I.

PATIENTS PROFILE

Name: J.D
Age: 55 years old Gender: Male
Chief Complaint: Posterior Myocardial infarction, chest pain
History of Illness:

Twelve days before admission, he had a posterior myocardial infarction that required
emergent percutaneous coronary angioplasty of the right coronary and left circumflex arteries.
He was admitted at the coronary intensive care unit and was subjected to undergo emergent
percutaneous coronary angioplasty of the right coronary and left circumflex arteries.

At the time of the angioplasty, the Left ventricular end diastolic pressure was 12 mmHg.

In the coronary intensive care unit, J.D. experienced 2 types of chest pain. The first type,
non-radiating chest tightness associated with shortness of breath, was relieved with oxygen
therapy and intravenous nitroglycerin and morphine. Administration of intravenous heparin was
started. Administration of medications: Clopidogrel 75 mg, atorvastatin 20 mg, and Aspirin 325
mg, was resumed, and the dose of Metoprolol was increased from 50 mg 2 times a day to 75 mg
2 times a day. The second type of pain was a sharp, reproducible, right-sided anterior chest pain.
He described it as a muscle spasm in the chest affecting his windpipe and feeling of being
choked. He reported no relief with treatment of Nitroglycerin and Morphine.
J.Ds vital signs remained stable at the ICU:
BP = 90/60 to 100/70 mm Hg, RR = 12/min to 16/min, HR = 66/min to 80/min.

Other manifestations observed to him are as follows:
Pulsus paradoxus = < 10 mmHg
no pulsus alternans
basal chest crackles upon auscultation
Right jugular venous distention = <4 cm above sternal angle
S4 and a systolic murmur heard upon auscultation
ECG findings: sinus rhythm with first-degree heart block and no acute ST segment or T-
wave changes.

On the first 2 days of stay in the ICU after implantation of pacemaker, he had experienced
chest discomfort and anxiety. Moreover he reported fatigability, and loss of appetite. Other
assessments are as follows:
shortness of breath
heart sounds became progressively more distant
HR=90 bpm
BP=80/50 mmHg
Paradoxical pulse pressure = 16mmHg
Urine output = < 30 ml per hour, concentrated
Cyanotic nailbeds
Cool and diaphoretic skin
Increased WBC count = 23.6 x 109/L (normal, 4 x 109/L to 11 x 109/L)
Serum creatinine level increased to 288 mol/L (normal, 45-100 mol/L)
Echocardiogram confirmed a pericardial effusion, was subsequently drained of 220 mL
of serosanguineous fluid

The following interventions are done to J.D:
Treatment with nitroglycerin was discontinued
40 mg of furosemide was given
The rate of intravenous administration of dextrose and isotonic sodium chloride solution
was increased to 100 mL/h.
Administration of clopidogrel and heparin was discontinued
Protamine was given
Pericardiocentesis, a catheter was placed in the pericardium and was attached to a
Jackson-Pratt drainage system

He was scheduled for the repositioning of the pacemaker.
On the 3
rd
day:
Urine output decreased to less than 10 mL/h
Coarse crackles from the base to the middle of the lungs upon auscultation
Echocardiogram showed obstruction of the left ventricular outflow tract (LVOT)
Systolic BP decreased to 60 mm Hg
Respirations were labored at 30/min, and with oxygen saturation raging 85-88 %
Hemoglobin level decreased to 100 g/L (normal, 120-160 g/L)
Distant heart sounds

The following interventions are done to address the problems mentioned:
Infusion of dextrose and isotonic sodium chloride solution at 100 mL/h.
Repeated doses of furosemide
Low dose dopamine
Administration of 100% oxygen via a non-rebreather mask
Intravenous infusions of norepinephrine and phenylephrine, and esmolol
Sedated with midazolam and was intubated for mechanical ventilation

This time an echocardiogram was obtained and revealed severe systolic anterior motion
of the mitral valve leaflet and almost complete LVOT obstruction (resulting in decreased cardiac
output and increased mitral regurgitation) and a small right and left ventricular circumferential
effusion. Hemodynamic readings remained relatively consistent throughout the day: pulmonary
artery pressure (PAP) 50/25 mm Hg, with a mean of 30 mm Hg. Some difficulty occurred in
maintaining a consistent systemic vascular resistance index despite the titration of
norepinephrine and phenylephrine. Nitric oxide was added to the pressure-support mechanical
ventilation circuit to help reduce the pulmonary pressures.

After few hours of his acute deterioration, spontaneous hemorrhage from the nose
developed, this may be due to hepatic ischemia, acute renal failure, or an inflammatory or stress
response. In addition, the hemoglobin level decreased to 70 g/L. He was suspected to have
disseminated intravascular coagulopathy and received a multiple transfusions of fresh-frozen
plasma, packed cells, and platelets and injections of vitamin K. No other sites of bleeding were
noted.

On the next few days there are no significant changes happened. However his
hemodynamic readings improved: cardiac index from 1.8-2.0 to 2.7, PAP 45/18 mm Hg, with a
mean of 26 mm Hg; pulmonary artery pressure (PAP) from 50/25 mm Hg, with a mean of 30
mm Hg to PAP 45/18 mm Hg, with a mean of 26 mm Hg; pulmonary capillary wedge pressure
from 19 mm Hg to 11 mmHg; right atrial pressure from 20 mm Hg to 9 mmHg.

He was kept sedated to optimize his comfort, and he was paralyzed to minimize oxygen
demand while he was receiving mechanical ventilation. When anuria developed he had
continuous renal replacement therapy.

Past Health/Family History
J.D. has hypertrophic cardiomyopathy for 10 years. He was also known to have
chronotropic incompetence and has been experiencing presyncope with exercise for 1 year. J.D.
claimed that he has a family history of cardiac disease. J.D. had been taking Clopidogrel 75 mg,
Atorvastatin 20 mg, and Aspirin 325 mg, was resumed, and the dose of Metoprolol 50 mg 2
times a day.

His father died of sudden cardiac death at age 38, and 3 uncles had a myocardial
infarction before the age of 45 years.

PRIORITIZATION

RANK PROBLEM CLASSIFICATION PROBLEM
1 Decreased cardiac output
related to impaired
contractility as evidenced by
variations in hemodynamic
parameters








Overt This is prioritized as 1
st

because according to
Maslows Hierarchy of
Needs oxygen is a
physiologic need. A
decrease in cardiac output
may cause inadequate
oxygenated blood
circulating into the different
systems that is required to
meet the metabolic
demands of the body. If this
problem will not be
resolved this could result to
inadequate tissue perfusion
which will further lead to
more serious problems or
worse could lead to death of
the patient.

2 Impaired gas exchange related
to ventilation-perfusion
imbalance as evidenced by
shortness of breath and
diaphoresis

Overt This is prioritized as 2
nd

because this has also
something to do with the
oxygenation of the tissues
needed to maintain its
proper functioning.
Moreover because of the
improper functioning of the
heart that affects the
circulation in the body, this
resulted to the impaired gas
exchange. This will also be
classified in the first level
of Maslows hierarchy of
needs.
3 Ineffective tissue perfusion:
cardiopulmonary, peripheral,
renal related to changes in
circulating volume as
evidenced by changes in pulse
pressure, presence of crackles,
shortness of breath, decreased
Overt This is the 3
rd
prioritized
problem because tissue
perfusion is interrelated
with blood flow/cardiac
output. If this problem will
not be addressed tissues will
be damaged thus unable to
urinary output

function properly, and may
lead to cell death. Moreover
this could also result to an
organ dysfunction.


4 Excess fluid volume related to
compromised regulatory
mechanism as evidenced by
shortness of breath and
presence of crackles upon
auscultation
Overt This identified problem is
also included in Maslows
first level of hierarchy of
needs. In the OFFTERAS it
was clearly stated that fluid
must be resolved after
addressing the problems
related to oxygenation.

5 Impaired skin and tissue
integrity related to mechanical
trauma secondary to
Pericardiocentesis and physical
trauma secondary to
myocardial injury

Overt On the second level of
Maslows Hierarchy of
Need, skin, the largest
organ of our body serves as
the first line of defense in
our body and its main
function is protection. And
when the skin is altered,
greater opportunity for
pathogenic bacteria to
invade and inoculate in
specific body part of a
susceptible human body.

6 Impaired physical mobility
related to limited
cardiovascular endurance as
evidenced by easy fatigability.
Overt On the fourth level of
Maslows Hierarchy of
Need, physical mobility is
under activity that refers to
the ability of humans to
move around their
environment. And if there is
impairment it can cause
limitation in the physical
movement of the body.

7 Activity intolerance related to
imbalance between oxygen
supply and demand as
evidenced by
Echocardiographic changes
reflecting severe systolic
anterior motion of the mitral
Overt On the fourth level of
Maslows Hierarchy of
Need, activity is included
Activity intolerance is the
state wherein an individual
has insufficient
physiological energy to






valve leaflet and almost
complete LVOT obstruction
endure or complete required
or desired daily activities.
Activity tolerance is
important for it may help
the patient to reduce
possibility of acquiring
another diseases or actual
problem.

8 Risk for imbalanced nutrition
less than body requirements:
inability to ingest food as
evidenced by lack of interest in
food.

Potential According to Maslows
hierarchy of needs, food is
essential to gain nutrients (
a source of nourishment) for
the metabolic needs of the
body. Nutrition is the
process of getting food into
your body and using it as
raw materials for growth,
fuel for energy, and
vitamins and minerals that
keep your body healthy and
functioning properly. And if
there is an inadequate food
intake, the body may not
function properly and
further problems may
develop.
9 Risk for infection related to
inadequate primary defenses
secondary to pericardiocentesis
Potential According to the rule, risk
problem should prioritized least,
because actual problem should
solve first. On the second level of
Maslows Hierarchy of Needs, it
is under protection where in
broken skin/traumatized
tissue gives a greater
opportunity for pathogenic
bacteria to invade and
inoculate in specific body
part of a susceptible human
body that will lead to
further damage or infection.


















PREDISPOSING FACTORS:
Age=55 yrs old
Gender=Man
Family History = Cardiac Disease
PRECIPITATING FACTORS:
Rate- responsive sequential dual chamber
pacemaker
Posterior M.I
Diastolic pressure 12 mmHg
Sufficient mass of the left ventricular wall is necrotic or ischemic and fails to pump
Stroke volume and heart rate decreases
BP falls: 80/50mmHg
Tissue perfusion is reduced
Inadequate blood supply for tissues and organs and for the heart muscle
Impaired tissue perfusion weakens the heart muscles and impairs its ability to pump
Decreased cardiac contractility
Decreased cardiac
output
Impaired gas exchange
Decreased blood
flow to the kidneys
Shortness of
breath, Increased
level of fatigue
Impaired Physical
mobility
Activity Intolerance
Decreased Kidney Function
Decreased GFR
Decreased Urine Output
Ineffective tissue
perfusion:
cardiopulmonary,
peripheral, renal


















Symmetrical/ Asymmetrical thickening of the interventricular septum and left ventricular free wall
Left ventricular cavity that is normal or reduced in size
Mitral valve touches the thickened interventricular septum and blocks outflow
Ventricle does not fully eject its volume of blood at systole
Hyper dynamic left ventricle generates a high speed of
flow through a narrowed outflow tract
High speed ejection of blood
Pulling the anterior leaflet of the mitral valve toward and
onto the thickened septum
Displacement of the papillary muscle and an anterior shift
and elongation of the mitral leaflets
Leaflet may be positioned in the path of the outflow tract
Propelled forward into the aortic outflow tract during ventricular ejection
Outflow obstruction
Decreased cardiac
output
Left ventricular
dysfunction
Impaired ventricular
relaxation and filling of a
hypertrophic and non
compliant left ventricle
B
A
Excessive
fluid
volume
Pericardiocentesis
Impaired Skin and
Tissue integrity
A
B
Ineffective tissue
perfusion:
cardiopulmonary,
peripheral, renal
































B
Increased left ventricular outflow pressure gradient and mitral regurgitation
Increased pressure gradient and hyper contractility
A
Continuous Cellular and Myocardial Tissue Injury
Impaired Skin and
Tissue integrity
ASSESSMENT EXPLANATION OF
THE PROBLEM
OBJECTIVES INTERVENTIONS RATIONALE EVALUATION
S> I feel like Im
being choked.

O> shortness of
breath

> easy fatigability

> (+) dysrhythmias

> Unable to
tolerate simple
activities

> RR= 30/min,
labored and with
100% oxygen
delivered via a
non-rebreather
mask, his oxygen
saturation was
85%;

> Nail beds were
cyanotic, and his
With the patients
condition, there is a
deficit in oxygenation
and/or carbon dioxide
elimination at the
alveolo-capillary
membrane which was
caused by the
pulmonary congestion.
LTO> After 48 hours of
nursing interventions, the
patient will be able to:
a.)be free of
symptoms of
respiratory distress,
such as
-shortness of breath
-dysrhythmias
-pinkish nailbeds

b.)gain normal
breathing pattern
and absence of
adventitious breath
sounds

STO> After 8 hours of
nursing interventions, the
patient will be able to:
a) Participate in
treatment regimen
(DBE, use of
oxygen) within
> Auscultate breath
sounds, noting crackles
and wheezes.



> Note respiratory rate,
depth, use of accessory
muscles, pursed-lip
breathing; and areas of
pallor or cyanosis.

> Evaluate pulse
oxymeter to determine
oxygenation.

> Assess energy level and
activity tolerance.



>Monitor ABGs
> Reveals presence of
pulmonary congestion
or collection of
secretions, indicating
need for further
intervention.

> To be able to assess for
the oxygenation on the
peripheral and central
circulation or signs of
respiratory distress.

> To assess for
respiratory
insufficiency.

> To recognize further
deterioration of
condition that already
leads to inability to
tolerate simple
activities.

> Increasing PaCO2 and
decreasing paO2 are
signs of respiratory
LTO:
Goal met if the patient
was able to manifest:
a.)free from symptoms
of respiratory distress
such as :
-shortness of
breath
-dysrhythmias
-pinkish nailbeds

b.) gain normal
breathing pattern and
absence of adventitious
breath sounds




STO:
skin was
diaphoretic and
cool.


> Auscultation
revealed
posterior basal
chest crackles.

> Chest radiograph
revealed a large
pleural effusion
and with chest
tube insertion

> Hgb = 100 g/L as
of 3
rd
post op day





A> Impaired gas
exchange related to
ventilation perfusion
imbalance as
evidenced by
shortness of breath
level of ability
and situation

b) Oxygen
saturation from
85 % to 95-98 %






>Maintain negative
pressure to the chest tube



> Maintain chair rest and
bedrest in a semi-
Fowlers position, with
the head of bed
elevated 20 to 30
degrees. Support arms
with pillows.

> Provide supplemental
oxygen at lowest
concentration indicated
by laboratory results
and client symptoms.

> Maintain adequate
intake and output

> Administer
medications, as
indicated, such as
failure

> Negative pressure is
essential to maintaining the
delicate balance between
the visceral and parietal
pleura and the integrity of
the lungs.
> Reduces oxygen
consumption and
demands and promotes
maximal lung inflation.


> Increase alveolar
oxygen concentration,
which may correct or
reduce tissue
hypoxemia.

> For mobilization of and
liquefy secretions.

> To treat underlying
conditions. Diuretics
reduce alveolar
congestion, enhancing
Fully met if the patient
was able to:
a) Participate in
treatment
regimen (DBE,
CE, use of
oxygen)
b) Oxygen
saturation from
85 % to 95-98
%


and diaphoresis Diuretics (Furosemide)
and Bronchodilators
(Aminophylline).




> Encourage adequate
rest and limit activities
to within client
tolerance. Promote
calm/restful
environment by
limiting visitors and
noise.


> Encourage frequent
position changes


gas exchange.
Bronchodilators
increase oxygen
delivery by dilating
small airways and exert
mild diuretic effect to
aid in reducing
pulmonary congestion.

> Helps limit oxygen
needs/consumption.





> Helps prevent
atelectasis and
pneumonia.



Reference: M.E. Doenges., M.F. Moorhouse., A.C.Murr.(2002).Nursing Care Plans:Guidelines for Individualizing Pateint Care 6
th
Edition pg.47-48