Beruflich Dokumente
Kultur Dokumente
College of Nursing
Submitted by:
Group3/NR-41
Acknowledgement
The group would like to extend their gratitude to the following persons who
contributed and have been part of this study.
First, to Mrs. Arlene Paduada, RN, clinical instructor in Intensive Care Unit, for
her willingness to share her knowledge about the subject matter as well as her guidance
and support in allowing us to conduct the study to the said client.
Then, to Mr. R, as our subject in this study, his presence gave us the idea of the
topic itself.
Next, to our parents who help us financially and for their loving support to finish
this study.
Lastly, to God, for giving us the wisdom, strength and guidance that helped us
throughout the study.
CHAPTER I: INTRODUCTION
1. Background of the Study
Coronary artery disease is atherosclerosis of the coronary arteries, producing
blockages in the vessels which nourish the heart itself. Atherosclerosis occurs when the
arteries become clogged and narrowed, restricting blood flow. Without adequate blood
flow from the coronary arteries, the heart becomes starved of oxygen and vital nutrients
it needs to work properly.
Coronary arteries are blood vessels on the heart. They are smooth and elastic,
allowing blood to flow freely.
Before your teen years, fat can start to deposit in the blood vessel walls. As you
get older, the fat builds up. This causes injury to your blood vessel walls. In an attempt
to heal itself, the fatty tissues release chemicals that promote the process of healing but
make the inner walls of the blood vessel sticky.
Then, other substances, such as inflammatory cells, proteins, and calcium that
travel in your bloodstream start sticking to the inside of the vessel walls. The fat and
other substances combine to form a material called plaque, which can narrow the flow
of blood in the artery (atherosclerosis).
Some plaque deposits are hard on the outside and soft and mushy on the inside.
Some plaque is fragile, cracking or tearing, exposing the soft, fatty inside. When this
happens, platelets (disc-shaped particles in the blood that aid clotting) come to the area,
and blood clots accumulate on the injured vessel wall. This causes the artery to narrow
even more. Sometimes, the blood clot breaks apart by itself, and blood supply is
restored.
Over time, the inside of the arteries develop plaques of different sizes.
Eventually, a narrowed coronary artery may develop new blood vessels that go around
the blockage to get blood to the heart. However, during times of increased exertion or
stress, the new arteries may not be able to supply enough oxygen-rich blood to the heart
muscle.
In other cases, the blood clot may totally block the blood supply to the heart
muscle, causing what is called an acute coronary syndrome. This is actually a name
given to three serious conditions: Unstable angina, Non-ST segment elevation
myocardial infarction (NSTEMI) or non-Q-wave MI, ST segment elevation myocardial
infarction (STEMI) or Q-wave MI.
The most common symptom is of coronary artery disease is angina or simply
chest pain. Angina can be described as a discomfort, heaviness, pressure, aching,
burning, numbness, fullness, squeezing or painful feeling. Other symptoms that can
occur with coronary artery disease include shortness of breath, palpitations,
tachycardia, weakness or dizziness, nausea, sweating.
The study focuses on Mr. R, 71 years old, male client. He was admitted last
August 31, 2011 at 5:50 pm in the Medical-Surgical ward of the Ospital ng Maynila
Medical Center. He was admitted due to complaints of chest pain. Upon admission, his
diagnosis was Coronary Arterial Disease. Moreover, he was diagnosed as having
anemia of chronic disease, pleural effusion secondary to pulmonary tuberculosis, and
psoriasis. All of the said diagnoses will tackle further in this study, most especially
Coronary Artery Disease.
The group had chosen this particular disease condition due to the curiosity and
interest regarding to the current situation of the patient. They do believe that taking this
opportunity would challenge them and they thought that it is a best experience to take
for the group to test how the condition works on client in reality. Through a thorough
and actual observation to the said disease, their knowledge upon the case would make
them further understand and achieved a best type of learning. This is also a good
opportunity to train their skills in doing and giving the actual, direct and potential care
to the patient in order to sharpen their skill as a future nurses.
readers of this study will also acquire more knowledge and skills that might help them
in their study in the near future.
To gather clients profile from clients chart and relatives which includes the past
and present history of illness, socio-demographic data and other related data that
are needed in the study.
To review the anatomy and physiology as well as the pathophysiology of the disease
condition.
To assess the results of the laboratory findings and diagnostic procedures done upon
the need of the client.
To identify priority nursing problems which are present to the client during disease
condition.
study focused on the main diagnosis of the client, which was Coronary Artery Disease,
other diagnosed diseases in the client was viewed brieftly in the study.
Mr. R.
Paco, Manila
71 y/o
November 23, 1939
Male
Filipino
Married
Catholic
Sedentary lifestyle
Ospital Ng Maynila
Hospital of Pangasinan
(3)
History of
Present Illness
(4)
Past Medical
History
B. Physical Assessment
General Survey
General Appearance: The client was received on bed with presence of nasogastric
tube, endotracheal tube and mechanical ventilator. He was weak and stuporous.
Has a Glasgow Coma Scale of 7.
Nutritional State: The client weighs 77 kgs. with a height of 56 feet. He was in
unhealthy appearance. Edema on peripheral extremities noted.
Vital Signs (taken last September 1, 2011)
Vital Signs
Results
Blood Pressure
70/50 mmHg
Temperature
36.9 C
Pulse Rate
114 beats/min
Respirations
26 breaths/min
Physical Examination
Type of
Area of
Assessment
Assessment
Used
Head
Inspection
Results
The clients head was proportionate to the body size.
There were no tenderness and wounds in the scalp.
The client was bald.
Eyes
Inspection &
palpation
Inspection
The ears of the client and facial skin were the same
color. No inflammation, lesions, or nodules were
apparent. Theres no visible discharge from the
auditory canal though cerumen noted. External
meatus was apparent. No redness or swelling was
noted. The alignments of the pinnas were symmetrical
and they were elastic and recoil when folded.
Palpation
Nose
Inspection
Mouth
Palpation
Inspection
Inspection
Skin and Nails
Clients skin was pale and scaly while his nails were
dirty and clubbing. His skin texture was cold and
clammy.
Palpation
Neck
Inspection
Palpation
Inspection
Thorax &
Percussion
Heart
Palpation
Auscultations
Inspection
Abdomen
Percussion
Palpation
Auscultation
Inspection
Extremities
Genitalia
Palpation
Inspection
Neurologic
Inspection &
status
Palpation
Hematology Results
Components
Normal
Values
WBC
15.6
4.8-10.8
Neutrophils
73.5
55-75
Lymphocytes
19.1
20-30
Monocytes
2.3
0-7
Eosinophils
0-3
Basophils
5.1
0-1
RBC
2.89
4-6.20
Hemoglobin
12-16
Hematocrit
24.8
34-47
MCV
85.8
80-90
MCH
27.7
27-31
MCHC
32.3
32-36
RDW
19.2
0.115-0.140
Platelet
116
150-400
Interpretation:
Based on the obtained values of the laboratory results, the white blood cells count
shows a higher than normal values which indicates that the client had an infection. The
values that were resulted in red blood cells, hemoglobin, and hematocrit fell below the
normal range which indicates that the clients RBC population may have a lower
variation and the client might possibly suffered from anemia. For the platelet count of
the client which was lower than normal values indicates that the client was
experiencing some mild bleeding disorders.
2. Blood Chemistry
Date of Results:
Test
Results
Normal Values
BUN
4.90 mmol/L
2.9-9.3 mmol/L
Creatinine
88 umol/L
57-113 umol/L
Uric acid
0.25 mmol/L
0.28-0.51 mmol/L
AST
32 IU/L
15-41 IU/L
ALT
65 IU/L
17-63 IU/L
Total Protein
BAR g/L
65-81 g/L
Albumin
BAR g/L
35-48 g/L
Globulin
0 g/L
15-35 g/L
A/G Ratio
Sodium
127 mmol/L
136-144 mmol/L
Potassium
4.3 mmol/L
3.6-5.1 mmol/L
Rh: Positive
Interpretation:
The blood crossmatching result shows that the clients type of blood was B
and has a Rh type of Positive which shows that the client has a B antigen on the surface
of his RBCs, and blood serum containing IgM antibodies against the A antigen.
Therefore, the client can receive blood only from individuals of groups B or O (with B
being preferable).
4. Troponin Result
Test
Result
Normal Value
Troponin I (Quanti)
1.07 ng/ml
0-0.034 ng/ml
Interpretation:
The troponin result obtained shows a higher than its normal value, which
indicates that the client has a damage or injury to the heart muscle, thus, specifically
proved that he was suffering from a myocardial infarction.
arteries which take the blood to the lungs. The pulmonary veins take blood from
the lungs to the left atrium. All the other veins in our body drain into the inferior
vena cava (IVC) or the superior. These two large veins then take the blood from
the rest of the body into the right atrium.
Valves
Valves are fibrous flaps of tissue found between the heart chambers and in the
blood vessels. They are rather like gates which prevent blood from flowing in the
wrong direction. They are found in a number of places. Valves between the atria
and ventricles are known as the right and left atrioventricular valves, otherwise
known as the tricuspid and mitral valves respectively. Valves between the
ventricles and the great arteries are known as the semilunar valves. The aortic
valve is found at the base of the aorta, while the pulmonary valve is found the
base of the pulmonary trunk. There are also many valves found in veins
throughout the body. However, there are no valves found in any of the other
arteries besides the aorta and pulmonary trunk.
Cardiovascular System
The cardiovascular system refers to the heart, blood vessels and the blood. Blood
contains oxygen and other nutrients which your body needs to survive. The
body takes these essential nutrients from the blood. At the same time, the body
dumps waste products like carbon dioxide, back into the blood, so they can be
removed.
The main function of the cardiovascular system is therefore to maintain blood
flow to all parts of the body, to allow it to survive. Veins deliver used blood from
the body back to the heart. Blood in the veins is low in oxygen (as it has been
taken out by the body) and high in carbon dioxide (as the body has unloaded it
back into the blood). All the veins drain into the superior and inferior vena cava
which then drains into the right atrium.
The right atrium pumps blood into the right ventricle. Then the right ventricle
pumps blood to the pulmonary trunk, through the pulmonary arteries and into
the lungs. In the lungs the blood picks up oxygen that we breathe in and gets rid
of carbon dioxide, which we breathe out. The blood is becomes rich in oxygen
which the body can use.
From the lungs, blood drains into the left atrium and is then pumped into the
left ventricle. The left ventricle then pumps this oxygen-rich blood out into the
aorta which then distributes it to the rest of the body through other arteries. The
main arteries which branch off the aorta and take blood to specific parts of the
body are:
Hepatic artery, which takes blood to the liver with branches going to
the stomach
The body is then able to use the oxygen in the blood to carry out its normal
functions. This blood will again return back to the heart through the veins and
the cycle continues.
Cardiac Cycle
The cardiac cycle is the sequence of events that occurs in one complete beat of
the heart. The pumping phase of the cycle, also known as systole, occurs when
heart muscle contracts.
The filling phase, which is known as diastole, occurs when heart muscle relaxes.
At the beginning of the cardiac cycle, both atria and ventricles are in diastole.
During this time, all the chambers of the heart are relaxed and receive blood. The
atrioventricular valves are open.
Atrial systole follows this phase. During atrial systole, the left and right atria
contract at the same time and push blood into the left and right ventricles,
respectively. The next phase is ventricular systole. During ventricular systole, the
left and right ventricles contract at the same time and pump blood into the aorta
and pulmonary trunk, respectively. In ventricular systole, the atria are relaxed
and receive blood.
The atrioventricular valves close immediately after ventricular systole begins to
stop blood going back into the atria. However, the semilunar valves are open
during this phase to allow the blood to flow into the aorta and pulmonary trunk.
Following this phase, the ventricles relax that is ventricular diastole occurs. The
semilunar valves close to stop the blood from flowing back into the ventricles
from the aorta and pulmonary trunk. The atria and ventricles once again are in
diastole together and the cycle begins again.
Components of the Heartbeat
The adult heart beats around 70 to 80 times a minute at rest. When you listen to
your heart with a stethoscope you can hear your heart beat.
The sound is usually described as "lubb-dupp". The "lubb" also known as the first
heart sound, is caused by the closure of the atrioventricular valves. The "dupp"
sound is due to the closure of the semilunar valves when the ventricles relax (at
the beginning of ventricular diastole).
D. Medical Management
Foley catheter is a thin, sterile tube inserted into your bladder to drain urine. It can be
left in place in the bladder of the client for a period of time. It is held with a balloon at
the end, which is filled with sterile water to hold it in place. The clients urine was
drained into a bag and can then be taken from an outlet device to be drained.
Laboratory tests were also conducted on the clients urine to look for infection, blood,
muscle breakdown, crystals, electrolytes, and kidney function. It was inserted to the
client because he was suffering from urinary incontinence thus assisting the client
during his urination.
Intravenous Therapy
Intravenous therapy or IV therapy is the giving of substances directly into a vein. It was
used to the client in order to correct electrolyte imbalances, to deliver medications and
for blood transfusion or as fluid replacement to correct. The client is hooked with D5W
IV Fluid in companion with some other medications such as dopamine drip.
Oxygen Therapy
availability of oxygen to the body tissues, especially when the patient is suffering from
hypoxia and/or hypoxemia. It is indicated to used as a medical treatment in both
chronic and acute cases, and can be used in hospital, pre-hospital or entirely out of
hospital, dependant on the needs of the patient and the views of the medical
professional advising, use in chronic conditions. It may also be indicated for any other
patient where their injury or illness has caused hypoxemia, although in this case oxygen
flow should be moderated to achieve target oxygen saturation levels, based on pulse
oximetry and lastly for personal use, high concentration oxygen is used as home
therapy to abort cluster headache attacks, due to its vasoconstrictive effects.
Pharmacotherapy
Endotracheal Intubation
suctioned from time to time, and also when the clients mouth was already dry, the
nurse wipes it with wet swabs.
Nasogastric Intubation
A nasogastric tube is used for feeding and administering drugs. For drugs and for
minimal quantities of liquid, a syringe is used for injection into the tube. For continuous
feeding, a gravity based system is employed, with the solution placed higher than the
patient's stomach. By inserting a nasogastric tube, the client had gained access to the
stomach and its contents. This will allow gastric immobility, and bowel obstruction to
be treated. In the case of the client, he was not able to ingest food properly so using this
NG tube, adequate nutrition was quite provided and some other oral medications were
also administered through this.