Complete GCP Cad

1
CHAPTER I
INTRODUCTION
Coronary artery disease is the most common type of heart disease and the leading
cause of death worldwide. It occurs when the arteries that supply blood to the heart becomes
narrowed or blocked by a buildup of plaque- cholesterol or other fatty deposits that build
on the inner wall of the artery. Over time, this plaque build-up results in a reduction of blood
flow to the heart, which can cause chest pain. If the artery becomes completely blocked,
usually by a blood clot, oxygen is prevented from reaching the heart, which can result in a
heart attack and/or damage to the heart tissue. (NewsMedical.Net)
Due to the increasing incidence of CAD across the world, it has been describe as an
epidemic. Globally, from the updated records of World Health Organization (WHO) showed
an estimated 17.7 million people died from Cardiovascular disease (CVD) in 2015,
representing 31% of all global deaths and of these deaths, an estimated 7.4 million were due
to Coronary Heart Disease (CHD), of which approximately 3.8 million men and 3.4 million
women die from CAD each year. Over three quarters these deaths take place in low-and
middle-income countries. (www.who.int/mediacentre/factsheets/fs317/en/).
According to the latest WHO data published in May 2014, about 87,881 or 16.86% of
total death in the Philippines were due to CHD and CAD. The age adjusted death rate is
161.43 per 100,000 of population ranks Philippines #29 in the world. According to the
National Statistics Office, it was noted that the most number of deaths was at the age of 80
and over with 85,705 or 17.8%. From these, 59.6% (51,074) were females while the
remaining 40% (34,631) were males. The most number of deaths in the Philippines occurred
in National Capital Region, which accounted for 75,019 or 15.6 percent of all deaths in the
country (http://www.worldlifeexpectancy.com/philippines-coronary-heart-disease).
In Davao Province, heart diseases which include CVD, CAD and CHD ranked second
to cerebrovascular diseases in year 2002. However, 2004, heart diseases slipped to the fifth
rank, with a mortality rate of 29.8% equivalent to 1,206 cases over the 1,811 cases in the past
2
5-year average equivalent to 48.1% (HEALTH RESEARCH PRIORITIES REGION 11 2006-

2010).
CAD is the most common cause of CVD deaths (45% of all CVD deaths) and it is
estimated that this disease will be responsible for a total of 11.1 million deaths globally in
2020.
It is apparent that number of CAD cases increases, globally, nationally and locally.
Decisively coronary artery disease (CAD) develops over time, the symptoms depend on the
stage of illness. Damage may be present without outward signs. Treatments work better early
on, which is why early identification and intervention are so important. Living in the shadow
of potential heart attack or other heart problems can be unnerving-but it can also be
motivating, thus, we have chosen this topic in our research study. With this study, we hope to
afford appropriate information dissemination; CAD is preventable by living a healthy
lifestyle that incorporates good nutrition, weight management and getting plenty of physical
activity, which play a big role in avoiding CAD.
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CHAPTER II
IDENTIFICATION OF THE CASE
A. Personal Information
Patient: Angkol Sex: male
Age: 61 y/o Religion: Catholic
Occupation: Kagawad Civil Status: Married
Address:Blk. 12 lot Piape Boulevard, Brgy. 22-c Davao City
Educational background: College level
Nationality: Filipino
Mothers Name: BaldomeraLacaran - deceased
Fathers Name: CandedoLacaran - deceased
Case #: 2017382576
Date Admitted: June 19,2017
Time Admitted: 1:06am
Chief Complaint: Chest pain and Dyspnea
Admitting Diagnosis: CAD (+) LVH (-) LVD, Sinus Tachycardia with SVT. CCS I
Admitting Dr. Dr. Michelle Angeli G. Sibre
Final Diagnosis: CAD (+) LVH (-) LVD, Sinus Tachycardia with SVT. CCS I
Requesting Dr. Anuar M. Metmug

4
5
B. FAMILY HEALTH HISTORY (GENOGRAM)
Maternal Paternal
65 73 76 84
60 74 79 82 69
50
57 65 63 61 59 56
LEGEND:
= Deceased = Male & Female = Patient = Alcoholic = Smoker
= Hypertension = Heart Failure = Diabetic = Liver Problem

6
Angkols parents came from a family who are very exposed to vices such as alcohol and
cigarette smoking. His uncle from paternal side died from heart failure. Both parents have a
hereditary disease of hypertension and diabetes mellitus on his maternal side. Angkols eldest
brother died of liver disease. The second and third siblings are both smoker and hypertensive.
Angkol is also a smoker and alcoholic. His younger and youngest sister are both with diabetis
mellitus.
C. Medical History
In 1990, the patient had a minor operation due to a cyst at his foot at San Pedro Hospital
in Bohol. Few years after, in 1995 he was admitted at the same hospital due to stress, but he
could not recall how many days he was admitted and what medication he had taken.
In 2002, he had a medical check-up due to a lump on his testicle, According to the examining
physician, it was due to a bacteria and was prescribed with a medicine, which he could not
tell what was it.
He also suffers severe abdominal pain that radiates to his back and got admitted in 2005.
It was then he was discovered to have a gall bladder stone and was operated.
He was diagnosed with PTB in 2010 and underwent to DOTS with 6 months medication.
He could no longer recall the name of medicines he had taken then.
After 7 years he already resides in Davao City; he experienced shortness of breath and
had a check-up at Sure-health clinic in Davao City. He was discovered to have a high level of
uric acid. A medication was prescribed for him to be taken for 1 month. Again, he could not
tell the name of the medicine. After medication, however, he still had shortness of breathing.
After 15 days, he went to a clinic in Cabaguio and according to the heart specialist who
assesed him stated that his condition was not due to high level of uric acid but rather
something's wrongs in his heart, he was then advised to be admitted in SPMC.
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D. History of Present Illness JEA

On June 18, 2017, he went to a clinic in Cabaguio and according to the heart specialist
who assessed him,there is something's wrong in his heart, he was then advised to be admitted
in a hospital. Later that night he experienced chest pain and dyspnea, thus he was admitted to
SPMC. How was the illness started? Symptoms?
Current illness????
E. Socio-Economic Background
Patient Angkol is a barangay kagawad with a salary of 12,000 pesos per month. He had
an internet business that earns more or less 5,000 pesos in a month. He is also a distributor of
soft drinks with more or less 10,000 pesos monthly income. And from May to June he would
make a bag with 2,000 gross earnings per day. He also has paid employee for his businesses.
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CHAPTER III
ANATOMY AND PHYSIOLOGY
Cardiovascular System
Heart
The heart is a muscular organ weighing between 250-350 grams located obliquely in the
mediastinum. It functions as a pump supplying blood to the body and accepting it in return for
transmission to the pulmonary circuit for gas exchange.
The heart contains 4 chambers that essentially make up 2 sides of 2 chamber (atrium and
ventricle) circuits; the left side chambers supply the systemic circulation, and the right side
chambers supply the pulmonary circulation. The chambers of each side are separated by an
atrioventricular valve (A-V valve). The left-sided chambers are separated by the mitral
(bicuspid) valve, and right-sided chambers are divided by the tricuspid valve. Blood flows
through the heart in only one direction enforced by a valvular system that regulates opening and
closure of valves based on pressure gradients.
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Unique properties of cardiac muscle
Cardiac muscle cells are branching striated, uninucleate (single nucleus) cells that contain
myofibrils.
Adjacent cardiac cells are connected by intercalated discs containing desmosomes and
gap junctions. The myocardium behaves as a functional syncytium because of electrical coupling
action provided by gap junctions.
Cardiac muscle has abundant mitochondria that depend on aerobic respiration primarily
to generate adenosine tri-phosphate (ATP), the molecule that provides energy for cellular
function.
Systemic Circulation
The systemic circuit originates in the left side of the heart and functions by receiving oxygen-
laden blood into the left atrium from the lungs and flows one way down into the left ventricle via
the mitral valve. From the left ventricle, oxygen rich blood is pumped to all organs of the human
body through the aortic semilunar valve
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Pulmonary Circulation
The pulmonary circuit is on the right side of the heart and serves the function of gas
exchange. Oxygen-poor systemic blood reaches the right atrium via 3 major venous structures:
the superior vena cava, inferior vena cava, and coronary sinus. This blood is pumped down to the
right ventricle via the tricuspid valve and eventually through the pulmonic valve, leading to the
pulmonary trunk that takes the oxygen deprived blood to the lungs for gas exchange. Once gas
exchange occurs in the lung tissue, the oxygen-laden blood is carried to the left atrium via the
pulmonary veins, hence completing the pulmonary circuit (see the image above).
Coronary Circulation
Coronary circulation is the circulation to the heart organ itself. The right and left
coronary arteries branch from the ascending aorta and, through their branches (anterior and
posterior interventricular, marginal and circumflex arteries), supply the heart muscle
(myocardial) tissue. Venous blood collected by the cardiac veins (great, middle, small, and
anterior) flows into the coronary sinus. Delivery of oxygen-rich blood to the myocardial tissue
occurs during the heart relaxation phase.
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Vessel Anatomy
An artery is a blood vessel that carries blood away from the heart to peripheral organs.
They are subdivided into larger conducting arteries, smaller distributing arteries, and the smallest
arteries, known as arterioles, that supply the capillary bed (the site of active tissue cells gas
exchange).
Capillaries are vessels that are microscopic in size and provide a site of gas, ion, nutrient,
and cellular exchange between blood and interstitial fluid. They have fenestrations that allow for
and enhance permeability for exchange of gas, ion, nutrient, and cellular elements.
12
A vein is a blood vessel that has a larger lumen, and sometimes veins serve as blood
reservoirs or capacitance vessels, containing valves that prevent backflow. This system of vessels
in general returns blood to the heart from the periphery
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CHAPTER IV
ETIOLOGY AND SYMPTOMATOLOGY
ETIOLOGY
Predisposing Factors
PRESENT ABSENT JUSTIFICATION

Patient Angkols uncle died
1. Family History
because of cardiovascular
disease.
A family history of heart disease

is associated with a higher risk of
CAD, especially if a close
relative or first degree relative
developed heart diseases at an
early age.
Mayoclinic.org
2. Age
Patient Angkol is 61 years old.
Getting older increases the risk of

damaged and narrowed arteries.
More than 45 yrs. for men &
more than 55 yrs. for women.
RNpedia.com
3. Gender
Patient Angkol is a male.
Men are generally at greater risk

of CAD than in women. Estrogen
provides women some protection
against CHD. However, the risk
for women increases after
menopause.
Mayoclinic.org
4. Race
Patient Angkol is Asian
Higher incidence in Africans

Americans than in Caucasian.
RNpedia.com
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Precipitating Factors
PRESENT ABSENT JUSTIFICATION

1. Cigarette
smoking
Patient Angkol was a smoker.
2. alcoholic
Smoking increases the risk of
developing CAD. Smoking
damages the lining of the arteries
leading to a build-up of fatty
material (atheroma) which
narrows the artery.
BritishHeartFoundation.org
3. Elevated high
blood
According to patient Angkol, his
cholesterol level is high prior to
cholesterol
admission.
(hyperlipidemia
)
High cholesterol levels can lead
to clogged arteries. LDL can
damage arteries that carry blood
from heart to the rest of the body.
Then once the damage has
started, LDL keeps on
penetrating and building up in the
artery walls.
WebMD.com
4. Hyperglycemia
(Diabetes
Patient did not have DM.
Mellitus)
High blood glucose causes
hardening of the arteries, which
can lead to heart attack.
www.niddk.nih.gov
15
5. Obesity
Patient Angkol is not overweight
nor obese.
Being overweight or obese are

linked to other risk factors such
as high blood pressure and
diabetes.
www.nhlbi.nih.gov
6. Physical
inactivity
Patient admitted that he lack of
regular exercise.
Lack of physical activity can

indirectly increase the risk of
CAD, because it also increases
the risk for diabetes and high
blood pressure.
WebMD.com
7. Use of oral
contraceptives
Patient Angkol is male.
Oral contraceptives may increase

the risk of high blood pressure
and blood clots in some women.
This is compounded if a woman
smokes or has additional existing
risk factors.
Dr. Kelly Anne Spratt, DO
Cardiology
Patient Angkoldidnt have any
8. Infection
possibly

infection.
associated
Literature has reported several

16
infectious agents that can be

associated with risk of CAD. This
association for some of them like
Helicobacter pylori, chlamydia
pneumonia, C. pneumonia and
cytomegalovirus.
www.niddk.nih.gov
Patient Angkol said that hes very
9. Behavior
patterns (stress,

stressed because of his work.
aggressiveness,
hostility)
Studies suggest that the high
levels of cortisol from long term
stress can increase blood
cholesterol, triglycerides, and
blood pressure. Stress can also
cause changes that promote the
buildup of plaque deposits in the
arteries.
www.urmc.rochester.edu
10. Environment
Patient Angkol is currently living
in Davao City.
Higher incidence in industrialize

regions. Inhalation exposure to
particulate air pollutants
decreases heart rate variability,
causes ST-segment depression
and endothelial dysfunction,
increases blood pressure and
blood coagulability, and
accelerates the progression of
17
atherosclerosis.
simkhovi@usc.edu
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SYMPTOMATOLOGY
SYMPTOMS PRESENT ABSENT JUSTIFICATION

1. General
If arteries are narrowed, blood
Weakness circulation gets hampered and the
muscles will not get enough oxygen to
perform various functions. This causes
muscle fatigue and general body
weakness.
MedicineNet.com
2. Fatigue
The person may feel fatigued all the time
if blood circulation is hampered.
MedicineNet.com
3. Shortness of
Shortness of breath can be caused by
breath reduced blood flow because of narrowed
arteries. When the lungs do not get an
adequate supply of blood, they will not
able to function efficiently. Shortness of
breath may occur before or during the
chest pain of a heart attack, and in some
cases, it may be without any chest pain.
MedicineNet.com
4. Heart
Palpitations are sometimes caused by a
palpitation problem with the heart rhythm, such as
atrial fibrillation.
MedicineNet.com
5. Cold Sweats
The brain needs a healthy supply of
and Dizziness oxygen to function efficiently. When
blood supply to brain is reduced because
of poor circulation, people can suffer
from dizziness and cold sweats.
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MedicineNet.com
6. Heartburn or
Some people experiencing a heart attack
indigestion can have belching and burping and
describe a feeling of indigestion.
Likewise, the pain and pressure of heart
attack may occur in epigastric or upper
middle abdominal area, similar to the
pain of heartburn.
MedicineNet.com
7. Nausea and
Nausea or feeling sick in the stomach is
vomiting a less common but possible symptom of
heart attack. Sometimes belching or
burping can accompany nausea. If it
became so severe, vomiting occurs.
MedicineNet.com
8. Chest Pain
Chest pain occurs when the heart muscle
(Angina) doesnt get enough oxygen-rich blood. In
men, they often report a crushing or
stabbing pain in their chest, while in
women, many say they felt pressure,
tightness or aching in their chest or back.
MedicineNet.com
9. Radiating Pain
As the pain and pressure aggravate, they
may spread to the arm/s, shoulder, neck,
jaw or radiating across the back.
MedicineNet.com
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CHAPTER V
PATHOPHYSILOGY
PREDISPOSING FACTORS PRECIPITATING FACTORS

Age Smoking
Gender Lack of Excises
Family History Stress
Diet
Hypertension
Alcohol consumption
Non-specific injury to arterial wall

(Endothelial Injury)
Desquamation of endothelial lining
Increased Permeability or Adhesion of

Molecules
Lipids (LDL) and Platelets Assimilate in

the Area
Oxidized LDL attracts monocytes and

macrophages to the site
Plaques begin to form from cells which

imbibed into the endothelium
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Lipids are engulfed by the cells (foam

cells) and
Smooth Muscle Cells Develop
Disruption of Plaque
Continuous aggregation of
platelets
Thrombus Formation
Rapid increase in size of the thrombus in

the Coronary artery wall
Coronary Atherosclerotic Heart Disease
Reduction of Blood Flow
Decrease Blood supply to the

myocardium
Decrease myocardial oxygen supply
Anaerobic Metabolism Myocardial Hypoxia
Lactic Acid Production Myocardial Cell necrosis

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Chest Pain Increase White Blood Cells
Decreased myocardial Inflammatory response

contractility
Decreased cardiac output Released of endogenous

pyrogens
HYPOTENSION Pyrogens will stimulate the

release of prostaglandins
Prostaglandins will reset the

Hypothalamic thermostat to
high temperature
HYPERTHERMIA
Decreased systemic circulation
Inadequate cerebral perfusion Dizziness; Lost

of consiousness
Dyspnea; Body
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weakness
Sympathetic receptors are Decreased perfusion of oxygenated
stimulated blood to other organs
Increase heart rate/ pumping

action as a compensatory
mechanism
Tachycardia
Decrease arterial pressure
Stimulation of baroreceptors
Peripheral vasoconstriction
Hypertension
Left Ventricular Hypertrophy
Deterioration of hearts ability to

pump
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Moderate Left Ventricular

failure
Right side of the heart

continuously propel blood to the
lungs
Left ventricle is unable to fully

eject the returning blood to
systemic circulation
Pulmonary Congestion
IF TREATED: IF NOT TREATED:

O2 inhalation It will lead to
Meds:
- Pulmonary edema
- Preload reducers
- Lower extremity and abdominal
(Furosemide)
swelling
- Morphine
- Build up in the membranes that
- Afterload reducers
surrounds the lungs (pleural
(Nitroprusside)
effusion)
- Beta- Blockers
- Congestion and swelling of the
- Angiotensin- converting
liver
enzyme inhibitor
- Calcium- channel blockers
- Nitrates
Surgical Management
- CABG or Coronary Artery
Bypass Grafting
25
Good Prognosis Poor Prognosis
DEATH
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CHAPTER VI
MEDICAL MANAGEMENT
IDEAL
Coronary artery disease develops when the major blood vessels that supply your heart
with blood, oxygen and nutrients (coronary arteries) become damaged or diseased. Cholesterol-
containing deposits (plaque) in the arteries and inflammation are usually to blame for coronary
artery disease. Treatment of coronary artery disease is aimed at controlling symptoms and
slowing or stopping the progression of disease. The method of treatment is based on many
factors determined by the symptoms, a physical exam, and diagnostic testing. In many cases, if
the blockage is less than 70 percent and not severely limiting blood flow, medications may be the
first line of treatment.
These various drugs can be used to treat coronary artery disease:
Cholesterol-modifying medications. By decreasing the amount of cholesterol in the

blood, especially low-density lipoprotein (LDL, or the "bad") cholesterol, these drugs
decrease the primary material that deposits on the coronary arteries. Your doctor can
choose from a range of medications, including statins, niacin, fibrates and bile acid
sequestrants.
Aspirin. Your doctor may recommend taking a daily aspirin or other blood thinner.
This can reduce the tendency of your blood to clot, which may help prevent obstruction
of your coronary arteries.If you've had a heart attack, aspirin can help prevent future
attacks. There are some cases where aspirin isn't appropriate, such as if you have a
bleeding disorder or you're already taking another blood thinner, so ask your doctor
before starting to take aspirin.
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Beta blockers. These drugs slow your heart rate and decrease your blood pressure,
which decreases your heart's demand for oxygen. If you've had a heart attack, beta
blockers reduce the risk of future attacks.
Nitroglycerin. Nitroglycerin tablets, sprays and patches can control chest pain by
temporarily dilating your coronary arteries and reducing your heart's demand for blood.
Angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor
blockers (ARBs). These similar drugs decrease blood pressure and may help prevent
progression of coronary artery disease.
Sometimes more aggressive treatment is needed. Here are some options:
Angioplasty and stent placement (percutaneous coronary revascularization). Your

doctor inserts a long, thin tube (catheter) into the narrowed part of your artery. A wire
with a deflated balloon is passed through the catheter to the narrowed area. The balloon
is then inflated, compressing the deposits against your artery walls.
A stent is often left in the artery to help keep the artery open. Some stents slowly
release medication to help keep the artery open.
Coronary artery bypass surgery. A surgeon creates a graft to bypass blocked

coronary arteries using a vessel from another part of your body. This allows blood to
flow around the blocked or narrowed coronary artery. Because this requires open-heart
surgery, it's most often reserved for cases of multiple narrowed coronary arteries.
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Actual/Doctors Order
July 19,2017 Justification/Rationale
@ 2:40AM
Pls. admitpatient under yellow service To ensure client illness will be corrected with
toICU3 close inspection.
Secure consent to care To be consented in all procedures to be done
IVF D5W @ KVO To help in rehydrating and excretory purposes
Diagnostics: To help determine severity of condition and to
2D'Echo, CBC with Plt, CXR, Crea, Na, K, rule out other complications.
SGPT, trop1
Meds
1.Nahvaradine 5g/tab now then BID
Hold: If with heart rate for < 60
2.Esmolol 500mg/kg IV bolus now then To control rapid heartbeats or
20mg/kg PRN for pain then maintain 10ml abnormal heart rhythms.
esmolol 100cc PNSS @ 8CC/unit.
Hook to cardiac Monitor To continuous monitoring of the heart
activity.
Monitor VS q hourly To determine the recovery
I & O q shift To determine Kidney complications

@ 7:15 AM
Give Amino 150mg IVTT to run in 10mins To measure the peripheral blood plasma level
STAT, FT4, BH
Artificial tachycardia Vs. Sinus nodal For gastric lavage.
tachycardia
Diagnostics: PT/APTT, 2 d' echo To create images of heart
Meds
1.Hold esmolol To treat fewer episodes
2.Hold Ivabradia To severedecompensation.
3.Start Amiodarone 300mg N+250cc To treat and prophylaxis
D5W to run 24 hours To help in rehydrating and excretory purposes
Hook to cardiac monitor To continuous observation and monitoring og
the heart activity
@ 6:20 pm Justification/Rationale
=HEMO NOTES=
Diagnostics: 2 d' echo To follow up blood chemistry
To provide excellent images of the heart
Continue to monitor Hook to cardiac monitor
Continue Meds For continuity of care
Watch out for any : such as hypokalemia, To monitor of any complications
dyspnea
29
Refer For collaboration of treatment

@ 9pm Justification/Rationale
Conferred with Dr. Maranian thru Dr.Libre
Start metoprolol tartrate 50mg/ tab now Totreatorprevent heart attack.

then 1 tab q 6 hrs. Hold for HR < 70 bpm

=Rounds of Dr. Maranian=
For ECG Stat To assess heart function.
Trans esophageal echocardiography (TEE) To produce pictures of your heart
2D echo To assessthe structure and function of the heart.
Start enoxapam 0.6cc SQ q2 first done To prevent and treat harmful blood clots.
now
Continue amiodarone drip: To correct life-threatening heart rhythm
D5W 200cc + 600mg amiodazone to run in 24 problems
hours for/min cycle
Continue metoprolol To treating high blood pressure, heart pain,
abnormal rhythms of the heart, and some
neurologic conditions.
For TEE to look for thrombus To provide a better look at the left atrium, left
atrial appendage, atrial septum, and thoracic
aorta.
Secure consent for elective To protect the patient.

Electrical cardioverias once with TEE(No to guide the management of atrial fibrillation
thrombus
For CCU admission facilitate pls. To facilitated patient care

Refer to anesthesia once of consent for the Can help protect and providers from Liability
procedure.
July 20, 2017

@ 3pm Justification/Rationale
Dr. Aniscal
Dx: 2D echo To assess the structure and function of the heart.
Continue present medication For continuity of care

I & O q shift To determine kidney complications
30
Transfer to ICU For co-management

July 21,2017 Justification/ Rationale
@10:30am
HBG run Can help diagnose diseases involving
abnormal hemoglobin production.
ECG run To assess heart function.
Hold amiodarone temporary while BP To treat and prevent certain types of serious,
<90/60 HR <60 life-threatening ventricular arrhythmias
Please provide droplight To keep patients thermoregulated
Start levophed drip 0.4mg levophed + For severe hypotension, shock or bradycardia.
46cc
Hold metoprolol Controlling irregular heartbeats
(arrhythmias)
July 21, 2017 Justification/Rationale

@10:pm
=Rounds for Dr. Maranian=
Coralan 2.5 mg/tab 1 tab BID start tonight To reduce the risk of hospitalization for
worsening heart failure
Amiodazone 150mg IVTT 1 dose .To treat and prophylaxis
Repeat PT ,APTT To identify the condition present.
K citrate now then 1 tab Q 6x4 dose Management of renal tubular acidosis

Transfer to ICU 3 For co-management
Dx: PT,APTT To monitor the dynamically changing
scenario based on laboratory results and
clinical observations.
31
Confirmed with Dr.Maranian

Hold amiodarone & metoprolol To treat arrhythmias &Controlling irregular
heartbeats (arrhythmias)
@1:50pm
Warfarin 2.5g/tab 1 tab OD To treat and prevent blood clots
Enoxaparin 0.6cc SQ Q12 To prevent and treat harmful blood clots.
Coralan 2.5 mg/tab 1 tab BID To reduce the risk of hospitalization for
K citrate / tab of 6x 4hrs. Management of renal tubular acidosis
Hook to cardiac monitor at all times To continuously observation and monitoring
of the heart activity

=Confirmed with Dr. Maranian=
Hydrate patient cautiously To maintain adequate hydration
Give PNSS 100cc now then Plain Normal Saline Solution. To maintain fluid and
Repeat BP after electrolyte balance. 100cc/hr is the appropriate rate
computed by the physician
@ 4:00pm Justification/Rationale
FD 200cc PNSS now To maintain fluid and electrolyte balance and monitor
Repeat BP after FD BP.
@4:45pm Justification/Rationale
FD another 200cc PNSS now To maintain fluid and electrolyte balance and monitor
repeat BP after FD BP.
CBG now To determine the glucose level in the blood
@ 8:00pm Justification/Rationale
Hydrate another FD 200cc PNSS To prevent hypovolemic shock or hypotension
Discontinue Levophed drip Because of the risk of increasing ischemia and
extending the area of infarction.
@9:00pm
=Conferred with Dr. Maranian=
Shift Metoprolol to amiodilol 6.25mg/tab Enhanced and sustained cardiac adrenergic drive
tab BID may resume now occurs in heart failure.
Hold coralan shift to Digoxin To reduce the risk of hospitalization for
worsening heart failure and to treat heart
failure
32
Start Digoxin 250mg/tab q4x6 doses to To treat heart failure

complete 1500meq the 250meq tab OD
@9:10pm Justification/Rationale
Dx: U/A, Lipid profile To help determine an individual's risk of heart
disease
O2 @ 2-3 via nasal canula as needed To deliver supplemental oxygen or increased
airflow
Digoxin 250meq /tab 1tab q 4hours x 6 To treat heart failure
doses then 250meq per tab OD
Canvedilol 6.25mg /tab to BID To treat high blood pressure and heart failure.
Warfarin 2.5 mg/ tab 1 tab OD To treat and prevent blood clots
Enoxaparin 0.6cc SQ q 12 hours until INR It helps prevent the formation of blood clots.
2
KCL to 1 tab TID To treat or prevent low amounts of potassium in
the blood.
VS q hourly To determine the recovery

@10am
Increase carvedilol to 25mg/tab tab q 12 To treat heart failure and hypertension (high
hours blood pressure).
Give 2 duvules of Calcium now then For the treatment of hypertension and prevention
continue 1 tab TID x6 doses of recurrent episodes of angina

@1:31pm
USD of Whole Abdomen + prostate To produce pictures of a mans prostate gland and
to help diagnose symptoms
ff-up 2 D echo result Albumin, LDH To verify the result
IVF: PNSS 1L @ 40CC/hr. To maintain balance between the fluid and
electrolytes and prevent dehydration.
LSLF/ Warfarin diet To control or decrease blood pressure and / or
fluid retention.
Continue present management For continuity of care
WOF: dyspnea, chest pain To monitor of any complications
Plan: rate control To prevent tachycardia
33
Refer accordingly To create collaborative treatment

@ 11am
Dr. Maranian
Increase carvedilol to 25mg/tab 1 tab q 12 hrs. To treat high blood pressure and heart failure.

@ 1:15pm
Dx: ff-up 2 D echo result To verify the result

@ 11 AM
Dx: APTT, PT INR, CBC, S, Na, Mg, Cal. To monitor the laboratory findings
IVF: D5W@ KVO rate To help in rehydrating and excretory purposes
LSLF To control or decrease blood pressure and / or
fluid retention.
ROM:
1. Warfarin 25mg tab 1 tab To treat and prevent blood clots
2. Carvedilol 25mg tab 1 tab To treat high blood pressure and heart failure.
3. Enoxaparin 0.6 cc SQ q12hr.
It helps prevent the formation of blood clots.
4. Digoxin 200 mg tab 1 tab OD To treat heart failure
5. Albumin 20% 50cc IV To maintain cardiovascular function
ff-up 2 D echo result To verify the result
VS q hourly To monitor progress
WOF: Hypotension To reduce risk of stroke patients with
hypertension.
@ 10:10PM Justification/Rationale
Dr. METMUG
Give digoxin 200mg IVTT now To treat heart failure

34
@ 6:00 AM
Dr. METMUG
Increase warfarin 2.5mg 1 tab-1 tab at HS To treat and prevent blood clots
(Alternate cycle)
Rpt. PT. INR on 7/30/17 To identify the condition present.
WOF: Hypotension To reduce risk of stroke patients
withhypertension.
Dx: 12 LECG To help determine severity of condition

@ 10:20AM
Dr. Maranian
Pls. Give last dose of coralan To reduce the risk of hospitalization for
@ 8 PM
Dr. Gatmaitan
Hold Digoxin To treat heart failure
Continue verapamil 80mg/tab TID treatment of venous thrombosis
EPS on secure
@ 5AM
Plan: Rpt. 2D echo after 1 week To follow up blood chemistry

@ 8 AM
Dx: Rpt. PT INR tomorrow @ 5am To identify the condition present.

Continue Enoxaparin 0.6cc q 12 hrs. It helps prevent the formation of blood clots.
WOF: Hypotension To reduce risk of stroke patients
with hypertension.
35

@ 11:00AM
Dr. Metmug
Endorsed to Dr. Doyugan
IVF: D5W @ KVO rate To help in rehydrating and excretory purposes
LSLF To control or decrease blood pressure and / or
fluid retention.
ROM:
1. Verapramil 80mg tab 1 tab TID treatment of venous thrombosis
2. Increase Warfarin 5mg tab i-1/2 tab It is used to treat blood clots
3. Enoxaparin 0.6cc SQ Q 12 hrs.
For an anti-inflammatory dose of doxycycline
4. Albumin 20% 50cc IV Treatment of hypovolemia with or without
shock.
After 3 weeks of therapeutic INR (2-3) do repeat To verify and follow up blood chemistry
2D echo.
WOF: Hypotension, chest pain To reduce risk of stroke patients
withhypertension.
@ 9:20PM
Dr. Anteros
Dx: 12L ECG To help determine severity of condition and to
Repeat PT with INR on Tuesday AM rule out other complications.
IVF: D5water 500cc to run at 10cc/hr. To render proper medical management
DAT Indicates that the gastrointestinal tract is tolerating
food.
May ambulate/ sit on bed To maintains muscle tone, muscle strength, and
joint flexibility
Avoid valsalva moreover To help men avoid premature ejaculation.
VS q 4 To monitor progress
WOF: Hypotension Toreduce risk of stroke patientswithhypertension.
36
CHAPTER VII
LABORATORY FINDINGS
HEMATOLOGY
Time Analyzed: 07/19/17 @ 1:39am Requesting Physician: Dr. Rosalyn Mauro
Test Result Justification
BType (ABO+Rh) The patient have type AB blood and Rh
positive
BT A The patient belongs to A Blood group
Blood Type Rh Positive It means that a protein (D antigen) is found on

the surface of your red blood cells.
Test Result Units Status Reference Range Justification
Blood Urine 3.73 mg/dL Normal 2.5-7.1 Within Normal range
Nitrogen
37
Calcium 2.27 mg/dL Low 8.5-10.2 If blood test

results indicate hypocalcemia,
we may notice muscle cramps
in legs or arms.
Creatinine 96.6 mL/min Normal 88-128 Within Normal range
Potassium 3.8 mEq/L Normal 3.5-5.0 Within Normal range
Clinical CHON
CK-MB 2.4 IU/L Low 5-25 Elevated levels of

creatinine have been
(Creatinine Kinase regarded as
biochemical
MB) markers of myocyte
necrosis.
Serology and Immunology

38
Troponin I 0.03 ng/mL High <0.01 The more damage

there is to the heart,
the greater the
amount
of troponin T
and I there will be
in the blood.
SGOT 35.5 U/L Normal 5-40 Within Normal range
SGPT 43.7 U/L Normal 7-46 Within Normal range
Time Analyzed: 07/20/17 @ 10:52am Requesting Physician: Dr. Mark Ramon Victor Llanes
HEMATOLOGY
Test Result Status Differential Range Justification

APTT 3.2 seconds High 1.5-2.5 Prolonged APTT
(Partial Thromboplastin mayVitamin K
Time) deficiency,
APTT Control 32.6 seconds Normal 30-40 seconds liver disease, DIC,
massive blood
transfusion leading to a
delusional coagulopathy,
39
patients receiving
thrombolytic therapy,
and multiple clotting
factor deficiencies.
Shortened APTT may

indicate increased risk of
thromboembolic events,
cancer, myocardial
infarction, thyroid
disorders, diabetes, and
pregnancy.
Prothrombin Time
PT Time 14.6 seconds High 11-14 seconds A prolonged PT means
that the blood is taking
too long to form a clot.
PT Inr 1.17 Normal 0.81.2 High PT INR indicates
(International Normalized blood is clotting too
Ratio) slow and could be at risk
for bleeding and also
indicate low levels of
Vitamin K
Low PT INR indicates

blood is clotting too fast
and need increased dose
of medication.
PT Activity 77.0 Normal 70-80 Prolonged PT
PT Control 14.2 seconds Normal 11-13.5 seconds mayVitamin K
deficiency,
liver disease, DIC,
massive blood
transfusion leading to a
40
delusional coagulopathy,
patients receiving
thrombolytic therapy,
and multiple clotting
factor deficiencies.
Shortened PT may
indicate increased risk of
thromboembolic events,
cancer, myocardial
infarction, thyroid
disorders, diabetes, and
pregnancy.
ABG Result
Time Analyzed: 7/21/17 @ 4:46pm
Measured Test Results Units Status Reference Range Justification

Measured Test
pH 7.41 Normal 7.35-7.45 Within normal range
PcO2 29 mmHg Low 35-45 Indicates hypocapnea
(Partial carbon dioxide)
PO2 150 mmHg High 80-100 Indicates hyperoxia
(Partial Oxygen)
Calculated Test
BE (B) -5.1 mmol/L Low -2-+2 Negative base excess
(Base Excess) means reduced base,
(metabolic acidosis)
HCO3 18.4 mmol/L Low 21-27 Indicate that there is a
(Bicarbonate) metabolic condition causing
the blood to be acidic
TCO2 19.3 mmol/L Low 19-24 This is an indication of
41
(Total Carbon Dioxide) bicarbonate level. Low

Bicarbonate level means low
TCO2.
SO2c 99 % Normal 95-100 Within Normal range
(Sulfur Dioxide)
Epithelial Cell 2 hpf Normal 2-5 Within Normal

range
Cast 0 % Normal 0-5 Within Normal
range
Bacteria 1.000 % % % %
Urine Exam
Physical
Examination
Appearance Clear % % Clear Normal
Color Light Yellow % % Yellow (light/pale Normal

to dark/deep amber)
Urine Chemistry
42
Protein Negative % % % %
pH 5.5 % Normal 4.5-8 Within Normal

range
Specific Gravity 1.011 % Normal 1.000 - 1.030 Within Normal
range
Glucose Negative % % % %
Micro Albumin Negative % % % %
Urine Bilirubin 1+ mg/dL Normal 0.5-1 Within Normal

range
Nitrate Negative % Normal Negative Within Normal
range
Leukocyte Esterase Negative WBC % Normal Negative Within Normal
range
Urine Ketone Negative % Normal Negative Within Normal
range
RBC 4 % Normal 2-4 Within Normal
range
WBC 5.0 % Normal 2-5 Within Normal
range
Glucose FBS 5.25 mmol/L Normal 5.6 to 6.9 Within Normal

range
43
SPECIAL LABORATORY
Time Analyzed: 07/22/17 @ 04:50pm Requesting Physician: Dr. Rosalyn Mauro
Serum Magnesium 1.01 mmol/L Normal 0.74-1.03 Within Normal range
Sodium 136.6 mmol/L Normal 136.00-144.00 Within Normal range
Serum Uric Acid 0.39 mg/dL Low 3.47.2
CBC & Platelet
Hemoglobin 139.0 g/dl Normal 135.0-175.0 High hemoglobin level

is most often caused by
low oxygen levels in
the blood, common
reasons include: certain
birth defects of the
heart that are present at
birth (CHD), failure of
the right side of the
heart, and scarring or
thickening of the lungs.
Low hemoglobin level

may be due to: anemia
caused by red blood
44
cells dying earlier than

normal and/or low level
of iron, folate, vitamin
B12, or vitamin B6.
Albumin 28.89 g/L Low 35-55 Hypoalbuminemia can

be caused by various
conditions, including
nephrotic syndrome,
hepatic cirrhosis, heart
failure, and
malnutrition
LDH 149.4 U/L Normal 140-280 Within Normal range
(Lactic Acid
Dehydrogenase )
45
Serology and Immunology
HBsag Quantitative Result Justification
0.360 Non-Reactive No hepatitis B surface antigen was found
HEMATOLOGY
Time Analyzed: 07/24/17 @ 1:46Pm
CBC and Platelet
Hemoglobin 148.0 g/dl Normal 135.0-175.0 High hemoglobin

level is most often
caused by low
oxygen levels in the
blood, common
reasons include:
certain birth defects
of the heart that are
46
present at birth
(CHD), failure of
the right side of the
heart, and scarring
or thickening of the
lungs.
Low hemoglobin
level may be due to:
anemia caused by
red blood cells
dying earlier than
normal and/or low
level of
iron, folate, vitamin
B12, or vitamin B6.
Hematocrit 0.44 g/dl Normal 0.40-0.52 High hematocrit is
most often
associated with
severe burns,
diarrhea, shock,
Addison's disease,
and dehydration.
Low hematocrit has

its common
conditions
including chronic
and recent acute
blood loss, kidney
diseases,
malnutrition,
47
vitamin B 12 and
folic acid
deficiencies, iron
deficiency,
pregnancy.
RBC Count 0.57 X106/uL Low 4.42-6.10 High RBC may

indicate
erythrocytosis,
CHD, dehydration,
pulmonary fibrosis,
and polycythemia
vera.
Low RBC may

indicate
Anemia, bone
marrow failure,
erythropoietin
deficiency, internal
or external
bleeding, leukemia,
nutritional
deficiencies,
including
deficiencies in iron,
copper, folate, and
vitamins B-6 and
B-12.
WBC Count 11.69 X103/uL High 5.0-10.0 High indicates a
viral or bacterial
infection such as
48
leukemia, Graves'
or Crohn's disease,
and chronic
bronchitis or
emphysema.
Low WBCcauses
AIDS, Aplastic
anemia,
Chemotherapy, and
vitamin deficiency.
Differential Count
Neutrophil 74 % Normal 55.00-75.00 High neutrophil

causes burn
injuries, heart
attack, kidney
failure, eclampsia
and cancer.
Low neutrophil
caused by
leukemia, aplastic
anemia, SLE, and
too little vitamin
B12 or folic acid in
the body.
Lymphocytes 14 % Low 20-75 High lymphocytes
may due to
lymphoma, chronic
bacterial infection,
hepatitis, multiple
myeloma, and
49
lymphocytic
leukemia.
Low lymphocytes
indicate AIDS,
lymphocytopenia,
systemic lupus
erythematosus
(lupus), rheumatoid
arthritis.
Monocytes 10 % Normal 2-10 High monocytes
may
indicatechronic
infections, in
autoimmune
disorders, in blood
disorders, and in
certain cancers.
Low monocytes
may
indicatebloodstream
infection,
chemotherapy, or a
bone marrow
disorder.
Basophil 1.000 % Normal 1-5 High may indicate
hypothyroidis,
hemolytic anemia,
paracytic infection,
viral infection,
allergic reaction
and polycythemia
50
vera.
Low basophil may

indicate severe
allergy,
hyperthyroidism,
stressed and taking
corticosteroids.
Eosinophil 1.000 % Normal 1-8 High eosinophil

may
indicateeosinophilia
allergic reaction
skin inflammation,
such as eczema or
dermatitis
andleukemia.
Low eosonophil is
one or an
occasional low
number is usually
not medically
significant.
Platelet Count 218 % Normal 150-400 High may indicate
thrombocythemia,
acute bleeding and
blood loss, allergic
reactions, cancer,
chronic kidney
failure, heart attack,
and iron deficiency.
51
Low may indicate

thrombocytopenia,
splenomegaly,
leukemia,
hemorrhage and
bleeding.
MCV 87.0 fl Normal 79.00-92.20 High MCV may
indicate liver
(Mean corpuscular disease,
volume) hypothyroidism,
reticulocytosis, too
little vitamin B12
and folic acid.
Low MCV may

indicate kidney
failure and anemia.s
MCH 29.2 pg Normal 25.70-42.00 High MCH levels
can indicate
(Mean corpuscular macrocytic anemia,
hemoglobin) which can be
caused by
insufficient vitamin
B12, insufficient
folic acid and can
be another cause of
macrocytic anemia.
Low MCH level

can be caused of
blood loss over
time, too little iron
in the body, or
52
microcytic anemia.
MCBC 33.6 g/dL Low 35.30-36.50 High MCHC level
can also be caused
(mean corpuscular by having too little
hemoglobin vitamin B12 or
concentration) folic acid in the
body.
Low MCHC can be

too low because of
blood loss over
time, too little iron
in the body, or
hypochromic
anemia.
Hematocrit 0.42 g/dl Normal 0.40-0.52 High hematocrit is

most often associated
with severe burns,
diarrhea, shock,
Addison's disease, and
dehydration.
Low hematocrit has its

common conditions
including chronic and
recent acute blood loss,
kidney diseases,
malnutrition, vitamin
53
B 12 and folic acid

deficiencies, iron
deficiency, pregnancy.
RBC Count 4.77 X106/uL Low 4.42-6.10 If the number

of RBCs is lower than
normal, it may be caused
by: anemia. bone marrow
failure. erythropoietin
deficiency
WBC Count 4.77 X103/uL Low 5.0-10.0 A low
WBC count indicate that
there is a disease or
condition affecting white
blood cells
Differential Count
Neutrophil 66 % Normal 55.00-75.00 High neutrophil causes

burn injuries, heart
attack, kidney failure,
eclampsia and cancer.
Low neutrophil caused

by leukemia, aplastic
anemia, SLE, and too
little vitamin B12 or
folic acid in the body.
Lymphocytes 24 % Normal 20-75 High lymphocytes may
due to lymphoma,
chronic bacterial
infection, hepatitis,
multiple myeloma, and
lymphocytic leukemia.
54
Low lymphocytes
indicate AIDS,
lymphocytopenia,
systemic lupus
erythematosus (lupus),
rheumatoid arthritis.
Monocytes 6.0 % Normal 2-10 High monocytes may
indicatechronic
infections, in
autoimmune disorders,
in blood disorders, and
in certain cancers.
Low monocytes may

indicatebloodstream
infection,
chemotherapy, or a
bone marrow disorder.
Eosinophil 3 % Normal 1-8 High eosinophil may
indicateeosinophilia
allergic reaction skin
inflammation, such as
eczema or dermatitis
andleukemia.
Low eosonophil is one

or an occasional low
number is usually not
medically significant.
Basophil 1.000 % Normal 1-8 High may indicate
hypothyroidis,
hemolytic anemia,
55
paracytic infection,
viral infection, allergic
reaction and
polycythemia vera.
Low basophil may

indicate severe allergy,
hyperthyroidism,
stressed and taking
corticosteroids.
Platelet Count 248 % Normal 150-400 High platelet countmay
indicate
thrombocythemia,
acute bleeding and
blood loss, allergic
reactions, cancer,
chronic kidney failure,
heart attack, and iron
deficiency.
Low platelet countmay

indicate
thrombocytopenia,
splenomegaly,
leukemia, hemorrhage
and bleeding.
MCV 88.30 fl Normal 79.00-92.20 High MCV may
indicate liver disease,
hypothyroidism,
reticulocytosis, too
little vitamin B12 and
folic acid.
56
Low MCV may

indicate kidney failure
and anemia.
MCH 29.1 Pg Normal 25.70-42.00 High MCH levels can
indicate macrocytic
anemia, which can be
caused by insufficient
vitamin B12,
insufficient folic acid
and can be another
cause of macrocytic
anemia.
Low MCH level can be

caused of blood loss
over time, too little iron
in the body, or
microcytic anemia.
MCHC 33.0 g/dL Low 35.30-36.50 High MCHC level can
also be caused by
having too little
vitamin B12 or folic
acid in the body.
Low MCHC can be too

low because of blood
loss over time, too little
iron in the body, or
hypochromic anemia.
57
CLINICAL
CHEMISTRY
Calcium 2.21 mmol/L Normal 1.75-2.39 Within the normal
range
Potassium 4.63 Mmol/L Normal 3.6-5.1 Within the normal
range
Serum Magnesium 0.75 mmol/L Normal 0.74-1.03 Within Normal range
Sodium 133.40 mmol/L Low 136.00-144.00 Low sodium

indicates a person
lost much water and
electrolytes
CLINICAL
CHEMISTRY
58
Lipid Profile
Cholesterol -3.95 mmol/L Normal -3.5-1 Within Normal range
Triglycerides 0.38 mmol/L Low 1.5-1.7 Indicates inability to

absorb fats or
hyperthyroidism
HDL-C 0.93 mmol/L Low 1.0-1.3 Low HDL levels are
linked to an increased risk
(High Density for
developing cardiovascular
Lipoprotein disease.
Cholesterol)
LDL 3.85 mmol/L High 2.59-3.34 High level of LDL can

lead to serious health
(Low Density problems such as clogged
arteries, heart disease, and
Lipoprotein) stroke.
VLDL 0.17 mmol/L Normal 0.02 -3.0 Within Normal range
(Very Low Density
Lipoprotein)
Glucose FBS 5.25 mmol/L Normal 5.6 to 6.9 Within Normal range
59
Requesting Doctor: Rozalyn Mauro

Clinical Indication/Impression: Cardiac Arrythmia
Date and Time of Examination: 07/19/2017 @ 7:56am
Exam Taken: CPA
Department: Emergency Medicine
Area: ER
ROENTGENOLOGICAL REPORT
NOTE: THIS RESULT IS BASED ON RADIOGRAPHIC FINDINGS
AND MUST BE CORRELATED ACCORDINGLY.
OFFICIAL READING
Chest PA (ADULT)
FINDINGS:
THE STUDY WAS TAKEN IN AP PROJECTION WITH OBLIQUITY TO THE RIGHT.

HAZY DENSITIES ARE SEEN IN BOTH LUNGS, BOTH IN PARAHILAR AREAS.
LINEAR DENSITIES ARE SEEN IN BOTH LUNGS RADIATING FROM THE HILUM AND IN THEIR PERIPHERY.
THE PULMONARY VASCULAR MARKINGS ARE PROMINENT. MINOE FISSURES IS THICKENED.
TRACHEAL AIR COLUMN IS AT THE MIDLINE.
THE HEART IS MAGNIFIED BUT APPEARS ENLARGED WITH INFEROLATERAL.
DISPLACEMENT OF THE CARDIAC APEX.
BOTH HEMIDIAPHRAMGS ARE INTACT. THE COSTOPHRENIC SULCI ARE BLUNTED.
SPURS ARE SEEN ALONG THE MARGINS OF THE THORACIC SPINE.
THE REST OF THE INCLUDED STRUCTURES ARE UNREMARKABLE.
IMPRESSIONS:
SUGGESTIVE LV CARDIOMEGALY WITH PULMONARY INTERSTITIAL EDEMA.
BILATERAL MINIMAL PLEUAL EFFUSION
THORACIC SPONDYLOSIS DEFORMANS
60
Requesting Doctor: Anwar M. Metmug

Clinical Indication/Impression: CAD (+)LVH (-)LVD, Sinus Tachycardia with SVT, CCSI
Date and Time of Examination: 07/25/2017 @ 01:22pm
Exam Taken: WHABD (P)
Department: IM
Area: ICU3 Central (Service Ward)
ULTRASOUND REPORT
Official Reading
WHOLE ABDOMEN: PROSTATE
FINDINGS:
The liver is normal in size, exhibiting a homogeneous parenchyma and a regular external outline. There are no dilated intrahepatic
ducts. The Hepatic arteries, portal vein and bile ducts are unremarkable. No focal mass lesions seen.
The gallbladder is normal in size and configuration. The walls are thickened at about 0.6cm with triaminar pattern. At least three well
defined, echogenic foci with no posterior sonic shadowing are seen adherent to the gallbladder wall with the largest measuring about
0.5cm.
There are no abnormal intraluminal masses seen within the common bile duct. Its largest artero-posterior diameter is 0.4cm.
There are no abnormal masses or enlarged lymph nodes in the variety of the abdominal aorta.
The pancreas is normal in size exhibiting a homogeneous parenchymal echopattern and a regular outline. No local mass lesions seen.
The spleen is normal in size with the following dimensions craniocaudal = 9.7cm, anteroposterior = 3.1cm, transverse = 9.2cm, it
exhibits a homogeneous parenchymal echopattern and a regular external outline.No focal mass lesion seen.
Length (cm) Width (cm) Thickness (cm) Parenchymal Thickness (cm)

Right Kidney 11.5 5.3 4.7 1.8
Left Kidney 10.6 5.2 4.5 1.4
61
There is no significant disparity in the size, shape and location of both kidneys. Both exhibit hypoechoic parenchymal echopattern
volume to that of the liver and spleen. The pelvocalyceal systems are well as the ureters are not dilated. The central echocomplexes of
both kidneys are prominent. A well-defined anechoic focus with internal echogenic debris measuring about 1.0 x 1.1 is seen in the
anterior pole of the right kidney.
The urinary bladder is adequately distended showing regular contour and smooth walls. There are no abnormal intraluminal echoes
seen.
The prostate gland measures 3.5 x 3.1 x 2.7 cm (LWT) with an approximate weight of 15 grams. It exhibits a homogeneous
parenchyma with no focal mass lesion noted within. No calcification seen within.
IMPRESSIONS:
GALLBLADDER WALL THICKENING, PROBABLY SECONDARY TO GENERALIZED EDEMATOUS STATE
GALLBLADDER POLYPOSIS
BILATERAL PROMINENT CENTRAL ECHOCOMPLEXES. CONSIDER NEPHROSCLEROSIS VS.
NEPHROLIPOMATOSIS
MILK OF CALCIUM CYST, RIGHT KIDNEY
62
ELECTROCARDIOGRAM REPORT
07/19/17 @ 2:54am Arterial tachycardia

1:00pm Sinus Nodal Tachycardia
07/20/17 - Arterial tachycardia
07/21/17 - @ 1:40am Arterial tachycardia
07/22/17 - @1:27am Arterial tachycardia Intermedial atrial flutter variable AV conduction
63
CHAPTER VIII
NURSING THEORY
Philosophy of Human Caring

By: Jean Watson
The goal of the nurse, according to Watson's theory, is to provide assistance with the
gratification of the patient's needs and protect the physical, mental, spiritual and socio-cultural
well-being of the patients. Applying the theory goes well beyond administering medicine and
performing procedures. Watson's theory in application involves a caring approach with all
nursing responsibilities.
Application of Theory
When applying Jean Watson's nursing theory, nurses must be conscious of the patient as
a whole and complete individual, regardless of disease or illness, to create a caring experience.
During the interview with Patient Angkol, the patient was cooperative but sometimes
become aloof. The nurse promoted interpersonal caring-healing interaction through kind words,
nurturing and caring gestures and non-verbal messages of support. Every time the nurse entered
the patient bed, the nurse always put a smile on her face and asks the patient on how he is doing.
The nurse encouraged and rendered health teachings to promote wellness and fast recovery and
provided him information about his disease.
Self-Care Deficit Theory

By: Dorothea Elizabeth Orem
According to this theory, the nurse is needed when the self-care demands are greater than
the self-care abilities. The over-all purpose of Orem's theory is not just to view the person as a
whole, but to utilize nursing knowledge to restore and maintain the patient's optimal health.
64
The nurses gave their service and care to patient Angkol. The patient was also unable to
take a bath by himself so the nurses washed him on bed with clean towel. They rendered health
teachings such as adding roughage on diet such as fruits and vegetables and to limit intake of
alcohol and processed foods.
The Nature of Nursing Model

By: Virginia Henderson
This theory states that nurses have the unique function to assist the individual, sick or
well, to do things for patients that they normally would do for themselves if they could, that is if
they were physically able or had the required knowledge, and to do this in such a way that
patients would work toward independence so that they can begin to perform the relevant
activities for themselves unaided. The nurse serves to make patient complete, whole, or
independent.
Patient Angkol still lack the strength and knowledge, nurses act as a temporary proxy in
helping them meet their needs that neither the patient nor the family can provide.
A post-operative patient in the hospital primarily needs the nurses assistance in moving
about and assuming various positions in the bed. The nurses assisted him in his basic needs such
as changing his clothes on bed. The nurse aided the patient with the use of her knowledge and
skills. The nurse gradually allowed him to perform various tasks as long as he can tolerate it.
Furthermore, during the whole hospitalization process, the nurse not only assisted Angkol but
also educated him and his family as well. Through that, patient independence will be promoted
as he gains the strength and ability to perform activities of daily living.
65
CHAPTER IX
NURSING ASSESSMENT
Date of Assessment: July 27, 2017
Time: 8:00am
NEUROLOGICAL
The patient is oriented to time, place, and date when asked. He is alert and
answers the question appropriately. Speaks clearly and able to obey instructions. The patient
does not show any signs of neurological problems such as confusion, hallucinations and etc.
EYE/ VISON
The clients eyebrows are distinct and symmetrically aligned. Eyelashes appeared to be
equally distributed and curled slightly outward. The eyes are evenly placed and in line with each
other, none protruding. There were no presence of discharges, no discoloration and lids close
symmetrically with epicanthal fold. The sclera appeared to be white in color. The irises appeared
brown and the lens appears almost spherical. PERRLA (pupils equally round respond to light
accommodation), illuminated and non-illuminated pupils constricts. The patient has the ability to
follow objects to midline. No tears or swelling noted.
EARS/ HEARING
The Auricles are symmetrical and has the same color with his facial skin. The auricles are
aligned with the outer canthus of eye. The pinna recoils when folded with cartilage present. No
swelling, redness or tenderness assessed, tympanic membrane appears pearly and pink in color,
no signs of hearing impairment noted. Without impacted cerumen noted.
NOSE
The nose appeared symmetric, straight and uniform in color. There was no presence of
discharge or flaring. When lightly palpated, there were no tenderness and lesions. Nose is
symmetric and straight, with minimal nasal flaring noted, uniform in color. Mucosa is pink, no
lesions and nasal septum intact and in middle with no tenderness.
66
MOUTH/ TONGUE/ TEETH
The lips of the client are cyanotic in color and dry in texture. The buccal mucosa of the
client appeared as pink in color; moist, soft, glistening and with elastic texture; mucous
membranes are non- inflamed. The tongue of the client is centrally positioned. It is pale in color,
moist and slightly rough. The smooth palates are light pink and smooth while the hard palate has
a more irregular texture. The uvula of the client is positioned in the midline of the soft palate.
There are clear to whitish oral secretions noted. Clients teeth are complete although some are
decayed.
THROAT/ NECK
The neck is positioned at the midline without tenderness and flexes easily. The neck
muscles are equal in size. Neck can move freely. The lymph nodes of the client are not palpable.
The trachea is placed in the midline of the neck and is palpable. No mass palpated on the anterior
neck but there is a round and tender mass palpated on the nape.
RESPIRATORY SYSTEM
Theres a full and symmetric expansion of the lung. The client manifested labored and
arrhythmic breathing pattern. Crackles sound heard on both lung fields upon auscultation. The
patient has manifested an episode of Dyspnea; use of accessory muscles for respiration and
elevated shoulders upon breathing. He was given oxygen inhalation @ 4 Liters per hour via nasal
cannula.
CIRCULATORY/ CARDIOVASCULAR SYSTEM
The patient has a pulse rate of 120 beats per minute which is within normal range
and rhythm is normal as well as the quality of the pulse. No cyanosis noted and has capillary
refill of 3 seconds. No abnormal heart sounds noted upon auscultation. Blood pressure of 122/63.
67
GASTROINTESTINAL
There is round and tender mass palpated on the left upper quadrant of the abdomen. Dull
sound heard upon percussion. Slight distention of abdomen noted. The patient was not able to
defecate for 6 days.
GENITOURINARY
The bladder of the patient is not palpable. With urine output: 25-50cc/ hour. No presence
of hematuria noted.
MUSCOLOSKELETAL
The extremities are symmetrical in size and length. There were no presence of bone
deformities, tenderness and swelling. With normal circumflexion of the shoulders and abduction
and adduction of arms and legs are normal. There is a round and tender mass palpated on the left
upper leg.
INTEGUMENTARY
The patient has a good skin turgor, when skin is pinched it goes to previous state within
1-2 seconds. Patients skin temperature is within normal limit: 36 C. With dry skin noted. No
bleeding and skin lesions observed. There are round and tender mass noticed upon palpation in
the abdominal area, left leg and nape.
ACTIVITIES OF DAILY LIVING
Since the patient was still in the ICU, he is dependent when it comes to eating, bathing
and etc. He still needs to be assisted in his ADLs and turning from side to side.
PRESENT BEHAVIOR
The patient is alert and responsive to questions asked. He is in a good mood and smiles
often. The patient is open to several nursing intervention.
68
SOCIO- ECONOMIC STAUS
The patient is currently a Barangay Kagawad with a salary of 12,000 pesos a month. He
also have internet business and earns 5,000 pesos every month. He is also a distributor of soft
drinks which earns more or less 15,000 pesos a month. And every May to June, he is fond of
making school bags and earns 2,000 pesos per day. He also has paid his employees for his
business.
FAMILY CONCERNS
The familys greatest concern is about the recovery condition of the patient. They are
hopeful that the patient will gain improvement on his condition immediately as they wanted to
bring him home to enjoy life with him. They are also worried about possible nosocomial
infections they may acquire due to prolonged stay in the hospital.
Latest Vital Signs

BP- 122/63
PR-121 bpm
Temp.- 36.8 degrees celcius
O2 Sat- 98
69
CHAPTER X
NURSING MANAGEMENT
A. Nursing Care Plan
DAT CUES NEE NURSING SCIENTIFI GOALS/OBJECTI NURSING RATIONLAE EVALUATION

E/TI DS DIAGNOS C BASIS VE INTERVENTION
ME IS CRITERIA
Subjecti H Ineffective It is After the 2 days of 1.Establish Rapport. 1. To reduced After 2 days of
ve: E tissue a state in wh nursing intervention anxiety and gain nursing
July Malipo A perfusion ich an indivi the patient will cooperation. intervention the
27, nggihapo L related to dual has ade maintain adequate 2. Assess and monitor 2. These are patient was able
2017 nusahay T impaired crease in ox tissue perfusion as vital signs, skin color, general indicators to maintain
@ maamlab H transport of ygen resulti evidence by: sensations, movements of circulatory adequate tissue
8:00a i nag oxygen ng in failure and capillary refill of status and perfusion as
m mubakod secondary to nourish th - B/P within normal the extremities. adequacy of evidenced by:
P
ko, as to CAD e tissues at t range perfusion.
E
verbalize he capillary 3. Encourage quiet and 3. To conserve - B/P within
d by the R level. -Extremities warm restful atmosphere. energy and lower normal range :
patient C with absence of tissue oxygen 123/63
E pallor and cyanosis demands. -Extremities
P 4. Encourage early 4. To enhance warm with
T -Capillary refill time ambulation once venous return. absence of pallor
Objectiv I less than 3 seconds tolerated. and cyanosis
es: O 5. Discourage 5. To improve -Capillary refill
-ABG N -Breathing is within sitting/standing for long and facilitates time less than 3
Unstable - normal range periods. good circulation. seconds
bloodpre H 6. Record BP readings 6.Stable BP is -Breathing is
ssure E -Absence of labored for orthostatic changes needed to keep within normal
variation A breathing (drop of 20 mm Hg sufficient tissue range: 22 cpm
s L systolic BP or 10 mm perfusion. -Absence of
- T Hg diastolic BP with labored
70
Dyspnea H position changes). breathing

-Labored M 7. Monitor higher 7. Indicators of
breathin A functions, as well as location or Goal Met
g noted N speech, if patient is degree of
-Pallor A alert. cerebral
-Pale G circulation or
conjuctiv E perfusion are
a alteration in
M
- cognition and
E
Capillary speech content.
refill of N 8. Use pulse oximetry 8. Pulse oximetry
4 T to monitor oxygen is a useful tool to
seconds saturation and pulse detect changes in
- P rate. oxygenation.
Weaknes A 9. Check Hgb levels 9. Low levels
s noted T reduce the uptake
-Body T of oxygen at the
malaise E alveolar-capillary
noted R membrane and
N oxygen delivery t
o the tissues.
10. Check for pallor, 10. Nonexistence
cyanosis, mottling, cool of peripheral
or clammy skin. Assess pulses must be
quality of every pulse. reported or
managed
immediately.
11. Note urine output. 11. Reduced
intake or
unrelenting
nausea may
consequence in
lowered
circulating
volume, which
negatively affects
71
perfusion and
organ function.
12. Maintain oxygen 12. This enhances
therapy as ordered. myocardial
perfusion.
13. When patient 13.
experiences dizziness Orthostatic hypot
due to ension results in
orthostatic hypotension temporary
when getting up, decreased
educate methods to cerebral
decrease dizziness, perfusion.
such as remaining
seated for several
minutes before
standing, flexing feet
upward several times
while seated, rising
slowly, sitting down
immediately if feeling
dizzy, and trying to
have someone present
when standing.
14. Position patient 14.
properly in a semi- Upright positioni
Fowlers to high- ng promotes
Fowlers as tolerated. improved
alveolar gas
exchange.
15. Provide rest periods 15. Constant
between care activities activity can
and prevent duration of further increase
procedures. ICP by creating a
cumulative
stimulant effect.
16. Promote 16. Exercise
72
active/passive ROM prevents venous

exercises. stasis and further
circulatory
compromise.
17. Monitor peripheral 17. These are
pulses. Check for loss symptoms of
of pulses with bluish, arterial
purple, or black areas obstruction that
and extreme pain. can result in loss
of a limb if not
immediately
reversed.
18. Teach patient to 18. Early

recognize the signs and assessment
symptoms that need to facilitates
be reported to the immediate
nurse. treatment.
19. Encourage patient 19. Green leafy
to eat green leafy vegetable are rich
vegetables. in iron and
vitamins.
20. Administer 20. Medications
medications or and supplements
supplements as ordered. are use for
treatment or use
for minimizing
the occurrence of
further
complications.
73
DATE CUES NEEDS NURSING SCIENTIFIC GOALS NURSING RATIONALE EVALUATION

/ DIAGNOS BASIS OBJECTIVES INTERVENT
TIME IS CRITERIA IONS
07-28- Sub. A Decreased Arrhythmias is Within 8 hours of 1. Note skin 1. Cold, clammy, Goal Partially Met
17 @ NA C cardiac considered as nursing color, and pale skin Within 8 hours of
8:30 T output one of the intervention, the temperatur is secondary to nursing
AM Obj. I related to common patient will be e, and compensatory intervention, the
-ABG V alteration in causes of able to moisture. increase in patient was
-Decrease I heart rate decreased demonstrate sympathetic partially able to
activity T and rhythm cardiac output. adequate cardiac 2. Checked nervous demonstrate
tolerance Y output as for any system adequate cardiac
-Atrial Nurseslabs evidenced by : alterations stimulation output as
fibrillation E By Gil Wayne, in level of and low evidenced by :
-decrease X RN Blood pressure consciousn cardiac output
peripheral E and heart rate and ess. and oxygen Normal blood
pulses R rhythm within desaturation. pressure but
-With 02 @ C normal 3. Assess atrial
3-4 LPM via I parameters patients 2. Decreased fibrillation still
nasal cannula S heart rate cerebral noted
- VS taken as E Strong peripheral and blood perfusion and
follows: pulses pressure hypoxia are Strong
T: 37.0 P reflected in peripheral
PR: 54 A Ability to tolerate 4. Check for irrirability, pulses
RR: 18 T activity peripheral restlessness,
BP: 101/70 T pulses, and difficulty Ability to
02sat: 97 E including concentrating. tolerate
R capillary activity
N refill.
3. Increasing
5. Monitor hear rate and
pulse blood pressure
oximetry may indicate
and report the beginning
O2 of cardiac
saturation failure or other
<92% complication
74
6. Check 4. Weak pulses

symptoms are present in
for chest reduced stroke
pain volume and
cardiac output.
7. Maintain Capillary refill
oxygen is sometimes
therapy slow or absent.
8. Record 5. O2 sat of
intake and <92%
output. indicates the
need of
9. Place supplement
patient in a oxygen in the
semi myocardium.
recumbent
position 6. Low cardiac
output can
10. Administe further
r decrease
medication myocardial
as perfusion,
prescribed resulting in
(verapamil chest pain
)
7. The failing
heart may not
be able to
respond to
increased
oxygen
demands.
8. Reduced
75
cardiac output
results in
reduced
perfusion of
the kidneys,
with a
resulting
decrease in
urine output
9. Antiarrhythmi
c drug is
indicated with
atrial
fibrillation
10. Avoid lying

flat on bed as
this increases
preload
76
DATE/T CUES NEED NURSING SCIENTIFIC GOALS/OBJE NURSING RATIONL EVALUAT

IME S DIAGNOSI BASIS CTIVE INTERVENTIO AE ION
S CRITERIA N
Subjectiv P Acute pain Myocardial After the 2 1. Acknowledge 1. Ones Goal Met
e: H related to ischemia hours of nursing reports of pain perception After 2
Mukalit Y decreased occurs when intervention the immediately. of time may hours of
July 27, rajud ug S myocardial blood flow to patient will be become nursing
2017 sakit I flow your heart is able to: distorted intervention
maam, O reduced, during s, goals and
bisag L preventing it -reports painful objectives
natulog O from receiving decrease pain/ experiences. was met as
ko G enough reduce pain 2. Assess location, 2.For evidenced
makamat I oxygen. The intensity, and accurate by:
ako,as C reduced blood -Patient uses aggravating factors at assessment
verbalize flow is usually pharmacologica frequent interval by of pain. - reports
d by the N the result of a l and non the patients self- decrease
patient E partial or pharmacologica reported pain. pain/
E complete l pain-relief 3. 3. These are absence of
Objective D blockage of strategies. Assess for behavior potential pain,
s: S your heart's al and physiological indicators mawala
- arteries -Patient responses to pain. of pain in naman cya
Weaknes (coronary displays patients who maam basta
s noted arteries) that improvement in are unable to maka inum
-Pallor will lead to mood, coping. self-report. kog tambal
noted production of 4. Foresee the 4. Early
-Reports lactic acid need for pain intervention
pain in which is the relief. may - Patient
the chest responsible for decrease the uses
6 out of chest pain. total amount pharmacolo
10 of analgesic gical and
- required. non
77
pharmacolo
- Knife- 5. Provide with rest 5. To gical pain-
like pain intervals with quiet prevent relief
- environment and fatigue. strategies.
Guarding well-ventilated area.
behavior -Patient
noted 6. Get rid of 6. To relieve displays
- additional discomfort improveme
Restlessn stressors or caused by nt in mood,
ess noted sources of pressure and coping.
discomfort to improve
whenever circulation.
possible.
7. Position 7. Patients
comfortably. may
experience
an
exaggeration
in pain or a
decreased
ability to
tolerate
painful
stimuli if
environment
al,
intrapersonal
, or
intrapsychic
factors are
further
stressing
them.
78
8. Provide comfort 8. To
measures such as enhance
massaging of hands self-image
or back and by and divert
staying with the the attention
patient. of the
patient.
9. Encourage patient 10. To

to use relaxation distract
technique such as attention
focus breathing. and
reduce
tension.
11.
10. Implement use of 8. To reduce
Range of Motion drug therapy
Exercises, and as possible;
relaxation. however,
these may
11. Provide add to the
analgesics as action
ordered, of pharmaco
evaluating the logic
effectiveness and regimen.
inspecting for any 9.
79
signs and Effectivenes

symptoms of s of pain
adverse effects. medications
must be
evaluated
12. Administer individually
oxygen as ordered because it is
when necessary. absorbed
and
metabolized
differently
by patients.
Analgesics
may cause
mild to
13.Report to the severe side
physician when effects.
interventions are 10. O2
unsuccessful and administratio
ineffective. n facilitate
enough
distribution
of oxygen in
the blood
that will
decrease
pain.
11. Patients
who
demand pain
medications
at more
frequent
80
intervals
than
prescribed
may actually
require
higher doses
or more
potent
analgesics.
Date/ Cues Needs Nursing Scientific Goal Nursing Rationale Evaluation

Time Diagnosis Basis Objectives Intervention
Criteria
Sub. 6 days E Constipation The state in Within 8hrs. 1. Establish 1. To gain Within 8hrs.
nakowalanakalibangMa L related to which an of nursing rapport patients trust of nursing
am as verbalized by I medication individual intervention and alleviate intervention
the patient. M use. experiences a patient will their anxiety patient was
I change in be able to 2. Ascertain 2. To able to
N normal return to normal bowel determine return
Obj. A bowel habits normal functioning of patient normal
Medication use T characterized pattern of patient about normal bowel pattern of
Inadequate fluid I by a bowel how many pattern. bowel
intake O decreased in functioning times a day he functioning
low fiber diet N frequently as evidenced usually as evidenced
Inactivity, immobility and /or by: defecates. by:
VS of: P passage of formed 3. Monitor & 3. To formed
Temp. 36.7 A hard, dry stool at a record Vital establish stool at a
PR:161 bpm T stool. frequency Sign. baseline data. frequency
RR: 22 bpm T perceived as 4. Encouraged 4. For easy perceived as
BP:158/126mmHg E normal by regular intake defecation. normal.
R the patient. of food
81
N emphasizing
foods high in
fiber i.e fruits
such as apples
and bananas,
grains and
cereal.
5. Evaluate 5. Prolonged
current bed rest, lack
medication of exercise
usage that may and in activity
contribute to contribute to
constipation. constipation.
Educate client
about side
effect of use.
6. Encouraged 6. Delaying
daily fluid bowel
intake of 2000- movements
3000ml/day, if may increase
not constipation
contraindicated and
medically. subsequently
cause more
pain.
7. Asses 7. Sedentary
patients lifestyle
activity level. affects
elimination
patterns.
8. Encourage 8.Dehydration
Ambulation compounds
with assist as and
tolerated. contributes to
82
constipation.
Date/ Cues Needs Nursing Diagnosis Scientific Goal Nursing Rationale Evaluation
Time Basis Objectives Intervention
Criteria
7/27/ Sub. N/A H Risk for bleeding At risk for a Within 8hrs. 1. Obtain 1. Assess- Within 8hrs.
17 @ E related to decrease in of nursing complete ment of nursing
9:00 A anticoagulation blood intervention health history findings may intervention
am L therapy. volume that the patient for bleeding, indicate need the patient
T may will be able some for was able to
Obj. H compromise to takes individuals protective takes
Abnormal liver health. measures to know measures. measures to
function M prevent whereas
prevent
Aneurysm A bleeding and others do not.
bleeding and
Gastrointestinal N recognizes 2. Asses and 2. Tachycar-
disorder(ulcer) A signs of monitor Vital dia and recognizes
Trauma G bleeding that Signs. orthostatic signs of
Treatment-related side E need to be changes bleeding that
effects M reported accompany need to be
E immediately bleeding. reported
N to a health 3. Monitor 3. Sponta- immediately
T care platelet count neous to a health
professional. and bleeding care
P coagulation may occur at professional.
83
A platelet
T count 50,000
T per MM3
E and
R abnormal
N coagulation
test result.
4. Avoid 4. These
intravenous, procedures
subcutaneous can stimulate
injections and bleeding.
rectal
procedures.
5. Observe 5. Patient on
for skin anticoagulan
necrosis, t therapy
changes in remains at
blue or risk of
purple developing
molting of emboli.
feet that
blanches with
pressure of
fades when
legs are
elevated.
6. Awareness 6. This
to patient enables the
about effects patient to
of drugs like avoid
heparin and bleeding-risk
warfarin. situations.
7. Maintain 7. To
safe and prevent
comfortable depression
environment and injury.
84
for patient to
promote a
lifestyle that
focuses on
health
promotion.
8. Provide 8. This helps
psychological in patient's
and assurance
emotional and calming.
support to
patient.
9. Be active 9. Active
in decision participation
making about encourages
the treatment fuller
of the patient understandin
at risk for g of the
bleeding. rationale and
compliance
with the
treatment.
10. Keep in 10. To
touch with assure
blood availability
transfusion of blood
centre. when
needed.
85
B. DRUG STUDY
DATE/ BRAND ACTION INDICATION ROUTE/ DRUG ADVERSE PRECAUTION NURSING

TIME NAME DOSAGE/ INTERACTION EFFECT CONTRAINDICATIO RESPONSIBILITES
ORDERED TIME NS
INTERVAL
7/19/17 Nifediac Nifedipine Hypertensi PO, 5 mg/tab 1 Enhanced Dizziness, Cardiogenic Assess for anginal
prevents Ca on tab now then antihypertensive flushing, shock, acute pain, including
ion from angina BID effects w/ other headache, unstable angina, location, intensity,
entering the duration, and
pectoris antihypertensives, hypotension, use w/in 1 mth of
slow channels alleviating and
of cardiac and Raynauds aldesleukin, and peripheral MI. Treatment of
aggravating
smooth syndrome antipsychotic oedema, angina attack in factors.
muscles Concomitant use tachycardia, chronic stable Monitor BP
GENERIC HALF LIFE
NAME
during w/ fentanyl palpitations, angina or acute carefully during
Approx 2 hr
Nifedipine depolarisation during surgery nausea, reduction of BP in titration period.
, producing constipation, adults. Patient may
caused severe
peripheral and become severely
hypotension. May other GI
coronary hypotensive,
vasodilatation modify insulin disturbances
especially if also
. It reduces and glucose , increased taking other drugs
afterload, responses. micturition known to lower
peripheral Attenuation of frequency, BP. Withhold
resistance and tachycardic effect lethargy, eye drug and notify
BP; increases pain, visual physician if
coronary when used w/
disturbances systolic BP <90.
blood flow benazerpril. Monitor blood
and causes Prothrombin time , syncope,
sugar in diabetic
reflex may be vertigo, patients.
86
tachycardia. It increasedw/ migraine, Nifedipine has

has little or no coumarin mood diabetogenic
effect on anticoagulants. disturbances properties.
cardiac Monitor for
Increased serum , rashes
conduction gingival
and rarely has levels w/ (including
hyperplasia and
negative CYP3A4 erythema report promptly.
inotropic inhibitors (e.g. multiforme), This is a rare but
activity. azole antifungals, liver serious adverse
cimetidine, function effect (similar to
erythromycin, abnormalitie phenytoin-induced
s (including hyperplasia).
HIV-protease
Encourage pt. to
inhibitors, cholestasis),
avoid dangerous
nefazodone, pruritus, activities until
fluoxetine, gingival stabilized on the
quinupristin/dalfo hyperplasia, medicine or
pristin). myalgia, dizziness is not
CLASSIFI- ABSORPTION EXCRETION gynaecomas present.
CATION Rapidly and Via urine (80-95% tia, tremor, Instruct to limit
Cardiova almost as inactive caffeine.
impotence,
scular metabolites) and Encourage to
agent; completely fever.
faeces. avoid alcohol.
Calcium absorbed from Paradoxical Patients should
channel the GI tract. increase in change position
blocker ischaemic carefully as
Antiarrh chest pain orthostatic
ythmic hypotension can
during
(Class occur.
iv) initiation of
Nonnitra treatment.
te GI
vasodilat obstruction
or in some
tablets
covered in
87
indigestible
membrane.
88

TIME NAME DOSAGE/ INTERACTION EFFECT CONTRAINDICATIO RESPONSIBILITES
ORDERED TIME NS
INTERVAL
7/19/17 Mylan Metoprolol HTN PO, 50 mg/tab Additive effect w/ Dizziness, 2nd or 3rd degree Take apical pulse
selectively Angina now then 1 tab catecholamine- insomnia, AV block, sick and BP before
inhibits 1- pectoris q6 hrs, hold for depleting drugs tiredness, sinus syndrome, administering
adrenergic HR < 70 bpm drug. Report to
receptors but Cardiac and MAOIs. headache, hypotension,
physician
has little or no arrhythmias May antagonise vertigo, decompensated
significant
effect on 2- Stable 1-adrenergic confusion, heart failure, sinus changes in rate,
receptors symptomati stimulating bradycardia, bradycardia, rhythm, or quality
GENERIC HALF LIFE
NAME
except in high c heart effects of shortness of severe peripheral of pulse or
3-4 hrs
Metoprolol doses. It does sympathomimetic breath, arterial circulatory variations in BP
failure
not exhibit hypotension, disorders, prior to
tartrate
membrane Adjunct s.
administration.
stabilising or hyperthyroi Additive negative Raynaud's cardiogenic shock,
Monitor BP, HR,
intrinsic dism effects on SA or phenomenon severe asthma and
and ECG carefully
sympathomim Migraine AV nodal , CHF, bronchospasm, during IV
etic activity. prophylaxis conduction w/ peripheral untreated administration.
Emergency cardiac oedema, phaeochromocyto Expect maximal
glycosides, cold ma, Prinzmetal's effect on BP after
treatment of
nondihydropyridi extremities, angina, metabolic 1 wk of therapy.
cardiac Take several BP
arrhythmias ne Ca channel syncope, acidosis.
readings close to
blockers. chest pain,
Prophylaxis the end of a 12 h
or control of Paradoxical palpitations, dosing interval to
response to gangrene, evaluate adequacy
arrhytmias
epinephrine may claudication, of dosage for
89
on induction occur. hallucinatio patients with

of Increased plasma ns, hypertension,
anesthesia concentrations w/ nightmares, particularly in
patients on twice
Adjunct in CYP2D6 visual
daily doses. Some
the early inhibitors. disturbances patients require
management Increased risk of ; diarrhoea, doses 3 times a
of acute MI hypotension and constipation, day to maintain
heart failure w/ flatulence, satisfactory
myocardial GI pain, control.
depressant heartburn, Observe
nausea, hypertensive
general anaesth. patients with CHF
Risk of hiccups, closely for
pulmonary HTN xerostomia; impending heart
w/ vasodilators in bronchocons failure: Dyspnea
uraemic patients. triction, on exertion,
Reduced plasma wheezing, orthopnea, night
dyspnoea; cough, edema,
levels w/ distended neck
rifampicin. dry skin,
veins.
May increase maculopapul Lab tests: Obtain
negative inotropic ar, baseline and
and negative psoriasiform periodic
dromotropic , pruritus evaluations of
blood cell counts,
effect of
blood glucose,
antiarrhythmic liver and kidney
drugs. function.
May reduce Monitor I&O,
antihypertensive daily weight;
efficacy w/ auscultate daily
indometacin. for pulmonary
rales.
May increase
Withdraw drug if
effects of
90
hypoglycaemics. patient presents

symptoms of
mental depression
because it can
progress to
catatonia. Possible
CLASSIFI- ABSORPTION EXCRETION symptoms of
CATION Absorbed Via urine (as depression:
Beta blocker readily and metabolites and disinterest in
completely for unchanged drug) people,
the GI tract. surroundings,
food, personal
hygiene;
withdrawal,
apathy, sadness,
difficulty in
concentrating,
insomnia.
Monitor patients
with
thyrotoxicosis
closely since drug
masks signs of
hyperthyroidism.
Abrupt
withdrawal may
precipitate thyroid
storm.
91

TIME NAME DOSAGE/ INTERACTION EFFECT CONTRAINDICATI RESPONSIBILITES
ORDERED TIME ONS
INTERVAL
7/20/17 Lovenox Enoxaparin is Acute ST- 0.6 cc SQ q2, Increased risk of Hemorrhage Hypersensitivity Use a TB syringe or
a low elevation first dose now bleeding w/ (including at to enoxaparin, prefilled syringe to
molecular myocardial anticoagulants, the inj. site), heparin. Patients ensure accurate
weight infarction dosage.
platelet peripheral or w/ active major
heparin w/ Unstable Do not expel the air
anticoagulant aggregation unspecified bleeding, acute
angina bubble from the 30
inhibitors (e.g. edema, bacterial
properties. It Prophylaxis or 40 mg prefilled
acts by of venous dipyridamole, anemia, endocarditis, syringe before
GENERIC HALF LIFE
NAME
enhancing the thromboem salicylates, hematuria, recent injection.
Approximately
Enoxaparin inhibition rate bolism 4 to 5 hrs NSAIDs, ecchymosis, haemorrhagic Place patient in a
of activated during sulfinpyrazone). fever, stroke, active supine position for
clotting surgical injection of the
factors May increase confusion, gastric or
procedures drug.
bleeding w/ vit E. nausea, duodenal
including Deep vein Alternate injections
CLASSIFI- thrombin and ABSORPTION EXCRETION diarrhea, ulceration,
CATION
thrombosis between left and
factor Xa Rapidly and Via urine (40% as dyspnea, thrombocytopeni
Anticoagul Prophylaxis right anterolateral
through its almost unchanged drug; injection site a associated w/
ant of clotting and posterolateral
action on completely 10% as active
Antiplatelet in the pain. positive in vitro abdominal wall.
antithrombin absorbed metabolites)
& extracorpore test for platelet Hold the skin fold
III. al between the thumb
Fibrinolytic antibodies.
(Thrombol circulation and forefinger and
ytic) during insert the whole
hemodialysi length of the needle
s into the skin fold.
Hold skin fold
throughout the
92
injection. Do not
rub site post
injection.
Store at 1530 C
(5986 F).
Monitor platelet
count closely.
Withhold drug and
notify physician if
platelet count less
than 100,000/mm3.
Monitor closely
patients with renal
insufficiency and
older adults who are
at higher risk for
thrombocytopenia.
Monitor for and
report immediately
any sign or
symptom of
unexplained
bleeding.
Report to physician
promptly signs of
unexplained
bleeding such as:
pink, red, or dark
brown urine; red or
dark brown
vomitus; bleeding
gums or bloody
sputum; dark, tarry
stools.
93

ORDERED TIME ONS
INTERVAL
7/20/17 Coumadin Warfarin Prophylaxis PO 2.5 mg/tab Cholestatic Jaundice, Hypersensitivity. Monitor PT ratio or
inhibits & treatment OD hepatitis may hepatic Hemorrhagic INR regularly to
synthesis of of venous occur when taken dysfunction, tendency or adjust dosage.
vitamin K- thrombosis,
concomitantly with vasculitis, blood dyscrasias. Administer IV form
dependent atrial to patients stabilized
coagulation fibrillation ticlopidine, pancreatitis, Recent or
on Coumadin who
factors II, w/ antiplatelet agents, nausea, contemplated are not able to take
VII, IX, and embolization, NSAIDs, serotonin vomiting, surgery of CNS, oral drug. Dosages
GENERIC HALF LIFE
NAME
X as well as pulmonary reuptake inhibitors. diarrhea, eye or traumatic are the same. Return
Approximately
Warfarin the embolism, taste surgery resulting to oral form as soon
40 hrs.
anticoagulant adjunct in perversion, in large open as feasible.
protein C and prophylaxis
abdominal surfaces. Do not change
its cofactor of systemic brand names once
protein S. embolism pain, Bleeding
CLASSIFI- ABSORPTION EXCRETION stabilized;
These clotting after MI & in flatulence, tendencies bioavailability may
CATION Readily Via urine (92%,
Anticoagul factors are treatment of primarily as bloating, associated w/ be a problem.
absorbed by the
ant biologically coronary metabolites) rash, active ulceration Do not give patient
Antiplatelet activated by occlusion. GI tract; can
constipation or overt bleeding any IM injections.
& the addition also be Use caution when
of GI,
Fibrinolytic of carboxyl absorbed discontinuing other
genitourinary or
(Thrombol groups to key through the drugs; warfarin
glutamic acid resp tracts;
ytic) skin. dosage may need to
residues w/in cerebrovascular
be adjusted;
the proteins hemorrhage; carefully monitor
structure. cerebral PT values.
Warfarin aneurysms, Keep vitamin K
94
competitively dissecting aorta; readily available in

inhibits the pericarditis & case of overdose.
C1 subunit of pericardial Arrange for
the multi-unit frequent follow-up,
effusions;
vit K epoxide including blood
reductase bacterial
tests to evaluate
enzyme endocarditis. drug effects.
complex, thus Threatened
depleting abortion,
functional vit eclampsia &
K reserves preeclampsia.
and hence
reduces
synthesis of
active clotting
factors.
95

ORDERED TIME ONS
INTERVAL
7/20/17 Cordarone Amiodarone Pulseless D5W + 600 mg Increased Significant: Evidence or Monitor BP
is a class III ventricular amiodarone to concentration Bradycardia, history of carefully during
antiarrhythmi fibrillation run in 24 hours w/ inhibitors hypotension, thyroid infusion and slow
c agent but for 1 min the infusion if
or of CYP3A4. peripheral dysfunction,
exhibits significant
characteristics ventricular Reduced neuropathy. iodine
hypotension occurs;
of all tachycardia concentration sensitivity, bradycardia should
Vaughn- Supraventri w/ inducers of Nervous: severe resp be treated by
GENERIC HALF LIFE
NAME
Williams cular and CYP3A4. Benign failure, slowing the infusion
Approx 50 days
Amiodarone classes. Its ventricular May induce intracranial circulatory or discontinuing if
main effect is pressure, collapse, severe necessary.
arrhythmias bradycardia w/
to delay
paraesthesia, hypotension, Monitor heart rate,
repolarisation -blockers, Ca rhythm, and BP
by prolonging channel tremor, cardiogenic
until drug response
the action blockers, and nightmares, shock, sinus has stabilized;
potential other sleeplessness, bradycardia, SA report promptly
duration antiarrhythmic headache, heart block; 2nd symptomatic
(APD) and drugs. ataxia. or 3rd degree bradycardia.
effective Sustained
refractory May increase AV block, severe
CV: conduction monitoring is
period (ERP) risk of essential because
in myocardial arrhythmia w/ Thrombophlebit disturbances drug has an
tissues. drugs that is. (e.g. high grade unusually long half-
Additionally, cause AV block, life.
it inhibits hypomagnesae GI: Nausea, bifascicular/trifa Monitor for S&S of:
96
transmembran mia and vomiting, scicular block), Adverse effects,

e influx of Na hypokalaemia. metallic taste. sinus node particularly
via fast May increase disease (except conduction
channels, disturbances and
concentration Genitourinary: in patient w/
decreasing the exacerbation of
maximal rate of ciclosporin, Epididymitis. pacemaker). arrhythmias, in
of clonazepam, Lactation. patients receiving
depolarisation digoxin, Endocrine: Concomitant use concomitant
similar to flecainide, Phospholipidosi w/ drugs that antiarrhythmic
class I. It is a phenytoin, s. prolong QT therapy.
non- procainamide, interval. Monitor for
competitive elevations of AST
quinidine, Haematologic:
inhibitor of - and ALT. If
and - simvastatin, Haemolytic/apl elevations persist or
adrenergic and warfarin. astic anaemia. if they are 23 times
actions as that May affect Musculoskeleta above normal
of class II. drugs that are l: Myopathy. baseline readings,
Lastly, it P-glycoprotein reduce dosage or
produces Ophthalmologic withdraw drug
substrates.
negative promptly to prevent
CLASSIFI- ABSORPTION EXCRETION : Benign
CATION
chronotropic hepatotoxicity and
Variably and Via faeces and yellowish-
Belongs to effect in liver damage.
erratically urine (<1% as
class III nodal tissues
unchanged
brown corneal Auscultate chest
similar to absorbed from micro-deposits, periodically or
antiarrhyth drug)
mics. class IV. the GI tract. optic when patient
Cardivascu neuropathy/neu complains of
lar agent ritis, blindness. respiratory
symptoms. Check
for diminished
Dermatologic: breath sounds, rales,
Hot flushes, pleuritic friction
sweating, blue- rub; observe
grey skin breathing pattern.
discolouration. Supervision of
ambulation may be
indicated.
Others: Fatigue.
97
98

ORDERED TIME ONS
INTERVAL
7/21/17 Coralan Ivabradine is Chronic 2.5 mg/ tab 1 QT Luminous Resting heart Administer drug
a heart rate stable angina tab BID start prolongation phenomena in rate <70 with food
lowering pectoris in tonight may be the visual beats/min prior Monitor regularly
agent that for atrial flutter
coronary exacerbated by field to treatment,
works occurrence while
through artery disease heart rate (phosphenes), cardiogenic
taking this
selective and patients with reduction w/ blurred vision, shock, acute MI, medication.
specific normal sinus QT-prolonging bradycardia, severe Monitor regularly
GENERIC HALF LIFE
NAME
inhibition of rhythm drugs (e.g. other cardiac hypotension for atrial flutter
2 hrs
Ivabradine the cardiac Chronic heart quinidine, arrhythmias, (<90/50 mmHg), occurrence while
pacemaker If failure disopyramide, syncope, sick sinus taking this
current that medication.
pimozide, hypotension, syndrome, SA
controls the
asthenia, block, unstable Avoid excess
spontaneous ziprasidone).
dosage.
diastolic Concentration fatigue, or acute heart
Store it at room
depolarisation may be reduced headache, failure, temperature (25C).
in the sinus w/ CYP3A4 dizziness, pacemaker
node and inducers (e.g. nausea, dependent,
regulates constipation, unstable angina,
rifampicin,
heart rate.
barbiturates, diarrhoea, 3rd degree AV
phenytoin) and dyspnoea, block. Severe
may require muscle hepatic
ivabradine dose cramps, skin impairment.
adjustment. reactions, Pregnancy and
99
CLASSIFI- ABSORPTION EXCRETION angioedema, lactation.

CATION Almost Approx 4% as hyperuricaemi Concurrent use
Anti-anginal completely unchanged drug
drugs a, w/ potent
absorbed from via urine;
metabolites are eosinophilia, CYP3A4
GI tract. elevated inhibitors (e.g.
excreted to a
similar extent via blood- azole
urine and faeces. creatinine antifungals,
concentrations macrolides, HIV
. protease
inhibitors or
nefazodone),
moderate
CYP3A4
inhibitors (e.g.
verapamil or
diltiazem).
100

TIME NAME DOSAGE/ INTERACTION EFFECT CONTRAINDICATIONS RESPONSIBILITES
ORDERED TIME
INTERVAL
7/21/17 Urocit-K Potassium This K citrate 2 K citrate may Abdominal Hypersensitivity, Take medicine
citrate is a medication is durule now then interact with discomfort, hyperkalemia, with food.
urinary used to make 1 tab q6 x 4 aspirin, Benadryl, vomiting, Addison's disease, Take with a full
alkalinizing dose glass of water.
the urine less Lasix, Tylenol, diarrhea, anuria, uncontrolled
medication. It Swallow whole.
makes urine acidic. This vitamin B12, loose bowel DM, acute
Do not chew,
less acidic. effect helps vitamin B6 movements dehydration, adrenal break, or crush.
Potassium the kidneys or nausea insufficiency, renal
GENERIC HALF LIFE
NAME
citrate works get rid of uric Serious: insufficiency (GFR
unknown
K citrate by acid, thereby Hyperkalem <0.7ml/kg/min)
crystallizing helping to ia (potential Delayed gastric
stone-forming
prevent gout for cardiac emptying,
salts such as
calcium and kidney arrest), GI esophageal
CLASSIFI- ABSORPTION EXCRETION
oxalate, stones. This ulceration, compression, GI
CATION Rapidly Urine
calcium medication GI irritation obstruction,
phosphate, absorbed
can also concomitant
and uric acid prevent and anticholinergic Rx,
within the treat certain peptic ulcer dz,
urinary
metabolic active UTI
bladder by
increasing the problems Concomitant K+-
urinary pH (acidosis) sparing agents (e.g.,
and urine caused by triamterene,
citrate levels. kidney spironolactone,
disease. amiloride)
101

TIME NAME DOSAGE/ INTERACTION EFFECT CONTRAINDICAT RESPONSIBILITES
ORDERED TIME IONS
INTERVAL
7/21/17 Levophed Noradrenaline Emergency Levophed drip MAOIs, TCA, Bradycardia, Patients who Monitor constantly
,a measure in 4 mg + 46 cc cyclopropane & arrhythmias; are hypotensive while patient is
sympathomim BP pnss in soluset halothane anesth. anxiety, from blood vol receiving
etic amine, to run at norepinephrine. Take
restoration in Alkali & oxidizing transient deficits except
acts 0.05cc/hr and baseline BP and pulse
predominantl cases of titrate by 0.03 agents, headache. as emergency
before start of
y on - and - acute cc/hr q 15 min barbiturates, Plasma vol measure. therapy, then q2min
receptors in hypotension. chlorpheniramine, depletion Concomitant from initiation of drug
GENERIC HALF LIFE
NAME
the heart. It chlorothiazide, (prolonged use of until stabilization
1 min
Norepinephri therefore nitrofurantoin, administrati cyclopropane occurs at desired
causes phenytoin, Na on). Resp & halothane level, then every 5
ne bitartrate
peripheral min during drug
bicarbonate & difficulty, anesth. Patient
vasoconstricti administration.
on (- iodide, ischemic w/ mesenteric
Adjust flow rate to
adrenergic streptomycin, injury. or peripheral maintain BP at low
action), and a sulfadiazine Extravasatio vascular normal (usually 80
positive &sulfafurazole. n, necrosis thrombosis 100 mm Hg systolic)
102
CLASSIFI- inotropic ABSORPTION EXCRETION at inj site. unless it is life- in normotensive

CATION effect on the Orally ingested Urine patients. In previously
saving.
autonomic heart and noradrenaline is hypertensive patients,
nervous Continuous
dilation of destroyed in the systolic is generally
system administration
coronary GI tract, and the maintained no higher
agent; alpha- arteries (- in the absence than 40 mm Hg below
and beta- drug is poorly of blood vol
adrenergic preexisting systolic
adrenergic action). These absorbed after replacement; level.
agonist actions result subcutaneous hypoxia or Observe carefully and
in an increase injection hypercarbia. record mental status
in systemic (index of cerebral
blood circulation), skin
pressure and temperature of
coronary extremities, and color
artery blood (especially of
flow. earlobes, lips, nail
beds) in addition to
vital signs.
Monitor I&O. Urinary
retention and kidney
shutdown are
possibilities,
especially in
hypovolemic patients.
Urinary output is a
sensitive indicator of
the degree of renal
perfusion. Report
decrease in urinary
output or change in
I&O ratio.
Be alert to patients
complaints of
headache, vomiting,
palpitation,
arrhythmias, chest
103
pain, photophobia,
and blurred vision as
possible symptoms of
overdosage. Reflex
bradycardia may
occur as a result of
rise in BP.
Continue to monitor
vital signs and
observe patient
closely after cessation
of therapy for clinical
sign of circulatory
inadequacy.
104

ORDERED TIME
INTERVAL
7/21/17 carvidol Carvedilol is Left Shift metoprolol Decreased serum Bradycardia, Bronchial asthma or Do not discontinue
a non ventricular to carvedilol levels w/ syncope, related drug abruptly after
selective - dysfunction 6.25 mg 1 tab rifampicin. dizziness, bronchospastic
chronic therapy
adrenergic tab BID may (hypersensitivity
post Combination w/ headache, conditions. AV to catecholamines
blocking resume now
myocardial Ca channel fatigue, block 2nd and 3rd may have
agent which developed,
causes infarction blockers (e.g. asthenia, degree. Sick sinus
causing
vasodilation Hypertensio verapamil and arthralgia, syndrome or severe exacerbation of
GENERIC HALF LIFE
NAME
by blocking n diltiazem) can urinary bradycardia. angina, MI, and
6-10 hrs
Carvedilol the activity - Heart failure lead to incontinence Cardiogenic shock. ventricular
1 receptors. It arrhythmias); taper
exerts Angina bradycardia and , interstitial NYHA class IV
drug gradually
pectoris myocardial pneumonitis, heart failure. COPD over 2 wk with
antihypertensi
ve effect depression. generalisedo w/ bronchial monitoring.
partly by Potentiates edema, obstruction. Give with food to
diarrhoea, Metabolic acidosis. decrease
reducing total insulin-induced orthostatic
peripheral hypoglycaemic nausea, Severe peripheral hypotension and
resistance and action. vomiting, arterial circulatory adverse effects.
vasodilation. Monitor for
May increase hyperglycae disturbances. Severe
mia, wt hepatic impairment. orthostatic
hypoglycaemic hypotension and
effects of gain, cough, provide safety
antidiabetic abnormal precautions.
agents. Increased vision, Monitor patients
increased with diabetes
risk of
105
bradycardia w/ BUN and closely; drug may

digoxin. nonprotein mask
hypoglycemia or
nitrogen worsen
(NPN). hyperglycemia.
Take drug with
CLASSIFI- ABSORPTION EXCRETION meals
CATION Well absorbed Via bile (as
Beta from the GI metabolites)
blockers
tract
106

ORDERED TIME
INTERVAL
7/21/17 Lannett Digoxin is a Cardiac PO, 250 meq Effectiveness Extra beats, Digitalis toxicity, Be familiar with
cardiac failure tab q4 x 6 doses reduced by anorexia, ventricular patients baseline
glycoside OD data (e.g., quality
accompanie phenytoin, nausea and tachycardia/fibrillati of peripheral
which has
d by atrial neomycin, vomiting. on, obstructive pulses, blood
positive
fibrillation; sulphasalazine, Diarrhoea in cardiomyopathy. pressure, clinical
inotropic symptoms, serum
activity Managemen kaolin, pectin, elderly, Arrhythmias due to
electrolytes,
characterized t of chronic antacids and in confusion, accessory pathways creatinine
GENERIC HALF LIFE
NAME
by an increase cardiac patients receiving dizziness, clearance) as a
36-48 hrs
digoxin in the force of failure radiotherapy. drowsiness, foundation for
myocardial Metoclopramide restlessness, making
where assessments.
contraction. It
systolic may alter the nervousness, Take apical pulse
also reduces
the dysfunction absorption of solid agitation and for 1 full min
conductivity or dosage forms of amnesia, noting rate,
digoxin. Blood visual rhythm, and
of the heart ventricular quality before
through the dilatation is levels increased by disturbances administering. If
atrioventricul dominant; calcium channel , changes are noted,
ar (AV) node. withhold digoxin,
Digoxin also Managemen
blockers, gynaecomas
take rhythm strip
t of certain spironolactone, tia, local
exerts direct if patient is on
action on supraventric quinidine and irritation ECG monitor,
vascular calcium salts. (IM/SC inj), notify physician
107
CLASSIFI- smooth ular ABSORPTION EXCRETION rapid IV promptly.

CATION muscle and arrhythmias, Absorption Excreted mainly admin may Withhold
Digitalis indirect from the GI unchanged. medication and
glycosides particularly lead to notify physician if
effects tract is variable.
chronic vasocostricti apical pulse falls
mediated
atrial flutter on and below ordered
primarily by
& transient parameters
the autonomic Monitor for S&S
nervous fibrillation. hypertension of drug toxicity
system and an . Monitor I&O ratio
increase in during
vagal activity. digitalization,
particularly in
patients with
impaired renal
function. Also
monitor for edema
daily and
auscultate chest
for rales.
Observe patients
closely when
being transferred
from one
preparation (tablet,
elixir, or
parenteral) to
another
108

ORDERED TIME
INTERVAL
7/22/17 Kaliumdurul Potassium Hypokalemi 2 durules of Potassium-sparing GI Hyperchloraemia, Should be taken
e chloride is a a kalium now diuretics, ACE ulceration severe renal or with food
major cation Prophylaxis then continue 1 Swallow whole w/
inhibitors, (sometimes adrenal
of the tab TID x 6 glass of liqd, do
during ciclosporin and with insufficiency. not
intracellular doses
fluid. It plays treatment w/ potassium- haemorrhag break/chew/crush.
diuretics. containing drugs. e and Do not administer
an active role
to a patient in a
in the Antimuscarinics perforation
GENERIC HALF LIFE supine position.
NAME
conduction of delay gastric or with late
Approx. 16 sec
Potassium nerve emptying time formation of
impulses in consequently strictures)
chloride
the heart,
increasing risk of following
brain and
skeletal GI adverse effects the use of
muscle; esp of solid oral enteric-
contraction of dosage forms. coated K
109
CLASSIFI- cardiac ABSORPTION EXCRETION chloride

CATION skeletal and Well absorbed Mainly via the
electrolytes preparation;
smooth from the upper urine with small
hyperkalaem
muscles; GI tract amounts via the
sweat and faeces. ia. Oral:
maintenance
of normal Nausea,
renal vomiting,
function, diarrhoea
acid-base and
balance, abdominal
carbohydrate cramps. IV:
metabolism
Pain or
and gastric
secretion. phloebitis;
cardiac
toxicity.
110

ORDERED TIME
INTERVAL
7/23/17 Human Human Hypovolemia 50cc to run in 4 Albumin solution anaphylactic Albumin Check the
albumin 20% albumin Hypoalbumi hrs should not be shock hypersensitivity albumin level
increases nemia mixed by protein cardiac Anemia, heart from the protein
intravascular electrophoresis
Prevention of hydrolysates or failure failure, hypertension
oncotic results. Many
pressure and Central alcoholic solutions. loss of Renal disease
clinical problems
causes Volume Risk of atypical consciousne Hypernatremia are the result of
movement of Depletion reactions to ACE ss a serum albumin
GENERIC HALF LIFE
NAME
fluids from after inhibitors in circulatory deficit.
15-20 days
Albumin interstitial Paracentesis patients failure Assess for
into due to undergoing hypersensiti peripheral edema
intravascular in the lower
Cirrhotic therapeutic plasma vity
space. Human extremities when
albumin Ascites exchange with congestive
the albumin
solutions are Acute albumin human heart failure level is
available in Nephrosis(Tr replacement. pulmonary
111
CLASSIFI- various eatment ABSORPTION EXCRETION edema decreased.

CATION concentration Rapidly Excess excretion Albumin is the
Adjunct) dyspnea
Blood s. Solutions absorbed by the kidneys major protein
substitutes hypotension
containing compound
and Plasma hypertension
5% human responsible for
proteins albumin are tachycardia plasma colloid
usually used bradycardia osmotic
in vomiting pressure. With a
hypovolemic urticaria decreased
patients, angioneuroti albumin level,
whereas more c edema fluid seeps out of
concentrated the blood vessels
rash
25% solutions into the tissue
are erythematou spaces.
recommended s Assess for
in patients in confusional urinary output.
whom fluid state Renal and
and sodium headache collagen (lupus)
intake must chills diseases occur
be minimised with abnormal
pyrexia
e.g. patients protein fractions.
with flushing Urine output
hypoproteinae nausea should be
mia or pruritus 25mL/h or
cerebral hyperhidrosi 600mL/24 hours.
oedema or in s
paediatric
patients.
112

ORDERED TIME ONS
INTERVAL
7/23/17 lasix Furosemide LASIX is 40 mg IV to run Some products that ringing in Caution when Reduce dosage if
works by indicated in in 4 hrs may interact with your ears, there are losses given with other
blocking the adults and this drug include: hearing loss; of potassium antihypertensives;
absorption of readjust dosage
pediatric ethacrynic acid, itching, loss (vomiting,
sodium, gradually as BP
chloride, and patients for lithium. Check the of appetite, diarrhea)! A
responds.
water from the treatment labels on all your dark urine, pronounced Administer with
the filtered of edema medicines (such as clay-colored hypokalemia food or milk to
GENERIC HALF LIFE
NAME
fluid in the associated cough-and-cold stools, demands to be prevent GI upset.
Approx. 2 hrs
Furosemide kidney with products, diet aids, jaundice treated Give early in the
tubules, congestive or NSAIDs such as (yellowing (potassium day so that
causing a increased
heart failure, ibuprofen, of the skin sparing diuretics,
profound urination will not
increase in cirrhosis of naproxen) because or eyes) potassium
disturb sleep.
the liver, and they may contain substitution). For
the output of Avoid IV use if
urine renal disease, ingredients that men with oral use is at all
(diuresis). including the could increase prostate possible.
nephrotic your blood hyperplasia there WARNING: Do
syndrome. pressure or worsen is a risk of not mix parenteral
swelling (edema). urinary retention. solution with
113
CLASSIFI- ABSORPTION EXCRETION highly acidic

CATION Fairly rapidly Mainly via urine solutions with pH
Diuretic absorbed from below 3.5.
the GI tract Do not expose to
light, may
discolor tablets or
solution; do not
use discolored
drug or solutions.
Discard diluted
solution after 24
hr.
Refrigerate oral
solution.
Measure and
record weight to
monitor fluid
changes.
Arrange to
monitor serum
electrolytes,
hydration, liver
and renal
function.
Arrange for
potassium-rich
diet or
supplemental
potassium as
needed.
114

ORDERED TIME
INTERVAL
7/27/17 Calan Inhibits the Hypertension PO, 80 mg 1 tab Disopyramide: Anxiety, Hypersensitivity; Monitor blood
transport of Angina TID, PRN should be taken confusion, sick sinus syndrome; pressure and
calcium into pectoris within 48 hrs dizziness, BP <90 mmHg; pulse before
myocardial therapy,
Vasospatic before or 24 hours cough, CHF; severe hepatic
and vascular during dosage
smooth angina after verapamil is dyspnea, impairement
titration, and
muscle cells, Supraventric taken. shortness of periodically
resulting in ular Flecainide:may breath, throughout
GENERIC HALF LIFE
NAME
inhibition of arrhythmias have added effects dysuria, therapy
2.8-7.4 hrs
Verapamil excitation- and rapid on the heart. constipation, Monitor ECG
contraction ventricular Quinidine: may diarrhea periodically
coupling and during
rates in atrial cause low blood
subsequent prolong
contraction. flutter or pressure
therapy
CLASSIFI- fibrillation ABSORPTION EXCRETION
Monitor I & O
CATION 90% absorbed urine
Antianginal Assess for
from the GI
Antiarrhyth signs of CHF
mic tract (peripheral
antihyperten edema,
sive crackles,
dyspnea,
weight gain)
Monitor renal
and hepatic
functions
periodically
115
during long-
term therapy.
116
CHAPTER XI
HEALTH TEACHINGS
Primary:
Encourage the patient to have a sufficient rest.

Encourage patient not to do strenuous activities.
Encourage patient to perform active range of motion intermittently and activities of daily
living.
Encourage patient to eat nutritious foods rich in protein, iron, vitamin C such as lean
meat, green leafy vegetables, as ordered.
Encourage patient to avoid foods rich in cholesterol.
Secondary:
Orient the patients family about the patients condition and necessary
information/treatment and recovery process.
Instruct the family to remain at patients side to give physical support and
encouragement.
Teach significant others to assist the patient always in a comfortable position.
Instruct significant others to wash hands before and after contact with patient.
Instruct the family to maintain the environment of the patient safe and clean at all times.
Tertiary:
Instruct the patient to take the medications prescribed by the physician.

Instruct the patient to report for any abnormalities immediately to the physician or nurse.
117
CHAPTER XII
DISCHARGE PLANNING
Medications:
Discuss all take home medications to the patient and significant others.
Inform patient that the drugs may exhibit undesirable side effects.
Inform patient about the possible adverse effects that the drugs can cause.
Encourage to report to the physician if he suffers any of the adverse effects immediately.
Encourage patient to comply with the prescribe medication.
Exercises:
Encourage patient to have adequate rest and sleep.

Encourage patient to take regular breaks from any activity that demands to give him
stress.
Encourage to do deep breathing to manage stress.
Encourage to exercise regularly if tolerated.
Encourage to maintain healthy weight.
Treatment:
Orient the patients family about the patients condition and necessary information,
treatment and recovery process.
Encourage to comply with treatment regimen.
Encourage to quit smoking and avoid secondhand smoking
Hygiene:
Encourage patient to maintain good hygiene by taking a bath regularly

118
Outpatient Orders:
Encourage the patient to have regular medical check-ups or to consult the physician once
complications are noticed.
Diet:
Encourage to eat more nutritious foods such as green leafy vegetables, fruits, whole
grains, legumes and nuts-and is low in saturated fat, cholesterol and sodium.
Drink at least 8-10 glasses of water every day.
Significant Others:
Encourage significant others to have a healthy lifestyle as well to prevent the risk from
developing any heart problems.
Encourage to prepare foods that are healthy.
119
CHAPTER XIII
PROGNOSIS
Criteria Good Fair Poor Justification

Duration Recognition of the disease is delayed. The
duration of symptoms the patient experienced
chest pain and dyspnea.
Onset of Illness Onset of illness is poor because symptoms have

progressed rapidly and patient was admitted and
directed for 2D echo.
Complication of Patient Angkol already understands the
medication importance of his medications and its
compliance.
Family support The patients family is supportive for his
recovery. Moreover, they are always positive that
he well get better soon.
Environment The Intensive Care Unit (ICU) has good
environment. They provide bed for each patient
and to good sanitation due to proper waste
segregation.
Age The patient Angkol is in the adulthood stage
which increases his chance for recovery.
Precipitating Precipitating factors is poor since the patient is 6
Factors days constipated with medication used.
Summary:
Good: 4/7x 100 = 57.14%

Fair: 1/7 x 100 =14.28 %
Poor: 2/7 x 100 = 28.57 %
In general, the patient is in good prognosis which is at 57.14%

120
CHAPTER XIV
EVALUATION
Coronary artery disease (CAD) is characterized by atherosclerosis in the epicardial

coronary arteries. Atherosclerotic plaques, the hallmark of atherosclerosis, progressively narrow
the coronary artery lumen and impair antegrade myocardial blood flow. The reduction in
coronary artery flow may be symptomatic or asymptomatic, occur with exertion or at rest, and
culminate in a myocardial infarction, depending on obstruction severity and the rapidity of
development.
The patient has a good prognosis. The family can provide the medication prescribed, and
supportive towards the recovery. The patient comply and understand the importance of the
medication regimen and his family participates for the continuum of care for faster recovery.
121
CHAPTER XV
IMPLICATION OF THE STUDY
Coronary heart disease (CHD) is a disease in which a waxy substance called plaque
builds up inside the coronary arteries. These arteries supply oxygen-rich blood to your heart
muscle. When plaque builds up in the arteries, the condition is called atherosclerosis. The
buildup of plaque occurs over many years. Over time, plaque can harden or rupture (break open).
Hardened plaque narrows the coronary arteries and reduces the flow of oxygen-rich blood to the
heart. If the plaque ruptures, a blood clot can form on its surface. A large blood clot can mostly
or completely block blood flow through a coronary artery. Over time, ruptured plaque also
hardens and narrows the coronary arteries. The cause of this plaque formation is too much intake
of food rich in cholesterol and a poor physical exercise.
The patient has understood his condition and is aware of the treatment and procedure that
he will undergo. Patient Angkol now knows how to maintain a healthy lifestyle to prevent the
onset of chest pain and other complications. Not only did the patient benefited from the study but
also the members of the group. With the case of Patient Angkol, the group has applied the
knowledge and skills acquired from lectures and lessons. Through interviewing, the group has
applied therapeutic communication which allowed them to established rapport with the patient
and the patients significant others. Through the study, the group has enhanced and furthered
their knowledge on effective patient care specifically in the intensive care unit area of the
hospital.
122
REFERENCES
http://www.mayoclinic.org/diseases-conditions/coronary-artery-disease/diagnosis-
treatment/drc-20350619
https://medlineplus.gov/coronaryarterydisease.html
https://www.webmd.com/heart-disease/guide/heart-disease-coronary-artery-disease#1
https://en.wikipedia.org/wiki/Coronary_artery_disease
https://www.nhlbi.nih.gov/health/health-topics/topics/cad
http://www.heart.org/HEARTORG/Conditions/More/MyHeartandStrokeNews/Coronary-
Artery-Disease---Coronary-Heart-Disease_UCM_436416_Article.jsp
https://www.medicalnewstoday.com/articles/184130.php
http://www.nhs.uk/Conditions/Coronary-heart-disease/Pages/Introduction.aspx
https://www.bhf.org.uk/heart-health/conditions/coronary-heart-disease

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1

5-year average equivalent to 48.1% (HEALTH RESEARCH PRIORITIES REGION 11 2006-

IDENTIFICATION OF THE CASE

Patient: Angkol Sex: male

Age: 61 y/o Religion: Catholic

Occupation: Kagawad Civil Status: Married

Address:Blk. 12 lot Piape Boulevard, Brgy. 22-c Davao City

Educational background: College level

Mothers Name: BaldomeraLacaran - deceased

Fathers Name: CandedoLacaran - deceased

Date Admitted: June 19,2017

Time Admitted: 1:06am

Chief Complaint: Chest pain and Dyspnea

Admitting Dr. Dr. Michelle Angeli G. Sibre

Requesting Dr. Anuar M. Metmug

B. FAMILY HEALTH HISTORY (GENOGRAM)

= Deceased = Male & Female = Patient = Alcoholic = Smoker

= Hypertension = Heart Failure = Diabetic = Liver Problem

D. History of Present Illness JEA

ANATOMY AND PHYSIOLOGY

Unique properties of cardiac muscle

PRESENT ABSENT JUSTIFICATION

A family history of heart disease

Getting older increases the risk of

Men are generally at greater risk

Higher incidence in Africans

PRESENT ABSENT JUSTIFICATION

Being overweight or obese are

Lack of physical activity can

Oral contraceptives may increase

Literature has reported several

infectious agents that can be

Higher incidence in industrialize

SYMPTOMS PRESENT ABSENT JUSTIFICATION

PREDISPOSING FACTORS PRECIPITATING FACTORS

Non-specific injury to arterial wall

Desquamation of endothelial lining

Increased Permeability or Adhesion of

Lipids (LDL) and Platelets Assimilate in

Oxidized LDL attracts monocytes and

Plaques begin to form from cells which

Lipids are engulfed by the cells (foam

Rapid increase in size of the thrombus in

Coronary Atherosclerotic Heart Disease

Reduction of Blood Flow

Decrease Blood supply to the

Decrease myocardial oxygen supply

Anaerobic Metabolism Myocardial Hypoxia

Lactic Acid Production Myocardial Cell necrosis

Chest Pain Increase White Blood Cells

Decreased myocardial Inflammatory response

Decreased cardiac output Released of endogenous

HYPOTENSION Pyrogens will stimulate the

Prostaglandins will reset the

Decreased systemic circulation

Inadequate cerebral perfusion Dizziness; Lost

Increase heart rate/ pumping

Decrease arterial pressure

Left Ventricular Hypertrophy

Deterioration of hearts ability to

Moderate Left Ventricular

Right side of the heart