and other long-term complications.

b. General Objective 1. Describe Critical Care as a collaborative, holistic approach that includes the patient, family and significant others 2. Established priority critical measures instituted for any patient with a critical conditions. 3. Differentiate, describe, and specify critical care measures and management for admission due to coronary artery disease (Myocardial infarction). 4. Use of multidisciplinary Team to find simple solution. 5. Have knowledge on safe drug administration (preparations/computations) and correlate drug interaction to patient’s condition. Take good performers and transform into great performers in the areas of service to patients, clinical quality, staff satisfaction. 6. Evaluate the patient’s condition and provide nursing care according to the identified needs, report unusual manifestation/ findings and complication.

c. Importance of the study 1.  Explain cardiac physiology in relation to cardiac anatomy and the conduction system of the heart. Describe the essential components of heart anatomy and physiology to include path of blood flow, the role of arteries, veins, and capillaries. 2. Incorporate assessment of functional health patterns and risk factors into the health history and physical assessment of the patient with coronary artery disease. 3. Outline and define the physiologic/Pathophysiology sequence of events that lead to an acute myocardial infarction (AMI). 4.  List the critical parameters of assessment and treatment emergency responders must perform when first attending to a patient with an acute myocardial infarction. 5. Describe the information each of the following tests provide an critical care with physician or cardiac specialist when presented with a patient with a suspected AMI. 6. Define the following as to their prevention or treatment of an MI. 7.  Describe the key roles the following health

II. Data Base

a. Client’s Profile Name: A.P.G Age: 71 years old Sex: Male Address: # 405TNR, FTI Compound, Western Bicutan, Taguig City Birthday: October 2, 1937 Birthplace: Bohol TH Religion: 7 Day Adventist Status: Married Race: Filipino Reg. #: 901668 Admitted to E.R.: March 4, 2009, assisted by Maj. Benejane. Chief Complaint: Right side body weakness Diagnosis: Nosocomial Pneumonia; CAD, ACS, NSTMI, Killip II, HCVD, FC II, Intracerebral he, (L) Basal Ganglia with intraventricular extension Transferred to M.I.C.U.: March 7, 2009 Room #: 5 Rank: C/V/T

b. History 1. History of Present Illness The patient was not able to get up at early morning, as they notice. Then after two hours he had vomited episodely and cramping, so, their relatives rush up at Fort Santiago General Hospital. Then, they transferred at AFPMC V.Luna, around 10:00 AM.

2. Past Medical History He have a high blood pressure, not complaining for almost 10 years, he only taking the drugs that given to him since the last consultation. 3. Family Medical History He had history of hypertension and diabetes mellitus on paternal side. 4. Social History According to his wife, he used to smoke 8-10 sticks per day but he occasionally drinks any liquor. He sleeps 5-6 hours a day, irregular habit time of sleep.

5. 11 Functi onal Heal th Patter n (Gor do ns) in NAND A

1. Health perception-Health Management Pattern The patient was never ask a consultation at the Physician as long as he can stand alone and can walk. Until he woke up with vulnerable condition, the reason to seek a health management. 2. Nutritional-Metabolic Pattern He doesn’t care, too much, what should be the food to be intake, and what not should be, too. He always telling his wife “ano na lang ang kakainin ko?!”. And now he is feeding thru NGT with low salt, low cholesterol and 1,800kCal. 3. Elimination Pattern He used to commode at least once a day before he admit MICU, according to his wife. The physician ordered a Lactulose 30 cc to help him in bowel movement. 4. Activity-Exercise Pattern The patient working as a carpenter, before his condition getting bad. At the MICU, helping the patient turning sideto-side every two hours, as ordered by the physician, and do the passive R.O.M. 5. Sleep-Rest Pattern According to his wife, he sleep for almost 5-6 hour with

6. Cognitive-Perceptual Pattern He perform self-care within the level of ability to do the ADL and other activity. Since he got an Intracerebral hemorrhage, he had disturbed perceptual abilities due to his illness. 7. Self-Perception/self-concept Pattern He took a healthy body for granted, a kind of denial of the eventuality of aging and illness. Due to the threats to self-concepts about the self these condition may pose. 8. Role-Relationship Pattern He was hard worker and good father to his family. Because of his condition, he is now lying at room # 5, MICU. His family involved in decision making processes directed at appropriate solution for the situation crisis 9. Sexuality-reproductive Pattern He had children by their own. Since, he got CAD, less frequency and satisfaction of their sexual activity. 10. Coping-Stress Tolerance Pattern. When the patient felt stress, he used to smoke. Although he know there is other way to move the stress away.

11. Value-belief Pattern They do visit their church together with their family aside from his son, working on weekends. All we know, Adventist should not eat pork, but he still doing it.

Physical Assessment

1. Physical Assessment (head-to-toe) General Survey: Vital Signs

BP – 110/80 RR - 40 Temp. 37.4˚C PR – 101 bpm Unconscious patient lying on bed, with the position of semi-fowlers Integument Cold skin, from the body to lower extremity. The head, right and left arm are enough heat skin. Nails, delayed refill capillary Moist skin on his face and neck Head and neck Skull and face, shape symmetry Neck, no presence of contusions. Eyes, yellow conjunctiva, unequal pupil 2-3 mm pupil on left and 3-4 pupil on right Ears, lesion on auricle of the Left ear Nose, nasal flaring, placing an NGT (French 18) on his Left. Mouth, placing an Endotracheal tube with 7.0, plastering on his right lips; dry lips, yellowish teeth

Chest RR- 40 auscultated chest with crackles sounds Extra sounds on Heart sounds Abdomen, no contour, no lesions Apical pulse rate: 101 bpm Extremity Left arm infused IV Fluid Right arm, no muscle tone, no strength muscle, +1 edema scale Left and Right leg, are pale, cold & dry skin, delayed capillary refill Genito Elimination Urine, yellow-orange, 200 cc at 4 hours. Bowel, no bowel movements Neurological Glasgow Coma Scale: total score of 6 Eye: 2, he slightly his upper eyelid on pain Motor: 3, flexes abnormally Verbal: 1, no response Level of conciousness: comatose

2. Diagnostic procedure done, and possible to be done to the patient Persistent chest pain, ST- segment changes on the electrocardiogram (ECG), and elevated levels of total creatinine kinase (CK) and the CK-MB isoenzyme over a 72 hour usually confirm an MI. Cardiac troponins are useful in differentiating an MI from skeletal muscle injury, or when CK-MB measurements are low and a small MI has actually occurred. Auscultation may reveal diminished heart sounds, gallops, and, in papillary dysfunction, the apical systolic murmur of mitral valve area. When signs and symptoms are equivocal, assume that the patient has had an MI until tests rule it out. Diagnostic test results

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Serial 12-lead ECG: ECG abnormalities may be absent or inconclusive during first few hours following an MI. When present, characteristics abnormalities include serial ST-segment depression in subendocardial MI and ST-segment elevation in a transmural MI. Coronary Angiography: visualization reveals which vessels have been affected and the extent of damage. Serial serum enzyme levels: CK levels are elevated ; specifically, CK-MB or troponin levels. Myoglobin: because myoglobin always rises within 3-6 hours after an MI, lack of an increase within 6 hours indicates that an MI hasn’t occurred. Echocardiography: may show ventricular-wall motion abnormalities in patients with a transmural MI. Nuclear ventriculography (multigated acquisition scan or radionuclide ventriculography) scanning: Nuclear scanning can identify acutely damaged muscle by picking up radioactive nucleotide, which appears as a “hot spot” on the film. It’s useful in localizing a recent MI. Chest X-ray: venous congestion, cardiomegaly, and kerley’s B lines Cardiac catheterization: show decrease cardiac output, increase in Pulmonary arterial pressure, pulmonary artery wedge pressure and central venous pressure.

Anatomy 1. Right Coronary 2. Left Anterior Descending 3. Left Circumflex 4. Superior Vena Cava 5. Inferior Vena Cava 6. Aorta 7. Pulmonary Artery 8. Pulmonary Vein 9. Right Atrium 10. Right Ventricle 11. Left Atrium 12. Left Ventricle 13. Papillary Muscles 14. Chordae Tendineae 15. Tricuspid Valve 16. Mitral Valve

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Coronary Arteries. Because the heart is composed primarily of cardiac muscle tissue that continuously contracts and relaxes, it must have a constant supply of oxygen and nutrients. The coronary arteries are the network of blood vessels that carry oxygen- and nutrient-rich blood to the cardiac muscle tissue. The blood leaving the left ventricle exits through the aorta, the body’s main artery. Two coronary arteries, referred to as the "left" and "right" coronary arteries, emerge from the beginning of the aorta, near the top of the heart. The initial segment of the left coronary artery is called the left main coronary. This blood vessel is approximately the width of a soda straw and is less than an inch long. It branches into two slightly smaller arteries: the left anterior descending coronary artery and the left circumflex coronary artery. The left anterior descending coronary artery is embedded in the surface of the front side of the heart. The left circumflex coronary artery circles around the left side of the heart and is embedded in the surface of the back of the heart. Just like branches on a tree, the coronary arteries branch into progressively smaller vessels. The larger vessels travel along the surface of the heart; however, the smaller branches penetrate the heart muscle. The smallest branches, called capillaries, are so narrow that the red blood cells must travel in single file. In the capillaries, the red blood cells provide oxygen and nutrients to the cardiac muscle tissue and bond with carbon dioxide and other metabolic waste products, taking them away from the heart for disposal through the lungs, kidneys and liver. When cholesterol plaque accumulates to the point of blocking the flow of blood through a coronary artery, the cardiac muscle tissue fed by the coronary artery beyond the point of the blockage is deprived of oxygen and nutrients. This area of cardiac muscle tissue ceases to function properly. The condition when a coronary artery becomes blocked causing damage to the cardiac muscle tissue it serves is

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Aorta. The aorta is the largest single blood vessel in the body. It is approximately the diameter of your thumb. This vessel carries oxygen-rich blood from the left ventricle to the various parts of the body. Pulmonary Artery. The pulmonary artery is the vessel transporting de-oxygenated blood from the right ventricle to the lungs. A common misconception is that all arteries carry oxygen-rich blood. It is more appropriate to classify arteries as vessels carrying blood away from the heart. Pulmonary Vein. The pulmonary vein is the vessel transporting oxygen-rich blood from the lungs to the left atrium. A common misconception is that all veins carry de-oxygenated blood. It is more appropriate to classify veins as vessels carrying blood to the heart. Right Atrium. The right atrium receives de-oxygenated blood from the body through the superior vena cava (head and upper body) and inferior vena cava (legs and lower torso). The sinoatrial node sends an impulse that causes the cardiac muscle tissue of the atrium to contract in a coordinated, wave-like manner. The tricuspid valve, which separates the right atrium from the right ventricle, opens to allow the de-oxygenated blood collected in the right atrium to flow into the right ventricle. Right Ventricle. The right ventricle receives de-oxygenated blood as the right atrium contracts. The pulmonary valve leading into the pulmonary artery is closed, allowing the ventricle to fill with blood. Once the ventricles are full, they contract. As the right ventricle contracts, the tricuspid valve closes and the pulmonary valve opens. The closure of the tricuspid valve prevents blood from backing into the right atrium and the opening of the pulmonary valve allows the blood to flow into the pulmonary artery toward the lungs. Left Atrium. The left atrium receives oxygenated blood from the lungs through the pulmonary vein. As the contraction triggered by the sinoatrial node progresses through the atria, the blood passes through the mitral valve into the left ventricle. Left Ventricle. The left ventricle receives oxygenated blood as the left atrium contracts. The blood passes through the mitral valve into the left ventricle. The aortic valve leading into the aorta is closed, allowing the ventricle to fill with blood. Once the ventricles are full, they contract. As the left ventricle contracts, the mitral valve closes and the aortic valve opens. The closure of the mitral valve prevents blood from backing into the left atrium and the opening of the aortic valve allows the blood to flow into the aorta and flow throughout the body.

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Papillary Muscles. The papillary muscles attach to the lower portion of the interior wall of the ventricles. They connect to the chordae tendineae, which attach to the tricuspid valve in the right ventricle and the mitral valve in the left ventricle. The contraction of the papillary muscles opens these valves. When the papillary muscles relax, the valves close. Chordae Tendineae. The chordae tendineae are tendons linking the papillary muscles to the tricuspid valve in the right ventricle and the mitral valve in the left ventricle. As the papillary muscles contract and relax, the chordae tendineae transmit the resulting increase and decrease in tension to the respective valves, causing them to open and close. The chordae tendineae are string-like in appearance and are sometimes referred to as "heart strings." Tricuspid Valve. The tricuspid valve separates the right atrium from the right ventricle. It opens to allow the de-oxygenated blood collected in the right atrium to flow into the right ventricle. It closes as the right ventricle contracts, preventing blood from returning to the right atrium; thereby, forcing it to exit through the pulmonary valve into the pulmonary artery. Mitral Value. The mitral valve separates the left atrium from the left ventricle. It opens to allow the oxygenated blood collected in the left atrium to flow into the left ventricle. It closes as the left ventricle contracts, preventing blood from returning to the left atrium; thereby, forcing it to exit through the aortic valve into the aorta. Pulmonary Valve. The pulmonary valve separates the right ventricle from the pulmonary artery. As the ventricles contract, it opens to allow the de-oxygenated blood collected in the right ventricle to flow to the lungs. It closes as the ventricles relax, preventing blood from returning to the heart. Aortic Valve. The aortic valve separates the left ventricle from the aorta. As the ventricles contract, it opens to allow the oxygenated blood collected in the left ventricle to flow throughout the body. It closes as the ventricles relax, preventing blood from returning to the heart.

PHYSIOLOGY 

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The heart is the muscular organ of the circulatory system that constantly pumps blood throughout the body. Approximately the size of a clenched fist, the heart is composed of cardiac muscle tissue that is very strong and able to contract and relax rhythmically throughout a person's lifetime. The heart has four separate compartments or chambers. The upper chamber on each side of the heart, which is called an atrium, receives and collects the blood coming to the heart. The atrium then delivers blood to the powerful lower chamber, called a ventricle, which pumps blood away from the heart through powerful, rhythmic contractions. The human heart is actually two pumps in one. The right side receives oxygen-poor blood from the various regions of the body and delivers it to the lungs. In the lungs, oxygen is absorbed in the blood. The left side of the heart receives the oxygen-rich blood from the lungs and delivers it to the rest of the body. Systole. The contraction of the cardiac muscle tissue in the ventricles is called systole. When the ventricles contract, they force the blood from their chambers into the arteries leaving the heart. The left ventricle empties into the aorta and the right ventricle into the pulmonary artery. The increased pressure due to the contraction of the ventricles is called systolic pressure.

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The Sinoatrial Node (often called the SA node or sinus node) serves as the natural pacemaker for the heart. Nestled in the upper area of the right atrium, it sends the electrical impulse that triggers each heartbeat. The impulse spreads through the atria, prompting the cardiac muscle tissue to contract in a coordinated wave-like manner.

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The impulse that originates from the sinoatrial node strikes the Atrioventricular node (or AV node) which is situated in the lower portion of the right atrium. The atrioventricular node in turn sends an impulse through the nerve network to the ventricles, initiating the same wave-like contraction of the ventricles.

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The electrical network serving the ventricles leaves the atrioventricular node through the Right and Left Bundle Branches. These nerve fibers send impulses that cause the cardiac muscle tissue to contract.

1. Sinoatrial node (SA node) 2. Atrioventricular node (AV node) 3. Common AV Bundle 4. Right & Left Bundle Branches

A.

Laboratory Result and significant

HEM AT OLO GY

Significances:  Hematology: Hgb: still at normal ranges. Hct: acute massive blood loss RBC: decreasing due to side effects of the drugs. WBC: Increasing due to immunocompromised, immune responses. Platelet: increasing the fibrin that attract the platelet to increased Blood indices: MCHC: decreased in severe hypochromic anemia.  Coagulation: Bleeding time: defective in platelet function INR: prolonged in deficiency of fibrinogen; used to standardized the prothrombin time and anticoagulation therapy.  Serum enzyme levels: Na+ : decreased; myxedema K+ : decreased; GI losses, Vitamin D Deficiency Cl+ : decreased; pneumonia, febrile condition. Creatinine: decreased; check the status of the kidney Troponin: negative; if increased the patient may experience myocardial infarction.

IV. Pathophysiology & Schematic Diagram In an MI, an area of the myocardium is permanently destroyed; a condition in which the blood supply to the heart muscle is partially or completely blocked. The heart muscle needs a constant supply of oxygen-rich blood. The coronary arteries, which branch off the aorta just after it leaves the heart, deliver this blood. MI is usually caused by the reduced blood flow in a coronary artery of an atherosclerotic plaque and subsequent occlusion of the artery by a thrombus. Coronary artery disease can block blood flow, causing chest pain. In unstable angina and acute MI are considered to be the same process but different appoints along a continuum. specifically coronary atherosclerosis (literally “hardening of the arteries,” which involves fatty deposits in the artery walls and may progress to narrowing and even blockage of blood flow in the artery., As an atheroma grows, it may bulge into the artery, narrowing the interior (lumen) of the artery and partially blocking blood flow. With time, calcium accumulates in the atheroma. As an atheroma blocks more and more of a coronary artery, An atheroma, even one that is not blocking very much blood flow, may rupture suddenly. The rupture of an atheroma often triggers the formation of a blood clot (thrombus), the supply of oxygen-rich blood to the heart muscle (myocardium) can become inadequate. The blood supply is more likely to be inadequate during exertion, when the heart muscle requires more blood. An inadequate blood supply to the heart muscle (from any cause) is called myocardial ischemia. If the heart does not receive enough blood, it can no longer contract and pump blood normally. Other causes of MI include vasospasm, (sudden constriction or narrowing) of a coronary artery, decreased oxygen supply (e.g. from acute blood loss, anemia, or low blood pressure), and increased demand for oxygen (e.g. rapid heart rate, thyrotoxicosis, or ingestion of cocaine). In each case, a profound imbalance exists between myocardial oxygen supply and demand. The area of infarction develops over minutes to hours. As the cells are deprived of oxygen, ischemia develop, cellular injury occurs,, and the lack of oxygen results in infarction, or the death of cells. The area of the heart muscle supplied by the blocked artery dies.

#1 Smoking

Genetic Predisposition

Aging

DRUG STUDY

NURSING CARE MNGT.

a. Pr obl em Li st secretion blocking the airway of intubation tube for his oxygenation  adventitious sounds (crackles) on his chest  shortness ob breath, increasing the Respiratory rate and pulse rate  cool and pale skin, moisten skin on upper part of the body  physical immobilization 

3 ACTUAL PROBLEM

ASSESSMENT

Subjective: “hindi normal yung vital signs niya” as verbalized by the relative of the patient. Objective: Auscultated heart have extra sound shortness of breath cool & pale skin

NURSING DIAGNOSI S Ineffective cardiac tissue perfusion related to reduced coronary blood flow.

PLAN OF CARE

The patient will alleviate and appears comfortabl e and is free of pain and other sign and symptoms: respiratory rate, cardiac rate, and blood pressure return to prediscomf ort level.

INTERVENTION

initially assess, document, and report to the physician the following: the

patient’s description of chest discomfort, the effect of it on cardiovascular perfusion change in blood pressure and heart sounds, changes in LOC, decrease in urine output and to the skin temperature, nad other symptoms such as nausea, increase sweating, or complaints of unusual fatigue. obtain a 12 –lead ECG recording the symptomatic event, as prescribed by physician, to determine extension of infarction.

RATIONALE

EVALUATION

assist in determining cause and effect of the chest discomfort and provide a baseline data for characteristic s findings of ischemic pain and symptoms.

After rendering of nursing intervention, the patient had appears comfortable and is free from pain. Blood pressure is 110/80. Temperature of 37.1˚C. But the RR 40 and PR 101 bpm are still compensating to maintain cardiac output. The goal is partially met.

An ECG during symptoms may be useful in the diagnosis of an extension of MI. .

ASSESSMENT

NURSING DIAGNO SIS

PLAN OF CARE

INTERVENTION

RATIONALE

EVALUATION

administer oxygen at the level of prescribed.

Oxygen therapy increases the oxygen supply to the myocardium if actual oxygen saturation is less than normal. medication therapy is the first line of defense in preserving myocardial tissue. The side effects of the medications can be hazardous and the patient’s status must be assessed. physicals rest reduces myocardial oxygen consumption. Stress response, this results, this result, increase myocardial oxygen consumption.

After rendering of nursing intervention, the patient had appears comfortable and is free from pain. Blood pressure is 110/80. Temperature of 37.1˚C. But the RR 40 and PR 101 bpm are still compensating to maintain cardiac output. The goal is partially met.

administer medication therapy as prescribed, and evaluate the patient’s response continuously.

ensure physical rest; use the bedside commode with assistance; backrest elevated to promote comfort; diet as tolerated; arms supported during upper extremity activity; use of stool softener to straining stool. Provide a restful environment.

ASSESSMENT

adventitious breath sounds changes in respiratory rate and rhythm

NURSING DIAGNO SES Ineffective airway clearance related to copious tracheobro nchial secretions.

PLAN OF CARE

After of nursing intervention the patient will clear the airway patency.

INTERVENTION

RATIONALE

EVALUATION

assess, document & report to the physician on abnormal breath sound maintain the patency of oxygenation therapy Monitor Arterial Blood Gases Analysis suction tracheobronchial secretion established the turning patient as and “tapping back” , as prescribed by the physician.

can be used as a guide for activity prescription and a basis for patient health management. to provide an oxygen needed by the physiologic need of the body. to indicate the effectiveness of oxygenation therapy and changes that need to improve gas exchange. retention of secretions lead to decrease of oxygen supply help to loosen the secretions.

After of nursing intervention the patient will clear the airway patency.

ASSESSMENT

Objective: >Decreasing urinary output >abnormal breath sounds, crackles >dyspnea

NURSING DIAGNOSE S

PLAN OF CARE

INTERVENTION

RATIONALE

EVALUATION

risk for excess fluid volume, decreased organ perfusion

After of 8 hours of nursing intervention the patient will monitor fluid status and reduce occurrence of fluid excess.

>AUSCULTATE BREATH SOUNDS FOR PRESENCE OF CRACKLES.

> MAY INDICATE PULMONAR Y EDEMA SECONDARY TO CARDIAC DECOMPENS ATION. > DECREASED CARDIAC OUTPUT RESULTS IN IMPAIRED KIDNEY PERFUSION, SODIUM/WA TER RETENTION, AND REDUCED URINE OUTPUT. > Sudden changes in weight reflect alterations in fluid balance.\ >Sodium enhances fluid retention and should therefore be restricted during active MI phase and/or if heart failure is present.

After of 8 hours of nursing intervention the patient had monitor fluid status and reduce occurrence of fluid excess. the goal is met.

> Measure I&O, noting decrease in output, concentrated appearance. Calculate fluid balance.

>assess for edema and weigh daily.

>Provide low-sodium diet/beverages.

ASSESSMENT

Objectives: physical immobilization prolonged bed pressure

NURSING DIAGNO SES impaired skin integrity related to prolonged bed pressure.

PLAN OF CARE

INTERVENTION

RATIONALE

EVALUATION

After rendering of nursing intervention the patient will not be able to get a bed sore.

assess, document the skin patient. ask the physician if the patient will allowed to turn the patient on side-to side and the time interval. do the skin care

for guiding data. to avoid possible that can trigger to his disease. to avoid possible complication on skin.

After rendering of nursing care intervention the patient will not be able to get a bed sore.

POTENTIAL

PROBLEM

POTENTIAL CONSIDERATIONS following discharge from care setting (dependent on patient’s age, physical condition/presence of complications, personal resources, and life responsibilities)

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Activity intolerance —imbalance between myocardial oxygen supply/demand. Grieving, anticipatory—perceived loss of general wellbeing, required changes in lifestyle, confronting mortality. Decisional Conflict (treatment)—multiple/divergent sources of information, perceived threat to value system, support system deficit. Family Processes, interrupted—situational transition and crisis. Home Management, impaired—altered ability to perform tasks, inadequate support systems, reluctance to request assistance.

c. Discharge Planning use METHODS Medications Promotes adherence measures by thoroughly explaining the prescribed medication regimen and other treatment measures. Warn the patients together with relatives about adverse reaction to drugs, and advise them to watch the sign and symptoms of toxic (nausea, anorexia, vomiting, and yellow vision) Exercises Organize patient care and activities to maximize periods of uninterrupted rest. Assist with range-of-motion exercise. And turn him, every two hours, as ordered by physician. Don’t stress yourself, too much exercise. Enough, walk for 15 minutes. Treatment Antiembolism stockings help prevent venostasis and thromboplebitis. Encourage participation in a cardiac rehabilitation program.

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Healt h t eac hi ng  Wat ch f or si gn and sym pt om s of fl ui d ret ent ion (cr ack les, co ug h, tac hyp nea, and ed em a), whi ch may ind icat e i mpend ing HF. Ca ref ul ly moni tor dai ly w ei ght , int ak e and out put, resp irat ion, se rum enzy me lev el and b loo d pressur e. Oxy genat ion a nd OPD fol low up •  Oxy gen ad mini st rat ion at a m odest fl ow r at e for 3-6 hours . Diet of the pat ient •  Revi ew diet ary r est ri cti on wi th the p atient . A lo w sod ium, l ow f at , or low cho lest er ol diet and caf fei ne-f ree ma y b e or der ed , provide a l is t of foo d that h e shoul d avoid . Provi de a clear liqui d diet unt il nausea sub si des. As k diet itian t o sp eak to the pat ient ’s f am ily. Sp iri tual a nd sex ual teac hing •  Counse l p at ient to resume sexu al act ivi ty prog ressively .  Enc our ag es the fam ily t o see k out r el ig iou s act ivit ies, pert ai ni ng to sp iri tual issues.

Thank you…

..have a great day ahead…

VII. Referrences Medical-Surgical Nursing, 11th edition, Brunner & Suddarth’s (Smeltzer, Bare, Hinkle, Cheever) Handbook of Diseases, 3rd edition, Sarah Y. Yuan Nursing Drug Handbook 2008, 28th edition, Wolter Kluwer/Lippincott William & Williams http://www.cardioconsult.com http://www.aacn.org

VIII. Evaluation

Beltran, Jhon Marc Mr. Ephraim Mirafuentes & Staff Nurse (MICU): Highly competitive critical care nurse, that know how to assess, monitor and treat a critically ill patient, the better that patient’s chances are for early intervention. All of them excellence in the work environment. Their team using a method of habitual concentration our staff nurses could develop qualities of excellence for an improved outlook toward themselves, their work environment, and their profession. This improved outlook would lead to improved morale followed by an increase in retention within the unit, as well as progress in meeting our other goals. We recognized that our patient care, the attitudes of our nurses and staff, the helpfulness of peers, and even the cleanliness of the unit were based on tradition. During orientation, we learned what was expected of them in their individual units, and they continued this process by orienting others to the same routines. As we recognized, we needed to improve ourselves in reality, in the world of Intensive care unit. Because we must aware that our work was in critical situation. As we are the nursing student that would be excited to us learn more to do some activities in the role as they accept, in their life, around the Intensive care unit. We learned some nursing skills that we can used in critical situation. We, my group, are glad to be your nursing student. Thanks you so much.

Mariano, Ryan Medical Intensive Care Unit provides comprehensive and continuous care for patients who suffer from a serious illness or medical problem as well as social and psychological support for patients and their families. Their team includes board-certified, critical care physicians , highly trained nurses and other specialists who are specifically trained in critical care and provide round-the-clock care. We learned some nursing skills using their equipment in an intensive care unit (ICU) includes mechanical ventilation to assist breathing through an endotracheal tube or a tracheotomy; intravenous lines for drug infusions fluids, nasogastric tubes, suction pumps, drains and catheters; and a wide array of drugs including their medication management.

Tadifa, Joleen In MICU, patients are given 24-hour assessments by the healthcare team. Preparatory orders for the ICU generally vary from patient to patient since treatment is individualized. The initial workup should be coordinated by the attending ICU staff (intensiv and ICU nurse specialist), pharmacists (for medications and IV fluid therapy), and respiratory therapists for stabilization, improvement, or continuation of cardiopulmonary care. Well-coordinated care includes prompt consultation with other specialists soon after the patient is admitted to the ICU. The patient is connected to monitors that record his or her vital signs (pulse, blood pressure, and breathing rate). Orders for medications, laboratory tests, or other procedures are instituted upon arrival. The staff are highly skilled for critically ill patients. Using their advanced patient monitoring technology and sophisticated medical equipment, as providing continuous, comprehensive care for patients with serious conditions. providing expert healthcare and to treating patients with the compassion and respect they deserve. Patients requiring intensive care usually require support for airway or respiratory compromise (such as ventilator support), potentially lethal cardiac dysrhythmias. Critical care nurse are giving their intensive care to the patient, support for the above are usually admitted for intensive/invasive monitoring. Ideally, intensive care is usually only offered to those whose condition is potentially reversible and who have a good chance of surviving with intensive care support. Since the critically ill are so close to dying, the outcome of this intervention is difficult to predict.