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I.
ABSTRACT
23 year old, male patient sought consultation at the Emergency Room
II.
MAIN BODY
A. INTRODUCTION
Myocarditis is an inflammatory disorder of the myocardium with necrosis
of the myocytes and associated inflammatory infiltrate.
Myocarditis usually manifests in an otherwise healthy person and can
result in rapidly progressive (and often fatal) heart failure and arrhythmia.
When diagnosis is suspected and severe cardiovascular compromise follows,
it requires admission to Coronary Care Unit.
Potential causes may include toxins, medications, physical agents, and,
most importantly, infections. Viruses, bacteria, protozoa, and even worms
have been implicated as infectious agents. The most common forms appear
to be post viral in origin. These mostly include adenovirus and enteroviruses
such as the coxsackieviruses.
Unfortunately, the clinical features of myocarditis can vary widely, and
often no cardiac signs or symptoms occur, complicating its recognition. Its
clinical manifestations widely vary in mild forms to few or no symptoms are
noted.
In viral myocarditis, there is usually unexplained heart failure or
arrhythmias occur in the setting of systemic febrile illness, after symptoms of
an upper respiratory tract infection, gastroenteritis, and systemic afebrile
illness which precedes myocarditis followed by an abrupt onset of
hemodynamic collapse. Sometimes patient cant even remember having a
febrile illness because it can be mild. Other symptoms may include fatigue,
decrease exercise intolerance, palpitations, chest pain and syncope.
In severe cases, patient may present with acute cardiac decomposition
and may progress to death. Sign of diminished cardiac output, such as
tachycardia, weak pulse, cool extremities, decreased capillary refill, and pale
or mottled skin maybe present.
Medical care is aimed at minimizing hemodynamic demands of the body.
No specific proven therapy is available to prevent the myocardial damage, but
maintenance of tissue perfusion is the goal to avoid further complications.
The incidence of myocarditis is estimated to be 1 to 10 cases per 100,000
persons. The rate may be higher because the variety of clinical presentations
may cause underreporting (Tang, 2001). Mortality varies with the severity of
symptoms. Most patients with mild symptoms recover completely. Other
patients may develop cardiomyopathy and heart failure. Patients with
symptomatic heart failure and an ejection fraction of less than 45% had a 1year mortality rate of 20% and a 4-year mortality rate of 56% (Tang, 2001).
A. DEMOGRAPHICAL DATA
-This is the case of C.D.R., a 22 year old, male, Filipino, Roman
Catholic, born on April 17, 1992, presently residing in Agpaoa
Camp 7, Baguio City, Benguet, who was admitted in this institution
on October 02, 2014 due to dizziness, palpitations, chest
heaviness, choking sensation and vomiting.
B. HISTORY
3. HEREDOFAMILIAL HISTORY
-
(+) HPN, (+) Heart Disease (-) Cancer (-) DM (-) Asthma
4. SOCIOENVIRONMENTAL HISTORY
Occupation: student
Marital Status: Single
Smoking: none
Illicit Drug Use: none
Alcohol: none
Sexual History: none
Travel History: none
Exposure: none
C. COURSE OF CONFINEMENT
1st Hospital Day October 02, 2014
-At around 5:42 am, patient C.D.R was rushed at the emergency
room complex with chief complaints of dizziness, palpitations, chest
heaviness, choking sensation and vomiting.
-Oxygen was administered and 12 lead ECG was made.
-Troponin I reveals positive
-Patient was initially diagnosed as ACS, NSTEMI, High Lateral
Wall, 3rd Degree AV Block.
-Aspirin 4 tabs were given as loading dose
-Dobutamine 250mg drip was initiated due to un-appreciated blood
pressure.
-Further history reveals sore throat 2x a year and flu symptoms 2
days prior to admission; viral myocarditis was suspected
-Routine Blood works were done: CBC with platelet, Na, K,
creatinine, magnesium, phosphorus, SGOT, SGPT, PTPA, APTT,
and ABG
-CRP, ASO titer and ESR was also made to rule out myocarditis
-CXR PA was made as a routine work up and to rule out congestion
or cardiomegaly.
-Patient was admitted and brought to CCU with blood pressure of
90/70 and with the same symptoms.
D. ASSESSMENT
Neurological System
-
GCS = 15 (M6V5E4)
(+) dizziness
Respiratory System
-
(+) cough (-) crackles (-) wheezes (-) dyspnea (-) retractions
Cardiovascular
-
No BP in all extremities
Pale in color
(-) edema
(-) murmurs
Gastrointestinal
-
Renal
-
(-) dysuria (-) hematuria (-) frequency (-) flank pain (-) tea
colored
Hematology/Oncology
-
Endocrine
-
Musculoskeletal
-
Skin
Pale in color
Eye
-
ENT
-
Mental Health
-
(-) confusion
E. DIAGNOSTIC STUDIES
12 Lead ECG
October 2, 2014 5:45 am
- 3rd degree AV block
In this type of heart block, none of the electrical signals reach the
ventricles. When complete heart block occurs, special areas in the
ventricles may create electrical signals to cause the ventricles to
properties
change.
Usually,
this
leads
to
early
Sinus tachycardia
Rapid heartbeat may be the body's response to heart muscle
damage
October 8, 2014 3:50 pm
Inverted T waves
T-wave inversions may result from myocardial ischemia
October 2,
2014
October 3,
2014
October 4,
2014
October 10,
2014
CBC
Hgb
172
155
128
160
Hct
0.494
0.451
0.375
0.472
WBC
9.63
12.36
9.54
8.14
Neutrophils
0.756
0.765
0.738
0.679
Lymphocytes
0.172
0.147
0.179
0.219
Platelet
238
235
187
357
* White blood cells (WBCs) constitute the bodys primary defense system against
foreign organisms, tissues, and other substances. Increase in WBC is most
Prothrombin Time
% Activity
APTT
October 2, 2014
13.44
79.24 %
24.33
October 3, 2014
13.59
78.28 %
31.56
Serum
October 2, October 3, October 4, October 5,
October
Electrolytes
2014
2014
2014
2014
10, 2014
Na
131
136
132
130
130
K
4.6
4.4
3.8
3.2
4.8
Cl
95
Ca
2.31
2
2
2
Mg
1.21
0.78
P
0.88
Creatinine
96.9
79.1
74.9
72.5
BUN
4.1
4.1
SGOT
140
SGPT
34
Total
Cholesterol
3.10
Triglyceride
1.00
LDL
1.84
HDL
0.84
* Potassium deficiency can be caused by an inadequate intake of dietary
potassium.
October 2, 2014
Troponin I positive
* Troponin I is a protein in the striated cells of cardiac tissue and therefore
provides a unique marker for myocardial cardiac damage.
CRP positive
*C-reactive protein (CRP) is a glycoprotein produced by the liver in response to
acute inflammation. The CRP assay is a nonspecific test that determines the
ABGs
pH
7.425 Respiratory alkalosis, partial compensation, adequate O2
pCO2
20.9
HCO3 13.4
pO2
90
DRUG STUDY
1. Fondaparinux 2.5 g SQ now then OD
Therapeutic class: Anticoagulant
INDICATIONS
- To prevent deep vein thrombosis (DVT), which may lead to pulmonary
embolism, in patients undergoing surgery for hip fracture, hip replacement,
knee replacement, or abdominal surgery
ACTION
- Binds to antithrombin III (AT-III) and potentiate the neutralization of factor
Xa by AT-III, which interrupts coagulation and inhibits formation of
thrombin and blood clots.
ADVERSE REACTIONS
CNS: fever, insomnia, dizziness, confusion, headache, pain.
CV: hypotension, edema.
hemorrhage,
anemia,
hematoma,
postoperative
hemorrhage, thrombocytopenia.
Metabolic: hypokalemia.
Skin: mild local irritation (injection site bleeding, rash, pruritus), bullous
eruption, purpura, rash, increased wound drainage.
NURSING CONSIDERATIONS
- Monitor these patients closely for neurologic impairment.
- Monitor renal function periodically and stop drug in patients who develop
unstable renal function or severe renal impairment while receiving therapy.
- Routinely assess patient for signs and symptoms of bleeding, and
regularly monitor CBC, platelet count, creatinine level, and stool occult
blood test results. Stop use if platelet count is less than 100,000/mm3.
PATIENT TEACHING
- Tell patient to report signs and symptoms of bleeding.
ACTION
- Stimulates hearts beta 1 receptors to increase myocardial contractility and
stroke volume. At therapeutic dosages, drug increases cardiac output by
decreasing peripheral vascular resistance, reducing ventricular filling pressure,
and facilitating AV node conduction.
ADVERSE REACTIONS
CNS: headache.
CV: hypertension, increased heart rate, angina, PVCs, phlebitis, nonspecific
chest pain, palpitations, ventricular ectopy, hypotension.
GI: nausea, vomiting.
Respiratory: asthma attack, shortness of breath.
Other: anaphylaxis, hypersensitivity reactions.
NURSING CONSIDERATIONS
Alert: Because drug increases AV node conduction, patients with atrial fibrillation
may develop a rapid ventricular rate.
- Continuously monitor ECG, blood pressure, pulmonary artery wedge pressure,
cardiac output, and urine output.
- Monitor electrolyte levels. Drug may lower potassium level.
PATIENT TEACHING
- Tell patient to report adverse reactions promptly, especially labored breathing
and drug-induced headache.
- Instruct patient to report discomfort at I.V. insertion site.
2. Alprazolam 250 mcg at bedtime
ADVERSE REACTIONS
CNS: insomnia, irritability, dizziness, headache, anxiety,
confusion,
drowsiness,
light-headedness,
sedation,
vertigo,
restlessness,
malaise,
agitation,
tremor,
nightmare,
nervousness,
syncope,
akathisia,
mania.
CV: palpitations, chest pain, hypotension.
EENT: allergic rhinitis, blurred vision, nasal congestion.
GI: diarrhea, dry mouth, constipation, nausea, increased or
decreased
appetite,
abdominal pain.
anorexia,
vomiting,
dyspepsia,
dysmenorrhea,
sexual
1
dysfunction,
premenstrual
NURSING CONSIDERATIONS
Alert: Dont withdraw drug abruptly; withdrawal symptoms,
including seizures, may occur. Abuse or addiction is
possible.
Monitor hepatic, renal, and hematopoietic function
periodically in patients receiving repeated or prolonged
therapy.
Closely monitor addiction-prone patients.
INDICATIONS
Mild pain or fever
ACTION
- Thought to produce analgesia by inhibiting prostaglandin
and other substances that sensitize pain receptors. Drug
may relieve fever through central action in the hypothalamic
heat-regulating center.
ADVERSE REACTIONS
Hematologic: hemolytic anemia, leukopenia, neutropenia,
pancytopenia.
Hepatic: jaundice.
Metabolic: hypoglycemia.
Skin: rash, urticaria.
NURSING CONSIDERATIONS
Alert: Many OTC and prescription products contain
acetaminophen; be aware of this when calculating total daily
dose.
.
PATIENT TEACHING
Advise parents that drug is only for short term use; urge
them to consult prescriber if giving to children for longer than
5 days or adults for longer than 10 days.
Alert: Warn patient that high doses or unsupervised longterm use can cause liver damage. Excessive alcohol use
may increase the risk of liver damage. Caution long-term
alcoholics to limit drug to 2 g/day or less.
ACTION
- Thought to reduce cardiac oxygen demand by decreasing
preload and afterload. Drug also may increase blood flow
through the collateral coronary vessels.
ADVERSE REACTIONS
CNS: headache, dizziness, weakness.
CV: orthostatic hypotension, tachycardia, palpitations, ankle
edema, flushing, fainting.
EENT: sublingual burning.
GI: nausea, vomiting.
Skin: cutaneous vasodilation, rash.
NURSING CONSIDERATIONS
Monitor blood pressure and heart rate and intensity and
duration of drug response.
Drug may cause headaches, especially at beginning of
therapy. Dosage may be reduced temporarily, but tolerance
usually
develops.
Treat
headache
with
aspirin
or
acetaminophen.
PATIENT TEACHING
Caution patient to take drug regularly, as prescribed, and to
keep it accessible at all times.
Alert: Advise patient that stopping drug abruptly may cause
spasm of the coronary arteries with increased angina
symptoms and potential risk of heart attack.
Warn patient not to confuse S.L. with P.O. form.
ADVERSE REACTIONS
CNS: headache, restlessness, insomnia, dizziness, ataxia,
disorientation, hallucinations, delirium, excitement, agitation,
confusion.
CV: bradycardia, palpitations, tachycardia.
EENT: blurred vision, mydriasis, photophobia, cycloplegia,
increased intraocular pressure.
GI: dry mouth, constipation, thirst, nausea, vomiting.
NURSING CONSIDERATIONS
Alert: Watch for tachycardia in cardiac patients because
it may lead to ventricular fibrillation.
Many adverse reactions (such as dry mouth and
constipation) vary with dose.
Monitor fluid intake and urine output. Drug causes urine
retention and urinary hesitancy.
PATIENT TEACHING
Instruct patient to report serious or persistent adverse
reactions promptly.
.
6. Morphine 2 mg IV now then q 4 hours for severe chest
pain
Therapeutic class: Opioid analgesic
INDICATIONS
Moderate to severe pain
ACTION
- Unknown. Binds with opioid receptors in the CNS, altering
perception of and emotional response to pain.
ADVERSE REACTIONS
CNS: dizziness, euphoria, lightheadedness, nightmares,
sedation, somnolence, seizures, depression, hallucinations,
nervousness, physical dependence, syncope.
CV: bradycardia, cardiac arrest, shock, hypertension,
hypotension, tachycardia.
GI: constipation, nausea, vomiting, anorexia, biliary tract
spasms, dry mouth, ileus.
GU: urine retention.
Hematologic: thrombocytopenia.
Respiratory:
apnea,
respiratory
arrest,
respiratory
depression.
Skin: diaphoresis, edema, pruritus, skin flushing.
Other: decreased libido.
NURSING CONSIDERATIONS
Reassess patients level of pain at least 15 and 30 minutes
after giving parenterally.
Keep opioid antagonist (naloxone) and resuscitation
equipment available.
7. Diltiazem 30 mg BID
Therapeutic class: Antihypertensive
INDICATION:
Atrial fibrillation or flutter; paroxysmalsupraventricular
tachycardia
ACTION
- A calcium channel blocker that inhibits calcium ion influx
across cardiac and smooth muscle cells, decreasing
myocardial contractility and oxygen demand. Drug also
dilates coronary arteries and arterioles.
ADVERSE REACTIONS
CNS: headache, dizziness, asthenia, somnolence.
NURSING CONSIDERATIONS
Monitor blood pressure and heart rate when starting
therapy and during dosage adjustments.
Maximal antihypertensive effect may not be seen for 14
days.
If systolic blood pressure is below 90 mmHg or heart rate is
below 60 beats/minute, withhold dose and notify prescriber.
.
PATIENT TEACHING
Instruct patient to take drug as prescribed, even when he
feels better.
If nitrate therapy is prescribed during dosage adjustment,
stress patient compliance.
INDICATIONS
To prevent paroxysmal supraventricular tachycardia
ACTION
- Not clearly defined. A calcium channel blocker that inhibits
calcium ion influx across cardiac and smooth-muscle cells,
thus
decreasing
myocardial
contractility
and
oxygen
dizziness,
headache,
asthenia,
fatigue,
sleep
disturbances.
CV: transient hypotension, heart failure, bradycardia, AV
block, ventricular asystole, ventricular fibrillation, peripheral
edema.
GI: constipation, nausea, diarrhea, dyspepsia.
Respiratory:
dyspnea,
pharyngitis,
pulmonary
edema,
PATIENT TEACHING
Encourage patient to increase fluid and fiber intake to
combat constipation. Give a stool softener.
unstable
ventricular
tachycardia
ADVERSE REACTIONS
CNS: fatigue, malaise, tremor, peripheral neuropathy, ataxia,
paresthesia, insomnia, sleep disturbances, headache.
asymptomatic
corneal
microdeposits,
visual
NURSING CONSIDERATIONS
Be aware of the high risk of adverse reactions.
Obtain baseline pulmonary, liver, and thyroid function test
results and baseline chest X-ray. Give loading doses in a
hospital setting and with continuous ECG monitoring
because of the slow onset of antiarrhythmic effect and the
risk of life-threatening arrhythmias. Drug may pose life
threatening management problems in patients at risk for
PATIENT TEACHING
Tell patient to contact prescriber if he has vision changes,
weakness,
pins
and
needles
or
numbness,
poor
ACTION
- Inhibits cell-wall synthesis during bacterial multiplication.
ADVERSE REACTIONS
GI: diarrhea, nausea, pseudomembranous colitis, black hairy
tongue, enterocolitis, gastritis, glossitis, stomatitis, vomiting.
Hematologic: agranulocytosis, leukopenia, thrombocytopenia,
thrombocytopenic purpura, anemia, eosinophilia.
Skin: pain at injection site.
Other: hypersensitivity reactions, anaphylaxis, overgrowth of
nonsusceptible organisms.
NURSING CONSIDERATIONS
Dosage is expressed as total drug. Each 1.5-g vial contains 1
g ampicillin sodium and 0.5 g sulbactam sodium.
In patients with impaired renal function, decrease dosage.
ACTION
- Unknown. A selective beta blocker that selectively blocks
beta 1 receptors; decreases cardiac output, peripheral
resistance, and cardiac oxygen consumption; and depresses
renin secretion.
ADVERSE REACTIONS
CNS: fatigue, dizziness, depression.
CV: hypotension, bradycardia, heart failure, AV block, edema.
GI: nausea, diarrhea, constipation, heartburn.
Respiratory: dyspnea, wheezing.
Skin: rash.
NURSING CONSIDERATIONS
Always check patients apical pulse rate before giving drug. If
its slower than 60 beats/minute, withhold drug and call
prescriber immediately.
Monitor blood pressure frequently; drug masks common signs
and symptoms of shock.
PATIENT TEACHING
Instruct patient to take drug exactly as prescribed and with
meals.
Tell patient to alert prescriber if shortness of breath occurs.
Instruct patient not to stop drug suddenly but to notify
prescriber about unpleasant adverse reactions. Inform him that
drug must be withdrawn gradually over 1 or 2 weeks.
ACTION
Replaces potassium and maintains potassium level.
ADVERSE REACTIONS
CNS:
paresthesia
of
limbs,
listlessness,
confusion,
NURSING CONSIDERATIONS
Monitor ECG and electrolyte levels during therapy.
Monitor renal function.
PATIENT TEACHING
Teach patient signs and symptoms of hyperkalemia, and
tell patient to notify prescriber if they occur.
13. Lactulose 15 cc HS
Therapeutic class: Laxative
INDICATIONS
Constipation
ACTION
ADVERSE REACTIONS
GI:
abdominal cramps,
belching,
diarrhea,
flatulence,
NURSING CONSIDERATIONS.
INDICATIONS
Lower respiratory tract infections, community-acquired
pneumonia
ACTION
Prevents bacterial cell-wall synthesis during replication.
increases amoxicillins effectiveness by inactivating betalactamases, which destroy amoxicillin.
ADVERSE REACTIONS
CNS: agitation, anxiety, behavioral changes, confusion,
dizziness, insomnia.
GI:
nausea,
stomatitis,
vomiting,
glossitis,
diarrhea,
black
hairy
indigestion,
tongue,
gastritis,
enterocolitis,
angioedema,
overgrowth
of
nonsusceptible
NURSING CONSIDERATIONS
Alert: Both 250- and 500-mg film-coated tablets contain the
same amount of clavulanic acid (125 mg). Therefore, two
250-mg tablets arent equivalent to one 500-mg tablet.
Regular tablets arent equivalent to Augmentin XR.
PATIENT TEACHING
Tell patient to take entire quantity of drug exactly as
prescribed, even after feeling better.
Instruct patient to take drug with food to prevent GI upset. If
hes taking the oral suspension, tell him to keep drug
refrigerated, to shake it well before taking it, and to discard
remaining drug after 10 days.
Tell patient to call prescriber if a rash occurs because rash
is a sign of an allergic reaction.
INDICATIONS
Hypertension, left ventricular dysfunction after acute MI
ACTION
- Inhibits ACE, preventing conversion of angiotensin I to
angiotensin II, a potent vasoconstrictor. Less angiotensin II
decreases
peripheral
arterial
resistance,
decreasing
ADVERSE REACTIONS
CNS: dizziness, fainting, headache, malaise, fatigue, fever.
CV: tachycardia, hypotension, angina pectoris.
GI: abdominal pain, anorexia, constipation, diarrhea, dry
mouth, dysgeusia, nausea, vomiting.
Hematologic:
leukopenia,
agranulocytosis,
REFERENCES
Books
1. Brunner, L. S., Suddarth, D. S., & Smeltzer, S. C. O. (2008). Brunner &
Suddarth's textbook of medical-surgical nursing (11th ed.). Philadelphia:
Lippincott Williams & Wilkins.
2. Davis, F. (2010). Nursing diagnosis manual: planning, individualizing and
documenting
client
care
(3rd
ed.).
Philadelphia
: F. A. Davis Company.
3. Davis, F. (2012). Nursing drug handbook (32nd ed.). China: F. A. Davis
Company.
4. Doenges, M. et al., (2006). Nursing care plans: guidelines for
individualizing client care across the life span (7th ed.). Philadelphia
: F. A. Davis Company.