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ANGINA PECTORIS Nursing intervention Patient Care Management Goal: to relieve acute pain and reduce the cardiac

work load 1. Administer oxygen to relieve ischemia at a flow rate based on institutional policy and the patients condition. 2. Assess and document continuous ECG rhythm, vital signs, mental status, heart and lung sounds. 3. Assess and document pain characteristics: location, duration, intensity (have patient grade pain on a scale from 1 to 10), precipitating factors, relief measures and any symptoms that indicate changes in these parameters. 4. Assess vital signs with complaints of chest pain, and compare to baseline. 5. Begin IV nitroglycerin titrated until acute pain is relieved; check blood pressure every 15 minutes or according to institutional policy; maintain systolic blood pressure greater than 90 mm Hg or according to institutional protocol; document the patients response to therapy. 6. Administer IV morphine in small doses to relieve pain and decrease preload. 7. Give sublingual, oral, or topical nitroglycerin prophylactically for chronic pain. 8. Consider calcium channel blockers with Prinzmetals angina to block the influx of calcium into the cell; calcium channel blockers produce vasodilation of coronary and peripheral arteries. 9. Use beta-adrenergic blockers to decrease myocardial oxygen demand by decreasing contractility, heart rate, and blood pressure. 10. Notify the doctor and obtain a 12-lead ECG at the onset of recurring chest pain. 11. Maintain activity restrictions based on the patients activity tolerance to reduce myocardial oxygen demands. 12. Begin the patient on a low-cholesterol, low-sodium diet to alleviate the modifiable risk factors. 13. Consider percutaneous transluminal coronary angioplasty (PTCA) to improve blood flow through the stenotic coronary arteries. 14. Remember that a coronary artery bypass graft (CABG) may be indicated when medical treatment has been unsuccessful, based on the patients symptoms and the cardiac catheterization report. 15. Provide patient education, and ensure that the patient can recognize signs and symptoms necessitating medical attention (unrelieved chest pain after taking three nitroglycerin tablets sublingually 5 minutes apart). 16. Work with the patient and family to identify the patients risk factors and necessary life style modifications. 17. Refer the family to appropriate sources for cardiopulmonary resuscitation (CPR) training. 18. Ensure that the family can activate the emergency medical system if any problems occur at home.

MYOCARDIAL INFARCTION
Assessment: 1. Chest pain


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Character: variable, but often diffuse, steady substernal chest pain. Other sensations include a crushing and squeezing feeling in the chest. Other sensations include a crushing and squeezing feeling in the chest. Severity: pain may be severe; not relieved by rest or sublingual vasodilator therapy, requires opioids. Location: variable, but often pain resides behind upper or middle third of sternum. Radiation: pain may radiate to the arms (commonly the left), and to the shoulders, neck, back, or jaw. Duration: pain continues for more than 15 minutes.

Associated manifestations include anxiety, diaphoresis, cool clammy skin, facial pallor,hypertension or hypotension, bradycardia or tachycardia, premature ventricular or atrial beats, palpitations, dyspnea, disorientation, confusion, restlessness, fainting, marked weakness, nausea, vomiting, and hiccups. Atypical symptoms of MI include epigastric or abdominal distress, dull aching or tingling sensations, shortness of breath, and extreme fatigue (more frequent in women).

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Risk factors for MI include male gender, age over 45 for men, age over 55 for men, smoking;high blood cholesterol levels, hypertension, family history of premature CAD, diabetesand obesity. Diagnostic Evaluation: Serial 12-lead electrocardiograms (ECGs) detect changes that usually occur within 2 to 12 hours, but may take 72 to 96 hours

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ST-segment depression and T-wave inversion indicate a pattern of ischemia; ST elevation indicates an injury pattern.

Q waves indicate tissue necrosis and are permanent Nonspecific enzymes including aspartate transaminase, lactate dehydrogenase, and myoglobulin may be elevated More specific creatinine phosphokinase isoenzyme CK-MB will be elevated. Triponin T and I are myocardial proteins that increase in the serum about 3 to 4 hours after an MI, peak in 4 to 24 hours, and are detectable for upto 2 weeks; the test is easy to run, can help diagnose an MI up to 2 weeks earlier, and only unstable angina causes a false positive. White blood cell count and sedimentation rate may be elevated. Radionuclide imaging, positron emission tomography, and echocardiography may be done to evaluate heart muscle.

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Pharmacologic Intervention: 1.


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Pain control drugs to reduce catecholamine-induced oxygen demand to injured heart muscle. Opiate analgesics: Morphine Vasodilators: Nitroglycerin Anxiolytics: Benzodiazepines

Thrombolytic therapy by I.V. or intracoronary route, to dissolve thrombus formation and reduce the size of the infarction. Anticoagulants or other anti-platelet medications such as adjunct to thrombolytic therapy. Reperfusion arrhythmias may follow successful therapy. Beta-adrenergic blockers, to improve oxygen supply and demand, decrease sympathetic stimulation to the heart, promote blood flow in the small vessels of the heart, and provide antiarrhythmic effects. Calcium channel blockers, to improve oxygen supply and demand.

Nursing Interventions: 1. Monitor continuous ECG to watch for life threatening arrhythmias (common within 24 hours after infarctions) and evolution of the MI (changes in ST segments and T waves). Be alert for any type of premature ventricular beatsthese may herald ventricular fibrillation or ventricular tachycardia. 2. 3. 4. 5. 6. 7. 8. 9. Monitor baseline vital signs before and 10 to 15 minutes after administering drugs. Also monitor blood pressure continuously when giving nitroglycerin I.V. Handle the patient carefully while providing care, starting I.V. infusion, obtaining baseline vital signs, and attaching electrodes for continuous ECG monitoring. Reassure the patient that pain relief is a priority, and administer analgesics promptly. Place the patient in supine position during administration to minimize hypotension. Emphasize the importance of reporting any chest pain, discomfort, or epigastric distress without delay. Explain equipment, procedures, and need for frequent assessment to the patient and significant others to reduce anxiety associated with facility environment. Promote rest with early gradual increase in mobilization to prevent deconditioning, which occurs during bed rest. Take measures to prevent bleeding if patient is thrombolitic therapy Be alert to signs and symptoms of sleep deprivation such as irritability, disorientation, hallucinations, diminished pain tolerance, and aggressiveness.

10. Tell the patient that sexual relations may be resumed on advise of health care provider, usually after exercise tolerance is assessed. CERBROVASCULAR ACCIDENT Patient care management goal: to support the patients vital functions, restore cerebral blood flow, minimize neurologic deficits, and prevent progression Maintain a patent airway to promote adequate oxygenation Administer oxygen therapy with possible intubation and mechanical ventilation to ensure adequate tissue perfusion Maintain bed rest to minimize metabolic requirements Provide I.V. fluids to support blood pressure and maintain volume Administer dexamethasone to reduce cerebral edema Administer anticoagulants and antiplatelet drugs for thrombotic conditions after hemorrhage has been ruled out Administer sedatives, such as Phenobarbital, to decrease metabolic requirements Assess the patients neurologic status; observe for CVA progression and level of consciousness (LOC) change as evidenced by decreasing numerical score on the GLASGOW COMA SCALE. Correct cardiovascular abnormalities, such as atrial fibrillation, that may be contributing factors Consider surgical procedures to correct circulatory impairment, prevent repeated hemorrhage, or relieve cerebral pressure Begin bedside range-of-motion exercise to preserve mobility and prevent deformities Teach the patient to identify risk factors and necessary life-style modifications, such as diet, stress reduction, and smoking cessation Direct the family to community groups that provide support or rehabilitation

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Drugs used in the treatment for an ischemic stroke include: o o o o o o Blood thinner medications for stroke: Aspirin Clopidogrel (Plavix) Coumadin (Warfarin) Heparin Thrombolytic therapy for stroke: Tissue plasminogen activator (Alteplase, Activase) Must be administered within 4.5 hours of onset of symptoms

Drugs used for the treatment of a hemorrhagic stroke include: o o o o o o Medications that reduce brain swelling: Mannitol (Osmitrol, Resectisol) Medications to control high blood pressure in subarachnoid hemorrhage: Labetalol (Trandate, Normodyne) Nitroprusside (Nitropress) Hydralazine (Apresoline) Esmolol (Brevibloc) Medication to reduce the risk for seizures: Phenytoin (Dilantin)

Fosphenytoin (Cerebyx)

DIABETES MELLITUS (1 AND 2)


NURSING INTERVENTIONS:

Advice patient about the importance of an individualized meal plan in meeting weekly weight loss goals and assist with compliance. Assess patients for cognitive or sensory impairments, which may interfere with the ability to accurately administer insulin. Demonstrate and explain thoroughly the procedure for insulin self-injection. Help patient to achieve mastery of technique by taking step by step approach. Review dosage and time of injections in relation to meals, activity, and bedtime based on patients individualized insulin regimen. Instruct patient in the importance of accuracy of insulin preparation and meal timing to avoid hypoglycemia. Explain the importance of exercise in maintaining or reducing weight. Advise patient to assess blood glucose level before strenuous activity and to eat carbohydrate snack before exercising to avoid hypoglycemia. Assess feet and legs for skin temperature, sensation, soft tissues injuries, corns, calluses, dryness, hair distribution, pulses and deep tendon reflexes. Maintain skin integrity by protecting feet from breakdown. Advice patient who smokes to stop smoking or reduce if possible, to reduce vasoconstriction and enhance peripheral flow

INTRODUCTION: Diabetes mellitus is a condition in which the pancreas no longer produces enough insulin or cells stop responding to the insulin that is produced, so that glucose in the blood cannot be absorbed into the cells of the body. Symptoms include frequent urination, lethargy, excessive thirst, and hunger. The treatment includes changes in diet, oral medications, and in some cases, daily injections of insulin. The most common form of diabetes is Type II, It is sometimes called age-onset or adult-onset diabetes, and this form of diabetes occurs most often in people who are overweight and who do not exercise. Type II is considered a milder form of diabetes because of its slow onset (sometimes developing over the course of several years) and because it usually can be controlled with diet and oral medication. The consequences of uncontrolled and untreated Type II diabetes, however, are the just as serious as those for Type I. This form is also called noninsulin-dependent diabetes, a term that is somewhat misleading. Many people with Type II diabetes can control the condition with diet and oral medications, however, insulin injections are sometimes necessary if treatment with diet and oral medication is not working. The causes of diabetes mellitus are unclear, however, there seem to be both hereditary (genetic factors passed on in families) and environmental factors involved. Research has shown that some people who develop diabetes have common genetic markers. In Type I diabetes, the immune system, the bodys defense system against infection, is believed to be triggered by a virus or another microorganism that destroys cells in the pancreas that produce insulin. In Type II diabetes, age, obesity, and family history of diabetes play a role. In Type II diabetes, the pancreas may produce enough insulin, however, cells have become resistant to the insulin produced and it may not work as effectively. Symptoms of Type II diabetes can begin so gradually that a person may not know that he or she has it. Early signs are lethargy, extreme thirst, and frequent urination. Other symptoms may include sudden weight loss, slow wound healing, urinary tract infections, gum disease, or blurred vision. It is not

unusual for Type II diabetes to be detected while a patient is seeing a doctor about another health concern that is actually being caused by the yet undiagnosed diabetes. Individuals who are at high risk of developing Type II diabetes mellitus include people who:

are obese (more than 20% above their ideal body weight) have a relative with diabetes mellitus belong to a high-risk ethnic population (African-American, Native American, Hispanic, or Native Hawaiian) have been diagnosed with gestational diabetes or have delivered a baby weighing more than 9 lbs (4 kg) have high blood pressure (140/90 mmHg or above) have a high density lipoprotein cholesterol level less than or equal to 35 mg/dL and/or a triglyceride level greater than or equal to 250 mg/dL have had impaired glucose tolerance or impaired fasting glucose on previous testing

Diabetes mellitus is a common chronic disease requiring lifelong behavioral and lifestyle changes. It is best managed with a team approach to empower the client to successfully manage the disease. As part of the team the, the nurse plans, organizes, and coordinates care among the various health disciplines involved; provides care and education and promotes the clients health and well being. Diabetes is a major public health worldwide. Its complications cause many devastating health problems.

ANATOMY AND PHYSIOLOGY: Every cell in the human body needs energy in order to function. The bodys primary energy source is glucose, a simple sugar resulting from the digestion of foods containing carbohydrates (sugars and starches). Glucose from the digested food circulates in the blood as a ready energy source for any cells that need it. Insulin is a hormone or chemical produced by cells in the pancreas, an organ located behind the stomach. Insulin bonds to a receptor site on the outside of cell and acts like a key to open a doorway into the cell through which glucose can enter. Some of the glucose can be converted to concentrated energy sources like glycogen or fatty acids and saved for later use. When there is not enough insulin produced or when the doorway no longer recognizes the insulin key, glucose stays in the blood rather entering the cells.

PATHOPHYSIOLOGY:

Image Source: www.caninsulin.com/Pathophysiology-algorithm.htm DIAGNOSTIC TEST: Several blood tests are used to measure blood glucose levels, the primary test for diagnosing diabetes. Additional tests can determine the type of diabetes and its severity. Random blood glucose test for a random blood glucose test, blood can be drawn at any time throughout the day, regardless of when the person last ate. A random blood glucose level of 200 mg/dL (11.1 mmol/L) or higher in persons who have symptoms of high blood glucose (see Symptoms above) suggests a diagnosis of diabetes.

Fasting blood glucose test fasting blood glucose testing involves measuring blood glucose after not eating or drinking for 8 to 12 hours (usually overnight). A normal fasting blood glucose level is less than 100 mg/dL. A fasting blood glucose of 126 mg/dL (7.0 mmol/L) or higher indicates diabetes. The test is done by taking a small sample of blood from a vein or fingertip. It must be repeated on another day to confirm that it remains abnormally

high (see Criteria for diagnosis below). Hemoglobin A1C test (A1C) The A1C blood test measures the average blood glucose level during the past two to three months. It is used to monitor blood glucose control in people with known diabetes, but is not normally

used to diagnose diabetes. Normal values for A1C are 4 to 6 percent (show figure 3). The test is done by taking a

small sample of blood from a vein or fingertip. Oral glucose tolerance test Oral glucose tolerance testing (OGTT) is the most sensitive test for diagnosing diabetes and pre-diabetes. However, the OGTT is not routinely recommended because it is inconvenient compared to a fasting blood glucose test.

COMMON MEDICATION GIVEN IN HYPERTENSION


Diuretics Diuretics ("water pills") increase the amount of sodium and water excreted into the urine by the kidneys. It is thought that they lower blood pressure mainly by reducing the volume of fluid in the blood vessels. Diuretics commonly used for hypertension:

Acetazolamide - Diamox Chlorthalidone - Thalitone Hydrochlorothiazide - HydroDiuril, also sold as Microzide and Esidrix Indapamide - Lozol Metolazone - Zaroxolyn, also sold as Mykrox

Diuretics less commonly used for hypertension:

Amiloride hydrochloride - Midamor Bumetanide - Bumex Ethacrynic acid - Edecrin Furosemide - Lasix Spironolactone - Aldactone Torsemide - Demadex Triamterene - Dyrenium

Beta-blockers Beta blockers block the effect of adrenaline on the cardiovascular system, slow the heart rate, and reduce stress on the heart and the arteries. Acebutolol - Sectral Atenolol - Tenormin Betaxolol - Kerlone Bisoprolol - Zebeta, also sold as Ziac Carteolol - Cartrol Carvedilol - Coreg Labetalol - Normodyne, also sold as Trandate Metoprolol - Lopressor, also sold as Toprol Nadolol - Corgard Penbutolol - Levatol Propranolol - Inderal, Inderal LA Timolol - Blocadren

Calcium Channel Blockers Calcium channel blockers can reduce blood pressure by dilating the arteries and, in some cases, reducing the force of the heart's contractions. Amlodipine - Norvasc, also sold as Caduet and Lotrel Diltiazem - Cardizem, also sold as Dilacor and Tiazac Felodipine - Plendil Isradipine - DynaCirc Nicardipine - Cardene Nifedipine - Procardia XL, also sold as Adalat Nisoldipine - Sular Verapamil hydrochloride - Isoptin, also sold as Calan, Verelan, and Covera Angiotensin Converting Enzyme Inhibitors The angiotensin converting enzyme inhibitors (the "ACE inhibitors") can lower blood pressure by dilating the arteries. Benazepril - Lotensin Captopril - Capoten Enalapril - Vasotec, also sold as Vaseretic Fosinopril - Monopril Lisinopril - Prinivil, also sold as Zestril Moexipril - Univasc Quinapril - Accupril Ramipril - Altace Trandolapril - Mavik Angiotensin II Receptor Blockers The angiotensin II receptor blockers (the "ARBs") also reduce blood pressure by dilating the arteries. Candesartan - Atacand Irbesartan - Avapro Losartan - Cozaar Telmisartan - Micardis Valsartan - Diovan Other, Less Commonly Used Hypertension Drugs

Clonidine - Catapres Doxazosin - Cardura Guanabenz - Wytensin Guanfacine - Tenex Hydralazine hydrochloride - Apresoline Methyldopa - Aldomet Prazosin - Minipress Reserpine - Serpasil Terazosin - Hytrin

Combination Drugs For Hypertension

Amiloride and hydrochlorothiazide - Moduretic Amlodipine and benazepril - Lotrel Atenolol and chlorthalidone - Tenoretic Benazepril and hydrochlorothiazide - Lotensin HCT Bisoprolol and hydrochlorothiazide - Ziac Captopril and hydrochlorothiazide - Capozide Enalapril and hydrochlorothiazide - Vaseretic Felodipine and enalapril - Lexxel Hydralazine and hydrochlorothiazide - Apresazide Lisinopril and hydrochlorothiazide - Prinzide, also sold as Zestoretic Losartan and hydrochlorothiazide - Hyzaar Methyldopa and hydrochlorothiazide - Aldoril Metoprolol and hydrochlorothiazide - Lopressor HCT Nadolol and bendroflumethiazide - Corzide Propranolol and hydrochlorothiazide - Inderide Spironolactone and hydrochlorothiazide - Aldactazide Triamterene and hydrochlorothiazide - Dyazide, also sold as Maxide Verapamil extended release) and trandolapril - Tarka