Clinical Paper

ACKNOWLEDGMENT
Ours is a place of countless, amazing individuals who do

wonderful deeds in the service of others and for the welfare of
others. With the completion of this paper, the group would like to
extend their heartfelt gratitude to these individuals who have
graciously helped us.
First and righteously, to the Almighty God who is our every
breath, our sacred path and our mighty Saviour.
To the Dean of the college of Nursing, Sr. Mila Grace Silab, SPC,
for giving us the privilege to have our clinical rotation in the
Negros Oriental Provincial Hospital – Upper Annex headed by Mrs.
Editha Kinilitan.
To our clinical instructor, Mr. Persee James Baybay, RN for
guiding us all throughout this rotation and for graciously sharing his
knowledge.
To our ever dearest parents, for their immeasurable love and
undying support for us, especially, on our financial needs.
To each of our groupmates, for sharing the task and influencing
each other to complete this paper.
To the staff and personnel for warmly welcoming us and
accommodating us.
1
ABSTRACT
This is a case of patient B.V., 76- year old, female, widow,
Filipino residing at Candanqui, Asagra Tanjay City, Negros Oriental
who was admitted due to epigastric pain radiating to the chest, crampy
with a pain scale of 10/10 as 0 as no pain and 10 as severe pain last
April 14, 2011 at 6:05 in the morning in Negros Oriental Provincial
Hospital, Upper Annex. She was being referred in Holy Child Hospital
from Silliman University Medical Center due to inavailability
Intensive Care Unit. When she was being referred to Holy Child
Hospital she has been referred again in Negros Oriental Provincial
Hospital, Upper Annex due to financial problem. She was wheeled in via
stretcher in the Negros Oriental Provincial Hospital Emergency Room
with the following vital signs of: P=76 bpm, R=intubated, BP=120/80
mmHg, with an O2 saturation of 92%.
This paper includes the case overview, case data and information
which consist of patient’s biographical data, health history,
functional health pattern, review of systems, physical assessment,
laboratory examinations, and diagnostic exams. In order to understand
in full context the case of the patient, the normal anatomy and
physiology, the theoretical background as well as the medical,
pharmacological and nursing management are tackled and integrated.
On the other hand, case analysis and interpretation discuss the
pathophysiology of the disease, the real and appropriate medical,
pharmacological and nursing management which the patient has acquired.
Four priorities nursing care plans facilitate guidance or aid towards
rendering safe and quality care that the patient needs.
2
CHAPTER 1: OVERVIEW
I. INTRODUCTION
Acute Coronary Syndrome (ACS) refers to a spectrum of clinical
presentations ranging from those for ST-segment elevation myocardial
infarction (STEMI) to presentations found in non–ST-segment elevation
myocardial infarction (NSTEMI) or in unstable angina. ACS is almost
always associated with rupture of an atherosclerotic plaque and
partial or complete thrombosis of the infarct-related artery.
Myocardial Infarction commonly known as a heart attack is the
irreversible necrosis of heart muscle secondary to prolonged ischemia.
This usually results from an imbalance in oxygen supply and demand,
which is most often caused by plaque rupture with thrombus formation
in a coronary vessel, resulting in an acute reduction of blood supply
to a portion of the myocardium.
ST elevatum refers to a finding on an electrocardiogram, wherein
the trace in the ST segment is abnormally high above the isoelectric
line. Killip 2 includes individuals with rales in the lungs, an S3
gallop, and elevated jugular venous pressure.
In a STEMI, the coronary artery is completely blocked off by the blood
clot, and as a result virtually all the heart muscle being supplied by
the affected artery starts to die. This more severe type of heart
attack is usually recognized by characteristic changes it produces on
the ECG. One of those ECG changes is a characteristic elevation in
what is called the "ST segment." The elevated ST segment indicates
that a relatively large amount of heart muscle damage is occurring
(because the coronary artery is totally occluded), and is what gives
this type of heart attack its name.
This is the case of Mrs. B.V., a 76-year old widowed patient from
Tanjay City. She was admitted at Negros Oriental Provincial Hospital,
Upper Annex due to epigastric pain radiating to the chest, crampy with
a pain scale of 10/10 as 0 as no pain and 10 as severe pain last April
14, 2011 at 6:05 in the morning. Her impression was Acute Coronary
Syndrome, Inferior wall Myocardial Infarction, Killip 2. During her
hospital stay, she received both medical and nursing managements.
The researchers decided to choose this case because of several
reasons. First, this case was only being assigned to us by our
clinical instructor. Secondly, this case is interesting because this
is our first time to encounter Killip 2 as one of our impression or
diagnosis of our patient. And lastly, the researcher takes this as a
challenge since they have not yet had any background about STEMI that
would hopefully help in the understanding and analysis of the disease
per se.
3
II. OBJECTIVES
The following objectives are goal of this study;
1. Discuss the normal anatomy and physiology of the cardiovascular
system and respiratory system;
2. Determine the current health status of the patient through
thorough physical assessment, laboratory examinations and as
well as diagnostic procedures of which the patient has
undergone;
3. Properly trace the pathogenesis of the disease processes starting
from the precipitating and predisposing etiologic factors that
cause the disease of the patient;
4. Relate concepts and theories with the actual data gathered from
the patient;
5. Develop an effective and efficient nursing care plan including
the primary caregiver’s participation that could help the
patient in recovering fast and enhance the well-being of the
patient;
6. Rationalize all medical and nursing actions applied to the
patient;
7. Evaluate on the effectiveness of the interventions including the
medical and nursing care managements rendered to the patient.
4
III. SCOPE AND LIMITATIONS
This clinical paper will discuss the information related to the
care and condition of the patient during his present hospitalization;
included in this paper are the focused physical assessment, laboratory
results with their corresponding interpretations, background of the
normal anatomy and physiology of the affected systems, theoretical
background of the admitting impression in connection to the patient’s
status and manifestations, the pathophysiology constructed to trace
the progression of the disease process and the measures provided to
solve each existing problems and manifestations, the effectiveness of
these interventions reflected on the progress notes, and discharge
planning designed for the promotion of the patient’s well-being.
In the process of making this clinical paper, the group
encountered some limitations which are the following:
1. No enough data about the history of the patient because the
significant others don’t have enough knowledge about the
background of the patient and the patient seems irritable.
2. The researchers don’t have thorough physical assessment because
the patient doesn’t want to be disturbed.
3. The researchers were not able to perform percussion because the
patient refuses to cooperate and she complained of pain.
5
CHAPTER 2: CASE DATA AND INFORMATION
IV. HEALTH HISTORY
a. BIOGRAPHICAL DATA
Name: Mrs. B.V
Address: Candanqui Asagra, Tanjay City, Negros Oriental
Sex: Female
Age: 76 years old
Birth date: August 20, 1935
Place of Birth: Tanjay City, Negros Oriental
Nationality: Filipino
Marital Status: Widowed
Religion: Roman Catholic
Education: High School Graduate
Occupation: Farmer
Health Insurance: None
Referral: From Tanjay Urgent Care to Silliman University Medical
Center to Holy Child Hospital to Negros Oriental Provincial Hospital,
Upper Annex
Physician: Dr. M.R.J.S and Dr. M.J.H
Source and Realibility: 40% patient’s chart; 50% patient; 10%
significant others
b. REASON FOR SEEKING HEALTH CARE

“Nikalit man gud og sakit akong dughan dai” as verbalized by the
patient.
c. CURRENT HEALTH STATUS

Prior to admission, patient was working in the farm. At around
12:00 noon, patient went to the Tanjay Urgent Care to seek medical
check up for her granddaughter due to vomiting and diarrhea. At around
3:00 in the afternoon, patient went home to get some things for her
granddaughter because it was being admitted on that particular
institution. At around 9:00 in the evening, patient complained of
epigastric pain radiating to the chest, crampy with a pain scale of
10/10 as 0 as no pain and 10 as severe pain. So, the significant other
decided to seek medical attention in Silliman University Medical
Center and was being referred to Holy Child Hospital due to
inavailability of accommodation in the Intensive Care Unit. When the
patient was already referred in Holy Child Hospital, it was then
referred again in Negros Oriental Provincial Hospital, Upper Annex due
to financial problem.
6
d. PAST HEALTH HISTORY
Childhood Illness: Patient experienced measles, chickenpox, and mumps
during her childhood days.
Hospitalization: It was her first time to be admitted in the hospital

due to ACS, Inferior wall MI, ST Elevatum, Killip II last April 14,
2011 at 6:05 in the morning.
Surgeries: None
Serious Injuries: None
Serious/Chronic Illness: Myocardial Infarction, Diabetes Mellitus
Immunization: Patient could no longer remember.
Allergies: Patient had no allergies in foods, drugs, and environment.
Medication: None
Travel: From Tanjay City to Dumaguete City
7
e. FAMILY HISTORY
Legend:
Male Patient Died on unknown cause
Female + Deceased Asthma
Alive and Well Myocardial Infarction Acute Coronary Syndrome
MATERNAL SIDE PATERNAL SIDE
+ + + +
+ + + + +
+ +
76
8
PERTINENT FINDINGS:
The patient could no longer remember the age and the cause why
her grandmothers and grandfathers died. They are only two in the
family his brother died of unknown cause. Patient has six children,
all are alive and well and her husband died due to asthma but she
could no longer remember the age when her husband died.
9
V. FUNCTIONAL HEALTH PATTERN
Health Pattern/Beliefs: Patient believes on quack doctors and herbal
plants. She immediately seeks medical attention if she feels something
unusual or problems on her health and if she has money to consult a
physician.
Typical Day: Patient usually wakes up at 4:00 or 5:00 on the morning.

After waking up, she drinks a cup of coffee and eats a piece of bread.
After, she prepares food for her pig. At around 7:00 in the morning
she eats her breakfast together with her family. And after eating her
breakfast, she take some rest and few minutes later she go to the farm
and plants some camote, gabi, etc. at around 11:00 in the morning she
will go home to take his lunch. After eating her lunch, she will go
back at the farm. The distance of her farm from their house is 1
kilometer. At around 5:00 in the afternoon, she will go home. At
around 7:00 in the evening, she will eat her dinner together with her
family. She usually sleeps at around 9:00 in the evening.
Nutritional Health Pattern: Patient usually eats vegetables and fish.

She eats meat sometimes only. She eats three regular meals a day.
Activity and Exercise Patterns: She stated that walking from their
house to the farm which is 1 kilometer in distance and working in her
farm is one way of exercising her body.
Sleep and Rest Pattern: Patients usually had 5 to 6 hours of sleep.
Elimination Pattern: Patient could no longer remember how many times

she urinates in a day. She also defecated at least once a day.
Personal Habits: Patient doesn’t drink any alcoholic beverages and she
smoke lomboy sometimes if she feels nauseated.
Occupational Health Pattern: Patient works in a farm with fresh and

clean air. The environment is surrounded with plants and vegetables.
Environmental Health Pattern: Patient lives in peaceful environment

with clean and fresh air. She has also a friendly neighborhood.
Family Roles and Relationship: She has a good relationship with her
family and neighbors.
10
Stress and Coping: When patient feels stress she usually takes some
rest until stress relieves.
11
VI. GENERAL CONDITION OF THE PATIENT
-Lying on bed in semi-fowlers position.
-With O2 inhalation at 2L/min via nasal cannula.
-With ongoing IVF of PNSS 1 liter at 10 drops per minute with
sidedrip one of D5W 500cc + 2 amp amiodaron at 10 drops per
minute, with a sidedrip two of D5W 90cc + 1 amp Isoket at 2 mg
per minute infusing well at left radial vein.
-With foley bag catheter attached.
-With the following vital signs of:
T = 36.4 °C, afebrile
P = 90 bpm
R = 22 cpm, tachypneic
BP= 120/70 mmHg, normotensive
VII. REVIEW OF SYSTEM
Systems Inspection Palpation Percussion Auscultati

on
INTEGUMENTARY
• Skin -Uniform -Skin is

skin color warm.
with -Exposed
slightly areas are
darker drier than
exposed unexposed
areas. areas.
-No unusual -Coarse in
odor noted. texture.
-Many small -Poor skin
lesions turgor more
(e.g., than 3
macule, seconds noted
papule) on both upper
noted over and lower
her face extremities.
measured
between .
1cm to .5cm
in diameter
and length.
• Nails -Pale nail -Firm in
beds noted. texture.
-Angle of -Poor
nail capillary
attachment refill more
is 160 than 3
degrees. seconds on
-nail both upper
convex. and lower
extremities.
• Hair -Hairs are -Scalp is
12
evenly mobile and
distributed. nontender.
-Presence of
white hairs.
-fine body
hair noted
over the
body.
-presence of
hair in the
axilla.
-Scalp is
intact and
nontender.
HEAD ,FACE AND

NECK
• Head and -symmetrical -TMJ smooth,

Face in shape and symmetrical
round in in motion
contour. with no pain.
-facial
appearance
symmetrical
in features
and
movement.
• Sinuses -No -nontender -nontender
periorbital noted. noted.
edema or -resonant
discoloratio tone noted.
n.
-red glow
noted over
the eyebrow.
-absence of
red glow at
the roof of
the mouth.
• Nose -midline in -
placement. cartilaginous
-shape is portion is
symmetrical slightly
and mobile.
consistent -nontender
with age and noted.
gender. -nares
-no nasal patent.
flaring
noted.
-no drainage
noted.
-intact,
pink ad
moist nasal
mucosa with
no lesion
noted.
-septum
located
midline.
-medial and
13
inferior
turbinates
visible.
• Mouth and -lips are -lips are
Throat midline in soft,
placement, nontender,
symmetrical, and no masses
skin intact. noted.
-dryness -tongue is
noted on soft, without
lips. nodules
-pale pink noted.
noted on -Parotid
lips. glands and
-no unusual submandibular
odors noted. glands are
-no presence nontender.
of teeth.
-oral mucosa
is intact
and moist.
-pale pink
oral mucosa
noted.
-palate
intact.
-pale pink
noted on
palate.
-presence
of whitish
color noted
on the
tongue.
-tongue is
mobile and
nontender.
*we are not
able to
assessed
oropharynx,
uvula and
tonsils
because the
patient
cannot open
her mouth so
much and she
also refuse
to open it
widely.
• Neck -neck is in -nontender -no sounds
midline and no masses detected.
position, no noted.
bulges -lymphnodes
noted. are
nonpalpable.
-Nonpalpable
thyroid
gland.
EYE AND EAR
14
• Visual -Patient
Acuity could no
longer see
clearly in
5ft
distance.
-able to
identifies
the colors
being given.
-Peripheral
vision is
not intact
since our
patient is
too old
already.
• Extraocular -light seen
Muscles symmetricall
y on each
cornea.
-Gaze is
steady when
eye is
covered and
uncovered.
-Parallel
eye
movements in
all
directions.
• External -eyes are in -Eyeball is
Structures parallel firm and
alignment. nontender,
-eyelashes -nontender
are present noted on
and curving lacrimal
outward. gland and
-eyelids are nasolacrimal
in contact duct, gland
with the nonpalpable,
eyeball. and no
-a papule tearing
noted on noted.
the left
eye
measured .1
cm in
diameter
and length.
-eyeballs
protrude not
beyond the
frontal
bone.
-no
swelling,
redness, or
drainage
noted on
lacrimal
gland and
nasolacrimal
15
duct.
-pale pink
conjunctiva
noted.
-sclera is
light
yellowish
in color.
-positive
corneal and
blink
reflex.
-Iris is
dark brown
in color.
-Pupil
constrict
when focus
to near
object and
dilate if
far object.
• External -Intact and -soft and
Ear consistent pliable.
skin color. -nontender
noted.
RESPIRATORY
SYSTEM
• Chest *we are not -trachea is *we are

able to in midline able to
assess the position. percuss the
anterior, -nontender anterior,
lateral, and noted. lateral,
posterior -symmetrical and
chest of the chest posterior
patient excursion thorax
because she without lag. because the
refused to -tactile patient
neither fremitus is refuses to
stand nor equal cooperate
sit down. bilaterally. with us.
*we are not
able to
perform the
diaphragmat
ic
excursion
since the
patient
refuses to
cooperate
with us.
• Lungs -rhonchi
were heard
on both
lungs
during
expiration
.
CARDIOVASCULAR
16
SYSTEM
• Carotid -Carotid -Negative

Artery and artery has bruits.
Jugular visible -Negative
Venous pulsation. venous
System -Carotid hum.
artery is
not affected
to
positioning.
-Jugular
vein visible
in supine
position.
-Positive
carotid
pulsation.
-Jugular
vein
pressure
measured 2.1
cm at 45
degree
angle.
• Precordium -Positive -94 bpm,
pulsation at regular in
apex. rhythm.
-no aortic
murmurs
PERIPHERAL-
VASCULAR AND
LYMPHATIC
SYSTEMS
• Veins and -skin color

Lymphnodes uniform
-fingernails
of equal
thickness
-poor
capillary
refill in
both
extremities
more than 3
seconds
-no erythema
and streaks
-abdominal
contour is
flat
-leg hair
evenly
distributed
• Pulses and -cervical
Lymphnodes nodes non-
palpable
-brachial,
radial, ulnar
pulses are
easily
17
palpated
-
infraclavicul
ar, axillary
and
epitrochlear
nodes are
non-palpable
-femoral,
popliteal,
posterior
tibial and
dorsalis
pedis are
easily
palpated
-no calf pain
is present on
dorsiflexion
-inguinal
lymph nodes
are non-
palpable
-decreased
peripheral
pulses
BREAST
• Breast -breast -Breast soft

slightly and nontender
assymetrical -nipples
-skin color elastic, non
lighter than tender.
exposed
areas
-no dimpling
or
retraction
-nipples
everted,
pointing in
the same
direction,
no discharge
and lesions
-areola and
nipple
darker than
breast
tissue
• Axillae -skin
intact.
-No rashes
and lesions.
• Lymphnodes -clavicular
nodes non-
palpable
ABDOMEN
• Abdomen -abdominal -abdomen soft -bowel *we are
18
skin intact and nontender sounds not able
with no -no present at to perform
lesions or organomegaly a rate of 8 percussion
masses or or masses, clicks per because
-umbilicus nontender minute in the
inverted and each patient
midline quadrant. refuses to
-no cooperate.
abdominal
distention
• Abdominal
Aorta
• Liver *we are not
le to palpate
this arabea
because the
patient
refuses to
cooperate
• Spleen *we are not
le to palpate
this arabea
because the
patient
refuses to
cooperate
• Kidneys *we are not
le to palpate
this arabea
because the
patient
refuses to
cooperate
• Bladder *we are not
le to palpate
this area
because the
patient
refuses to
cooperate
• Inguinal -inguinal
Lymphnodes lymph nodes
non palpable
MOTOR-
MUSCULOSKELETAL
SYSTEM
• Posture *we are not

able to
assess
posture
because the
patient
refuses to
cooperate
• Gait *we are not
able to
assess
posture
because the
patient
19
refuses to
cooperate
• Cerebellar -movements
Function accurate
• Limbs Right arm:
Circumferenc
e: 22 cm
Left arm:
Circumferenc
e: 21 cm
Right leg:
Circumferenc
e: 31 cm
Left leg
Circumferenc
e: 30 cm
• Muscles and -muscles
Joints soft and non
tender in
relaxed
state and
firm and non
tender in
contracted
state
-joints
midline with
no visible
bony
overgrowth,
swelling,
redness,
nontender.
-+4 muscle
strength.
SENSORY-
NEUROLOGIC
SYSTEM
• Cranial -CN II, III,

Nerves IV and VI:
parallel eye
movements in
all
directions;
patient
could no
longer see
clearly in
5ft
distance;
pupils
constrict
when there
is light and
dilate if
there is no
light.
-CN V:
Positive
corneal and
20
blink
reflex.
-CN VII:
Facial
appearance
symmetrical
in features
and
movements.
-CN IX and
X: Swallow
and cough
reflex
intact.
Speech
clear.
-CN XII: can
protrude
tongue
medially, no
atrophy.
Presence of
whitish
discolorati
on on the
tongue.
• Sensory -able to
Function identifies
areas being
stimulated
by light
touch.
21
VIII. LABORATORY EXAMINATION
a. Blood Chemistry
 Is the chemical composition of the blood. The levels of
various substances in the blood can provide clues to a
patient's condition. Routine blood work to check blood
chemistry is often a part of a diagnostic workup, with the
blood being analyzed to check for specific elements which
could contribute clues to the diagnosis.
Random Blood Sugar (RBS)

 A blood glucose test measures the amount of a sugar, called
glucose, in a sample of your blood. Glucose is a major
source of energy for most cells of the body, including
those in the brain. The carbohydrates you eat eventually
end up as glucose in the blood.
Table 1.1
BLOOD CHEMISTRY 04/14/11
Component Result Reference Range Significance

• RBS 135 mg/dL 45-130 mg/dL High
Interpretation:
Since our patient is diabetic, her sugar in the blood is
increase.
Sodium
 Plays a major role in regulating the amount of water in the
body. Also, the passage of sodium in and out of cells is
necessary for many body functions, like transmitting
electrical signals in the brain and in the muscles. The
sodium levels are measured to detect whether there's the
right balance of sodium and liquid in the blood to carry
out those functions.
Potassium
 Is essential to regulate how the heart beats. Potassium
levels that are too high or too low can increase the risk
of an abnormal heartbeat. Low potassium levels are also
associated with muscle weakness.
22
Table 1.2
BLOOD CHEMISTRY 04/14/11
• Na+ 142.4 mmol/L 135-148 mmol/L Normal

• K+ 4.0 mmol/L 3.5-5.3 mmol/L Normal
Blood Urea Nitrogen (BUN)

 The nitrogen component of urea, B.U.N. is the end product
metabolism and its concentration is influenced by the rate
of excretion. Increases can be caused by exercise protein
intake, intestinal bleeding, exercise or heart failure.
Decreased levels may be due to a poor diet, malabsorption,
liver damage or low nitrogen intake.
Creatinine
 Is the waste product of muscle metabolism. Its level is a
reflection of the bodies muscle mass. Low levels are
sometimes seen in kidney damage, protein starvation, liver
disease or pregnancy. Elevated levels are sometimes seen in
kidney disease due to the kidneys job of excreting
creatinine, muscle degeneration, and some drugs involved in
impairment of kidney function.
Fasting Blood Sugar (FBS)

 is one of the tests used to diagnose diabetes mellitus
(another being the oral glucose tolerance test).It is also
used to determined by taking a sample of venous blood after
an overnight fasting. The sugar level is then evaluated in
the blood sample.
Uric Acid
 Is the end product of purine metabolism and is normally
excreted through the urine. High levels are noted in gout,
infections, kidney disease, alcoholism, high protein diets,
and with toxemia in pregnancy. Low levels may be indicative
of malabsorption, a diet low in purines, liver damage, or
an overly acid kidney.
23
Cholesterol
 Is a critical fat that is a structural component of cell
membrane and plasma lipoproteins, and is important in the
synthesis of steroid hormones, glucocorticoids, and bile
acids. Mostly synthesized in the liver, some is absorbed
through the diet, especially one high in saturated fats.
Elevated cholesterol has been seen in artherosclerosis,
diabetes, hypothyroidism, and pregnancy. Low levels are
seen in depression, malnutrition, liver insufficiency,
malignancies, anemia, and infection.
Tryglycerides
 Stored in adipose tissues as glycerol, fatty acids and
monoglycerides are reconverted as triglycerides by the
liver. Ninety percent of the dietary intake and 95% of the
fat stored in tissues are triglycerides. Increased levels
may be present in artherosclerosis, hypothyroidism, liver
disease, pancreatitis, myocardial infarction, metabolic
disorders, toxemia, and nephrotic syndrome. Decreased
levels may be present in chronic obstructive pulmonary
disease, brain infarction, hyperthyroidism, malnutrition,
and malabsorption.
Chol_HDL (High Density Lipoprotein)

 Is the cholesterol carried by the alpha lipoproteins. A
high level of HDL is an indication of a healthy metabolic
system if there is no sign of liver disease or
intoxication. The two mechanisms that explain how HDL
offers protection against chronic heart disease are that
HDL inhibits cellular uptake of LDL and serves as a carrier
that removes cholesterol from the peripheral tissues and
transports it back to the liver for catabolism and
excretion.
Chol_LDL (Low Density Lipoprotein)

 Is the cholesterol rich remnants of the lipid transport
vehicle VLDL (very-low density lipoproteins) there have
been many studies to correlate the association between high
levels of LDL and arterial artherosclerosis. Due to the
expense of direct measurement of LDL a calculation, known
as the Friedewald formula is used. It is Total Cholesterol
- HDL Cholesterol - (Triglycerides/5). When triglyceride
24
levels are greater than 400 mg/dL, this calculation is not
accurate.
Serum Glutamic-Pyruvic Transaminase (SGPT)

 Is an enzyme found primarily in the liver but also to a
lesser degree, in the heart and other tissues. It is useful
in diagnosing liver function more so than sGOT levels.
Decreased sGPT in combination with increased cholesterol
levels is seen in cases of a congested liver. Increased
levels are also seen in mononucleosis, alcoholism, liver
damage, kidney infection, chemical pollutants, or
myocardial infarction.
Table 1.3
BLOOD CHEMISTRY 04/15/11 10:13 am
Components Result Reference Significance

Range
• BUN 42 mg/dL 11-36 mg/dL High
• Creatinine .93 mg/dL .57-.9 mg/dL High
• FBS 139 mg/dL 70-110 mg/dL High
• Uric Acid 5.3 mg/dL 2.5-6.8 mg/dL Normal
• Cholesterol 154 mg/dL 0-200 mg/dL Normal
• Tryglycerides 72 mg/dL 0-250 mg/dL Normal
• Chol_HDL 47 mg/dL 45-65 mg/dL Normal
• Chol_LDL 93 mg/dL 0-150 mg/dL Normal
• SGPT 90 U/L 0-76 U/L High
Interpretation:
Patient has elevaterd BUN, creatinine, fasting blood sugar, and
serum glutamic-pyruvic transaminase. Since our patient has myocardial
infarction due to inadequate oxygen supply in the myocardial cells the
heart will try to compensate, so, the workload increases which results
into increase metabolism which is the by product is BUN.
The creatinine also is increase because once there is a problem
in regulating the bood, the kidney will also try to compensate in
order have homeostasis in the body since our patient has already had
infarction and the activity of the myocardial cells are altered so,
the regulation of the blood was also impaired and the kidney will
continue to compensate until it will become exhausted and it might
result into kidney malfunction. Since, the kidney is the only organ
that secretes creatinine in the body.
Fasting blood sugar of our patient is high because she is also a
diabetic. The serum glutamic pyruvic transaminase is also high because
the patient has myocardial infection. According to MedicineNet.com
(2011), SGPT is an enzyme that is normally present in liver and heart
25
cells, and is released into blood when there is liver or heart
damaged. Since, the patient has infarction the myocardial cells are
affected where the SGPT is present.
Troponin T
 Primarily ordered for people who have chest pain to see if
they have had a heart attack or other damage to their
heart. Either a troponin I or a troponin T test can be
performed; usually a laboratory will offer one test or the
other. Troponins are sometimes ordered along with other
cardiac biomarkers, such as CK–MB or myoglobin. However,
troponins are the preferred tests for a suspected heart
attack because they are more specific for heart injury than
other tests (which may become positive in skeletal muscle
injury) and remain elevated for a longer period of time. It
is also used to help diagnose a heart attack, to detect and
evaluate mild to severe heart injury, and to distinguish
chest pain that may be due to other causes. In patients who
experience heart-related chest pain, discomfort, or other
symptoms and do not seek medical attention for a day or
more, the troponin test will still be positive if the
symptoms are due to heart damage.
Table 1.4
BLOOD CHEMISTRY 04/15/11 02:25 pm
• Troponin T >2.0 ng/mL <0.03

Positive
Interpretation:
Patient underwent Troponin T because she experienced epigastric
pain radiating to the chest with a pain scale of 10/10 as 0 as no pain
and 10 as severe pain prior to admission. Since this test is being
ordered if the patient have chest pain to see if they have had a heart
attack or other damage to their heart.
26
b. Urinalysis
 Is the physical, chemical, and microscopic examination of
urine. It involves a number of tests to detect and measure
various compounds that pass through the urine.
Table 1.5
MACROSCOPIC EXAMINATION 04/14/11 9:40 am
Component Result Normal Significance

Characteristic
• Color Lt. Yellow Pale to Amber Normal
Yellow
• Transparency Turbid Clear / Abnormal
Transparent
• Sp. Gravity 1.030 1.003-1.030 Normal
• Glucose Trace Negative Abnormal
• Protein +1 Negative Abnormal
• pH 6.0 4.0-8.0 Normal
Interpretation:
Patient underwent urinalysis because this is used to evaluate if
the organs, especially the kidney is well functioning. Normally,
protein and glucose should not be detectable in the urine. Since our
patient has increased creatinine which indicates malfunctioning of the
kidney, so, the functions of the kidney is affected or altered,
especially filtration of waste products. And also, the patient has
increased sugar in the blood. Patient has turbid urine due to presence
of protein in the blood.
Table 1.6
MICROSCOPIC EXAMINATION 04/14/11 9:40 am
• Pus Cells 6.10/hpf 5-10/hpf Normal

• WBC 8.12/hpf 0-5/hpf High
• Epith. Few Few Normal
Cells
• Crystals (-) Negative Normal
• Amoph. Moderate Few Abnormal
Urates
• Bacteria Moderate Few Abnormal
Interpretation:
Since, the patient has malfunctioning kidney, the ability to
filter waste or toxic materials is altered and also the white blood
cells of the patient is increase which indicates infection.
27
c.
Table 1.7
04/14/11 8:50 am
Component Result
• Pro Time 14 secs

• INR 1.2
• % Act 85.3
• Cont. 13 ins
d. Diagnostic Clinical Laboratory

Hematocrit
 It means "to separate blood", a procedure which is done
following the blood draw through the proper use of a
centrifuge. It is the measurement of the percentage of red
blood cells in whole blood. It is an important determinant
of anemia (decreased), polycythemia (increased),
dehydration (elevated), increased R.B.C. breakdown in the
spleen (decreased), or possible overhydration (decreased).
Hemoglobin
 Is the main transport of oxygen and carbon dioxide in the
blood. It is composed of globin a group of amino acids that
form a protein and heme which contains iron atoms and
imparts the red color to hemoglobin. As with Hematocrit, it
is an important determinant of anemia (decreased),
dehydration (increased), polycythemia (increased), poor
diet/nutrition, or possibly a malabsorption problem.
White Blood Cells (WBC)

 White blood cells main function is to fight infection,
defend the body by phagocytosis against invasion by foreign
organisms, and to produce, or at least transport and
distribute, antibodies in the immune response.
Platelet
 Platelets (also known as thrombocytes) are the smallest
formed elements of the blood. They are vital to coagulation
of the blood to prevent excessive bleeding. Elevated levels
suggest dehydration or stimulation of the bone marrow where
28
the cells are produced and decreased levels may indicate an
immune system failure, drug reactions, B12, or folic acid
deficiency.
Table 1.8
HEMOCHROME
• WBC- 15.9 K/uL 4.0-11.0 K/uL High

Leukocytes
• Hgb 11.8 g/dL 11.5-16.5 g/dL Normal
• Hct 34.9% 37.0-47.0% Low
• Plt 237 K/uL 150-400 K/uL Normal
Interpretation:
Patient has increased white blood cells which indicates infection
and has decreased hematocrit which indicates anemia.
Table 1.9
LEUCOCYTES FORMULA
Components Result Reference Range Significance
• Lymphocyte 8 20-45 Low

• Monocyte 5 0-10 Normal
• Neutrophil 85 40-75 High
• Eosinophil 2 0-6 Normal
• Basophil 0 0-1 Normal
Interpretation:
Patient has increased neutrophil which indicates current
infection.
IX. DIAGNOSTIC STUDIES

Electrocardiogram
 Is a diagnostic tool that measures and records the
electrical activity of the heart in exquisite detail.
Interpretation of these details allows diagnosis of a wide
range of heart conditions.
Interpretation: ST segment elevated
29
CHAPTER 3: LITERATURE REVIEW
X. ANATOMY AND PHYSIOLOGY
THE CARDIOVASCULAR SYSTEM
The Heart
Heart is a hollow muscular organ that pumps blood through the
body. The heart and blood vessels make up the circulatory system,
which is responsible for distributing oxygen and nutrients to the body
and carrying away carbon dioxide and other waste products. The heart
is the circulatory’s system power supply. It beats ceaselessly because
the body’s tissues-especially the brain and the heart itself- depend
on constant supply of oxygen and nutrients delivered by the flowing
blood. If the heart stops pumping blood for more than a few minutes,
death will result.
The human heart is shaped like an upside-down pear and is located
slightly to the left of center inside the chest cavity. About the size
of a closed fist, the heart is made primarily of muscle tissue that
contracts rhythmically to propel blood to all parts of the body. This
rhythmic contraction begins in the developing embryo about three weeks
after conception and continues throughout an individual’s life. The
muscle rests only for a fraction of a second between beats. Over a
typical life span of 76 yars, the heart will beat nearlly 2.8 billion
and move 169 million liters of blood.
The Structure of the Heart

The human heart has 4 chambers. The upper 2 chambers, the right
and left atria, are receiving chambers for blood. The atria are
30
sometimes known as auricles. They collect blood that pours in from
veins, blood vessels that return blood to the heart. The heart’s lower
two chambers, the right and left ventricles, are the powerful pumping
chambers. The ventricles propel blood into arteries, blood vessels
that carry blood away from the heart. A wall of tissue separates the
right and left side of the heart. Each side pumps blood through a
different circuit blood vessels: The right side of the heart pumps
oxygen poor blood to the lungs, while the left side of the heart pumps
oxygen rich blood to the body. Blood returning from a trip around the
body has given up most of its oxygen and picked up carbon dioxide in
the body’s tissues. This oxygen poor blood feeds into 2 large veins,
the superior vena cava and inferior vena cava, which empty into the
right atrium of the heart.
The right atrium conducts blood to the right ventricle, and the
right ventricle pumps blood into the pulmonary artery. The pulmonary
artery carries blood to the lungs, where it picks up a fresh supply of
oxygen and eliminates carbon dioxide. Blood passes from the left
atrium into the left ventricle, from where it is pumped out of the
heart into the aorta, the body’s largest artery. Smaller arteries that
branch off the aorta distribute blood to various parts of the body.
The Myocardium
Muscle tissue, known as myocardium or cardiac muscle, wraps
around a scaffolding of tough connective tissue to form the walls of
the heart’s chambers. The atria, the receiving chambers of the heart
have relatively thin walls compared to the ventricles, the pumping
chambers. The left ventricle has the thickest walls- nearly 1 cm (0.5
in) thick in an adult because it must work the hardest to propel blood
to the farthest reaches of the body.
The Pericardium
A tough, double-layered sac known as the pericardium surrounds
the heart. The inner layer of the pericardium, known as the
epicardium, rests directly on top of the heart muscle. The outer layer
of the pericardium attaches to the breastbone and other structures in
the chest cavity and helps hold the heart in place. Between the 2
layers of the pericardium is a thin space filled with a watery fluid
that helps prevent these layers from rubbing against each other when
the heart beats.
The Endocardium
31
The inner surface of the heart’s chambers is lined with a thin
sheet of shiny, white tissue known as the endocardium. The same type
of tissue, more broadly referred to as endothelium, also lines the
body’s blood vessels, forming one continuous lining throughout the
circulatory system. This lining helps blood smoothly and prevents
blood clots from forming inside the circulatory system.
Function of the Heart

The heart's duties are much broader than simply pumping blood
continuously throughout life. The heart must also respond to changes
in the body's demand for oxygen. The heart works very differently
during sleep, for example, than in the middle of a 5-km (3-mi) run.
Moreover, the heart and the rest of the circulatory system can respond
almost instantaneously to shifting situations-when a person stands up
or lies down, for example, or when a person is faced with a
potentially dangerous situation
The Cardiac Cycle

Although the right and left halves of the heart are separate,
they both contract in unison, producing a single heartbeat. The
sequence of events from the beginning of one heartbeat to the
beginning of the next is called the cardiac cycle. The cardiac cycle
has two phases: diastole, when the heart's chambers are relaxed, and
systole, when the chambers contract to move blood. During the systolic
phase, the atria contract first, followed by contraction of the
ventricles. This sequential contraction ensures efficient movement of
blood from atria to ventricles and then into the arteries. If the
atria and ventricles contracted simultaneously, the heart would not be
able to move as much blood with each beat.
During diastole, both atria and ventricles are relaxed, and the
atrioventricular valves are open. Blood pours from the veins into the
atria, and from there into the ventricles. In fact, most of the blood
that enters the ventricles simply pours in during diastole. Systole
then begins as the atria contract to complete the filling of the
ventricles. Next, the ventricles contract, forcing blood out through
the semilunar valves and into the arteries, and the atrioventricular
valves close to prevent blood from flowing back into the atria. As
pressure rises in the arteries, the semilunar valves snap shut to
prevent blood from flowing back into the ventricles. Diastole then
begins again as the heart muscle relaxes-the atria first, followed by
the ventricles-and blood begins to pour into the heart once more.
32
THE RESPIRATORY SYSTEM
Your respiratory system is made up of the organs in your body

that help you to breathe. The goal of breathing is to deliver oxygen
to the body and to take away carbon dioxide. The gaseous exchange
essential for life is the primary function parts of the respiratory
system. Six basic parts of respiratory system are: nose, pharynx,
larynx, trachea, bronchi, and lungs.
Lungs
The lungs are the main organs of the respiratory system. In the
lungs oxygen is taken into the body and carbon dioxide is breathed
out. The red blood cells are responsible for picking up the oxygen in
the lungs and carrying the oxygen to all the body cells that need it.
The red blood cells drop off the oxygen to the body cells, then pick
up the carbon dioxide which is a waste gas product produced by our
cells. The red blood cells transport the carbon dioxide back to the
lungs and we breathe it out when we exhale. Each lung is divided into
upper and lower lobes. The right lung is larger and heavier than the
left lung, which is somewhat smaller in size because of the position
of the heart. Several lung parts and functions act as protective
mechanisms to keep out irritants and foreign particles. The hairs and
mucus in the nose prevent foreign particles from entering the
respiratory system. The breathing tubes in the lungs secrete mucus,
33
which also helps protect the lungs from foreign particles. This mucus
is naturally pushed up toward the epiglottis, where is passed into the
esophagus and swallowed.
Mechanisms of Breathing
To take breathe in, the external intercostal muscles contract,
moving the ribcage up and out. The diaphragm moves down at the same
time, creating negative pressure within the thorax. The lungs are held
to the thoracic wall by the pleural membranes, and so expand outwards
as well. This creates negative pressure within the lungs, and so air
rushes in through the upper and lower airways. Expiration is mainly
due to the natural elasticity of the lungs, which tend to collapse if
they are not held against the thoracic wall. This is the mechanism
behind lung collapse if there is air in the pleural space.
34
XI. THEORETICAL BACKGROUND
Acute coronary syndrome (ACS)
 Refers to a spectrum of clinical presentations ranging from
those for ST-segment elevation myocardial infarction
(STEMI) to presentations found in non–ST-segment elevation
myocardial infarction (NSTEMI) or in unstable angina. ACS
is almost always associated with rupture of an
atherosclerotic plaque and partial or complete thrombosis
of the infarct-related artery
ETIOLOGY
-Smoking*
-Family history
-Lack of regular physical activity
-Obesity
-Diabetes Mellitus
-Hypertension
-Job stress*
-Decreased oxygen saturations
MANIFESTATIONS
-Chest pain (including squeezing, crushing, pressure, tightness
or heaviness in the chest)*
-Pain or discomfort in your arms, shoulders, neck, back or jaw.*
-Indigestion, such as heartburn and upset stomach.*
-Nausea and vomiting*
-Stomachache
-Shortness of breath*
-Sweating*
-weakness or fainting*
NOTE: * indicates patient’s manifestations
MANAGEMENT
MEDICAL MANAGEMENT
-Sublingual nitroglycerin and aspirin are given if not done by
emergency medical personnel prior to arrival at the emergency
department
-Oxygeyn is administered via nasal cannula at a rate of 2to 4
liters per minute.
35
-Morphine sulfate is given IV for pain unrelieved by
nitroglycerin
SURGICAL MANAGEMENT
-Coronary Artery Bypass graft consists of the construction of new
conduits (vessels to transport blood) between the aorta, or other
major arteries, and the myocardium distal to the obstructed coronary
artery. The procedure involves one or more grafts using the internal
mammary artery, saphenous vein, radial artery, gastroepiploic artery,
and/or inferior epigastric area.
NURSING MANAGEMENT
-Monitor blood pressure, breath sounds and pulse rate
-Careful monitoring of intake and output
-Promote bed rest as while in distress, and then promote gradual
increase of activity
-Provide small frequent meals and decrease salt
-Create a relaxing environment
-Monitor progression of pain
-Provide psychological support
ST Segment Elevation Myocardial Infarction (STEMI)

The coronary artery is completely blocked off by the blood clot,
and as a result virtually all the heart muscle being supplied by the
affected artery starts to die. This more severe type of heart attack
is usually recognized by characteristic changes it produces on the
ECG. One of those ECG changes is a characteristic elevation in what is
called the "ST segment." The elevated ST segment indicates that a
relatively large amount of heart muscle damage is occurring (because
the coronary artery is totally occluded), and is what gives this type
of heart attack its name.
ETIOLOGY
-Increasing age (over age 65)*
-Diabetes
-Smoking*
-Physical stress*
-Atherosclerosis
CLINICAL MANIFESTATIONS
-substernal chest pain
36
-crushing and squeezing feeling of the chest*
-diaphoresis*
-cool clammy skin
-facial pallor
-hypertension
-tachycardia*
-dyspnea*
-confusion
-restlessness
-marked weakness*
-nausea
-vomiting*
-epigastric pain*
-shortness of breath*
NOTE: * indicates patient’s manifestations
MANAGEMENT
MEDICAL MANAGEMENT
-Thrombolytic therapy by I.V. or intracoronary route, to dissolve
thrombus formation and reduce the size of the infarction.
-Anticoagulants or other anti-platelet medications such as
adjunct to thrombolytic therapy.
-Beta-adrenergic blockers, to improve oxygen supply and demand,
decrease sympathetic stimulation to the heart, promote blood flow
in the small vessels of the heart, and provide antiarrhythmic
effects.
-Calcium channel blockers, to improve oxygen supply and demand.
SURGICAL MANAGEMENT
-Coronary surgical revascularization with CABG surgery is
recommended for patients who fail medical management, have left
main coronary artery or three vessel disease and are not
candidates for PCI
-Coronary Artery Bypass graft consists of the construction of new
conduits (vessels to transport blood) between the aorta, or other
major arteries, and the myocardium distal to the obstructed
coronary artery. The procedure involves one or more grafts using
the internal mammary artery, saphenous vein, radial artery,
gastroepiploic artery, and/or inferior epigastric area.
-Percutaneous coronary intervention- the patient will have
cardiac catheterization to locate the blockage, assess the
37
severity of the blockage , determine the presence of collateral
circulation, and evaluate left ventricular function
NURSING MANAGEMENT
-Monitor continuous ECG to watch for life threatening arrhythmias
-Monitor baseline vital signs before and 10 to 15 minutes after
administering drugs. Also monitor blood pressure continuously
when giving nitroglycerin I.V.
-Take measures to prevent bleeding if patient is thrombolitic
therapy
-Be alert to signs and symptoms of sleep deprivation such as
irritability, disorientation, hallucinations, diminished pain
tolerance, and aggressiveness.
-Tell the patient that sexual relations may be resumed on advise
of health care provider, usually after exercise tolerance is
assessed.
38
MEDICAL MANAGEMENT
1. Intravenous fluid therapy
 Is a commonly used procedure in hospitals and medical
facilities that delivers fluids through sterile tubing into
a needle inserted into a vein.
For the patient:

 PNSS 1L @ 10gtts/min.
 an aqueous solution of 0.9 percent sodium chloride, isotonic
with
the blood and tissue fluid, used in medicine chiefly for ba
thingtissue and, in sterile form, as a solvent for
drugs that are to be
administered parenterally to replace body fluids.
Nursing considerations:
 Check for signs of IV infiltration.
 Regulate and monitor the flow rate. It should be in the

right amount.
 In giving IV medications, it should be slowly administrated
to lessen the pain.
 IV fluids should be slowly administrated to prevent
overload.
2. Anti-coagulant
 A drug that helps prevent the clotting (coagulation) of
blood. These drugs tend to prevent new clots from forming
or an existing clot from enlarging. They don't dissolve a
blood clot. Anticoagulants are also given to certain people
at risk for forming blood clots, such as those with
artificial heart valves or who have atrial fibrillation.
 Check for hypersensitivity of the drug.
 Check for allergies.
 Consider the 5 rights of medication before administering

it.
 Monitor the patient for adverse reactions.
39
 Instruct the patient to report any unusual symptoms
immediately.
 Monitor patient for unusual bleeding or bruising; drug
significantly increases risk of bleeding.
3. Antianginals
 Block coronary vasospasm (coronary vasodilators) or inhibit
clot formation are used to treat variant and unstable
angina, respectively. These drugs act by increasing
coronary blood flow and oxygen supply, or by preventing
vasospasm and clot formation, and associated decreases in
blood flow. Drugs that reduce myocardial oxygen demand are
also given to patients with these two forms of angina to
reduce oxygen demand and thereby help to alleviate the pain.
Nursing Considerations:
 Monitor arterial blood gas values and methemoglobin levels.
 Monitor vital signs closely, especially blood pressure.

 Consider the 5 rights of medication before administering it.

immediately.
4. Antiarrythmics
 Are used to treat abnormal heart rhythms resulting from
irregular electrical activity of the heart.
Nursing consideration:
 ECG should be monitored continuously.
 Assess for signs and symptoms of ARDS.

 Assess for signs of pulmonary toxicity.
 Monitor Blood Pressure Frequently.


it.
40
immediately.
5. Anti-ulcer
 Block the secretion of gastric acid by the gastric parietal
cells. The extent of inhibition of acid secretion is dose
related. In some cases, gastric acid secretion is
completely blocked for over 24 hours on a single dose. In
addition to their role in treatment of gastric ulcers, the
proton pump inhibitors are used to treat syndromes of
excessive acid secretion.
Nursing Consideration:
 Assess vital signs.
 Check for abdominal pain, emesis, diarrhea, or
constipation.
 Evaluate fluid intake and output.


it.
immediately.
6. Anti-diabetics
 A substance that helps a person with diabetes controls
their level of glucose (sugar) in the blood. Antidiabetic
agents include insulin and the oral hypoglycemic agents.
Nursing Consideration:
 Observe patient for signs and symptoms of hypoglycemic
reactions (abdominal pain, sweating, hunger, weakness,
dizziness, headache, tremor, tachycardia, anxiety) when
combined with oral sulfonylureas.
 Monitor serum folic acid and vitamin B12 every 1-2 year in
long term therapy.
41
it.

immediately.
7. Anti-infectives
 Pertaining to a substance used in the treatment of an
infection.
 Observe patient for signs and symptoms of anaphylaxis
(rash, pruritus, laryngeal edema, wheezing).
 Assess patient for infection (vital signs, appearance of
wound, sputum, urine, and stool).

it.

immediately.
8. Oxygen therapy
 The administration of oxygen as a therapeutic modality. It
is prescribed by the physician, who specifies the
concentration, method of delivery, and liter flow per
minute. It alleviates tiredness and decreases shortness of
breath of the patient.
 The 02 that the patient had is via nasal cannula/ nasal
prongs regulated at 2L/min.
 It is the most inexpensive device used to administer
oxygen. It doesn’t interfere with the client’s ability to
eat or talk.
Nursing Considerations:
 Place cautionary signs reading “No Smoking: Oxygen in use” on
the clients door, at the foot or head of the bed, and on the
oxygen equipment.
42
 Check the nasal catheter if it’s working properly with your
hand.
 Assess skin, breathing pattern, chest movement, and Lung
sounds to check the effectivity of the therapy.
 Regulate the flow rate as prescribed.
 Monitor V/S to note any signs of distress.
PHARMACOLOGICAL MANAGEMENT
Generic name: Amiodarone

Brand name: Cordarone
Therapeutic class: Antiarrythmics
Action: Prolongs action potential and refractory period; Inhibits
adrenergic stimulation; Slows the sinus rate, increases PR and QT
intervals, and decreases the peripheral vascular resistance
Indication: ventricular arrhythmias
Contraindication: severe sinus node dysfunction, 2nd and 3rd degree AV
block and bradycardia
Adverse reactions:
CNS: dizziness, fatigue, malaise, headache, insomnia
EENT: corneal microdeposits
Respiratory: acute respiratory distress syndrome, pulmonary
fibrosis
CV: CHF, bradycardia, hypotension
GI: anorexia, constipation, nausea, vomiting, abdominal pain
Derm: photosensitivity, blue discoloration
Endo:hypothyroidism
Neuro: ataxia, involuntary movement, paresthesia, peripheral
neuropathy
Dosage: 200 mg
Route: IVTT
Timing: twice a day
 ECG should be monitored continuously.
 Assess for signs and symptoms of ARDS.

 Assess for signs of pulmonary toxicity.
 Monitor Blood Pressure frequently
43
Generic name: Cefotaxime
Brand name: Claforan
Therapeutic class: anti-infectives
Pharmacologic Class: third generation cephalosporins
Action: Cefotaxime binds to one or more of the penicillin-binding
proteins (PBPs) which inhibits the final transpeptidation step of
peptidoglycan synthesis in bacterial cell wall, thus inhibiting
biosynthesis and arresting cell wall assembly resulting in bacterial
cell death.
Indication: urinary infections
Contraindication: Hypersensitivity to cephalosporins.
Adverse reactions:
CNS: seizures
GI: pseudomembranois colitis, diarrhea, nausea, vomiting, cramps,
jaundice
Derm: rashes, urticaria,
Helmatologic: bleeding, blood dycrasias, hemolytic anemia
Dosage: 1 g
Route: IVTT
Timing: every 8 hours
 Assess patient for infection (vital signs, appearance of wound,
sputum, urine, and stool).
 Observe patient for signs and symptoms of anaphylaxis (rash,
pruritus, laryngeal edema, wheezing).
44
Generic name: Ciprofloxacin
Brand name: Cipro, Cipro XR
Therapeutic class: anti-infectives
Action: Inhibit bacterial DNA by inhibiting DNA gyrase.
Indication: Urinary tract and gynecologic infections
Contraindication: Hypersensitivity.
Adverse reactions:
CNS: seizures, dizziness, drowsiness, headache, insomnia,
agitation, confusion
CV: arrythmias
GI: hepatotoxicity, abdominal pain, diarrhea, nausea, altered
taste
Derm: Photosensitivity
Endo: hyperglycemia
Dosage: 500 mg 1 tab
Route: per orem
Timing: twice a day
 Assess patient for infection (vital signs, appearance of wound,
sputum, urine, and stool).
 Observe patient for signs and symptoms of anaphylaxis (rash,
pruritus, laryngeal edema, wheezing).
45
Generic name: Clexane
Brand name: Lovenox
Pharmacologic Class: Low-molecular-weight heparin
Therapeutic class: Anticoagulant
Action: Inhibits thrombus and clot formation by blocking factor Xa and
factor IIa. This inhibition accelerates formation of antithrombin III-
thrombin complex (a coagulation inhibitor), thereby deactivating
thrombin and preventing conversion of fibrinogen to fibrin.
Indication: Prevention of ischemic complications of unstable angina or
non-Q-wave myocardial infarction
Contraindication: Hypersensitivity to drug, heparin, sulfites, benzyl
alcohol, or pork products
Adverse reactions:
CNS: dizziness, headache, insomnia, confusion, cerebrovascular
accident
CV: edema, chest pain, atrial fibrillation, heart failure
GI: nausea, vomiting, constipation
GU: urinary retention
Hematologic: anemia, bleeding tendency, thrombocytopenia,
hemorrhage
Metabolic: hyperkalemia
Skin: bruising, pruritus, rash, urticaria
Other: fever; pain, irritation, or erythema at injection site
Dosage: 5mg
Route: Subcutaneous
Timing: every 12 hours
 Monitor CBC and platelet counts. Watch for signs and symptoms of
bleeding or bruising.
 Monitor fluid intake and output. Watch for fluid retention and
edema.
46
Generic name: Clopidogrel (paracetamol)
Brand name: Plavix
Pharmacologic class: Platelet aggregation inhibitor
Therapeutic class: anti-coagulant, fibrinolytic, and antiplatelets
Action: Clopidogrel inhibits adenosine diphosphate (ADP) from binding
to its receptor sites on the platelets and subsequent activation of
glycoprotein GP IIb/IIIa complex thus preventing fibrinogen binding,
platelet adhesion and aggregation..
Indication: ST elevation MI (STEMI)
Contraindication: Hypersensitivity. Active pathological bleeding.
admin within 7 days after MI and ischemic stroke, coagulation
disorders.
Adverse reactions: Dyspepsia, abdominal pain, nausea, vomiting,
flatulence, constipation, gastritis, gastric and duodenal ulcers. GI
upset, diarrhoea, paraesthesia, vertigo, headache, dizziness, pruritus
and rashes.
Dosage: 75 mg
Route: Per orem
Timing: Once a day
 Monitor hemoglobin and hematocrit periodically.
 Monitor patient for unusual bleeding or bruising; drug
significantly increases risk of bleeding.
 Assess for occult GI blood loss if patient is receiving naproxen
concurrently with clopidogrel.
47
Generic name: Isosorbid mononitrate
Brand name: Imdur
Pharmacologic Class: Nitrate
Therapeutic class: Antianginal
Action: Promotes peripheral vasodilation and reduces preload and
afterload, decreasing myocardial oxygen consumption and increasing
cardiac output. Also dilates coronary arteries, increasing blood flow
and improving collateral circulation.
Indication: Promotes peripheral vasodilation and reduces preload and
afterload, decreasing myocardial oxygen consumption and increasing
cardiac output. Also dilates coronary arteries, increasing blood flow
and improving collateral circulation.
Contraindication: Hypersensitivity to drug, severe anemia, Acute
myocardial infarction, Angle-closure glaucoma, Concurrent sildenafil
therapy
Adverse reactions:
CNS: dizziness, headache, apprehension, asthenia, syncope
CV: orthostatic hypotension, tachycardia, paradoxical bradycardia
EENT: sublingual burning (with S.L. route)
GI: nausea, vomiting, abdominal pain
Skin: flushing
Dosage: 60 mg 1 tab
Route: via NGT
 Monitor arterial blood gas values and methemoglobin levels.
 Monitor vital signs closely, especially blood pressure.
48
Generic name: Metformin
Brand name: Glucophage
Pharmacologic class: biguanides
Therapeutic class: antidiabetics
Action: decreases hepatic glucose production; decreases intestinal
glucose absorption and increases sensitivity to insulin
Indication: Type 2 diabetes inadequately controlled by diet and
exercise alone
Contraindication: Renal Impairment, CHF requiring pharmacological
treatment, acute or chronic metabolic acidosis.
Adverse reactions: nausea, anorexia, vomiting, diarrhea, lactic
acidosis, decreased vitamin B12 absorption.
Dosage: 500 mg
Route: IVTT
Timing: Three times a day
 Observe patient for signs and symptoms of hypoglycemic reactions
(abdominal pain, sweating, hunger, weakness, dizziness, headache,
tremor, tachycardia, anxiety) when combined with oral
sulfonylureas.
 Monitor serum folic acid and vitamin B12 every 1-2 year in long
term therapy.
49
Generic name: Omeprazole
Brand name: Prilosec
Pharmacologic Class: Proton-pump inhibitor
Therapeutic class: Anti-ulcer agent
Action: Binds to an enzyme on gastric parietal cells in the presence
of acidic gastric pH, preventing the final transport of hydrogen ions
into the gastric lumen
Indication: Epigastric pain
Contraindication: Hypersensitivity to drug or its components
Adverse reactions:
CNS: dizziness, headache, asthenia
GI: nausea, vomiting, diarrhea, constipation, abdominal pain
Musculoskeletal: back pain
Respiratory: cough, upper respiratory tract infection
Skin: rash
Dosage: 40 mg
Route: IVTT
Timing: Once a day
 Assess vital signs.
 Check for abdominal pain, emesis, diarrhea, or constipation.
Evaluate fluid intake and output.
50
51
CHAPTER 4: ANALYSIS AND INTERVENTIOONS
I. PATHOPHYSIOLOGY
52
NURSING CARE PLAN
Name: BV Physician: Dr. MRJS Year Level: BSN- III
Age: 76 years old Clinical Instructor: Mr. Persee James Baybay, RN Date of Duty: 3/16/11
Sex: Female Clinical Area: NOPH – Upper Annex Time of Duty: 7:00-3:00 PM
Impression: Acute Coronary Syndrome, Student’s Name: Ailyn Chua
Inferior Wall Myocardial Infarction, Killip 2
Subjective Objective Cues Nursing Diagnosis Scientific Planning Interventions Rationale Expected
Reference/ Outcome
Cues Analysis
-Pain felt on Acute Pain related Acute pain is Immediate: Independent: Immediate:
the chest when to ischemia of the hallmark That after 15 -Monitor vital -To obtain That after
“Sakit coughing with a myocardial tissue manifestation of to 30 minutes signs baseline data. 15 to 30
akong pain scale of as evidenced by MI (Lewis, of nursing accurately. minutes of
dughan eh 8/10 as 0 as no verbal reports and 2008). Pain will interventions nursing
uboh dai”, pain and 10 as guarding behavior. occur due to , patient -Assess for -To help interventio
severe pain. inadequate will be able referred pain, determine ns, patient
as
oxygen supply to to: as possibility of was able
verbalized -Guarding Definition: the myocardial 1. Report appropriate. underlying to:
by the behavior noted. Unpleasant sensory cell which pain is condition or 1. Repor
patient. and emotional causes cell relieve organ t
-Grimace noted. experience arising starvation. Once d / dysfunction pain
from actual or the cell will control requiring is
-patient seems potential tissue starve, led. treatment. relie
irritable. damage or anaerobic 2. Reduced ved /
described in terms metabolism will pain -Assess pain’s -To rule out contr
-Positioning to of such damage facilitate scale location, worsening of olled
avoid pain. (International resulting into of 8/10 characteristic underlying .
Assocation for the lactic acid to 5/10 s, condition/deve 2. Reduc
53
-Sweating noted. Study of Pain); production which as 0 as onset/duration lopment of ed
sudden or slow is the by no pain frequency, complications. pain
-with an RR of onset of any product of and 10 quality, scale
22 cpm, intensity from anaerobic as intensity, and of
tachypneic. mild to severe metabolism which severe precipitating/ 8/10
with an causes cell pain. aggravating to
anticipated or death or 3. Follow factors. 5/10
predictable end infarction. prescri as 0
and a duration of Physically, the bed -Accept -Pain is as no
less than 6 individual will pharmac patient’s subjective pain
months. manifest facial ologica description of experience and and
grimace, l pain. cannot be felt 10 as
guarding regimen Acknowledge by others. sever
Source: Doenges, behaviour, . the pain e
M.E., Moorhouse, positioning to 4. Verbali experience and pain.
M.F & Murr, A.C. avoid pain, ze convey 3. Follo
( 2008). Nurse’s irritability, nonphar acceptance of w
pocket guide: etc. macolog ptient’s presc
Diagnoses, Once an ic response to ribed
prioritized individual will methods pain. pharm
interventions, experienced that acolo
and rationales pain, as the provide -observe -Observations gical
(11th ed.).p.498- body will relief. nonverbal may/may not be regim
503 Philadelphia, compensate some 5. Demostr cues/pain congruent with en.
Pennsylvania: F.A. vital signs of ate use behaviors. erbal reports 4. Verba
Davis Company. the patient will of or may be only lize
increase and relaxat indicator nonph
some organs will ion present when armac
also compensate. skills patient is ologi
and unable to c
diversi verbalize. metho
Source: onal ds
Lewis, S.L., activit -Monitor skin -Usually that
Heitkemper, ies, as color/temperat altered in provi
M.M., Dirksen, indicat ure and vital acute pain. de
S.R., O’Brien, ed, for signs. relie
P.G., & Bucher, individ f.
54
L.2008.Medical ual -Provide -To promote 5. Demos
surgical in situati comfort nonpharmacolog trate
Nursing. (7th on. measures. ical pain use
ed.) Vol. 1 Short term: management. of
p.803. Elsevier That after 1- relax
Singapore 2 hours of -Instruct -To distract ation
nursing in/encourage attention and skill
interventions use of reduce s and
, patient relaxation tension. diver
will be able techniques. siona
to: l
1. Report -Encourage -To prevent activ
pain is adequate rest fatigue. ities
relieve periods. , as
d or indic
control Dependent: ated,
led. -Administer -To maintain for
2. Reduce analgesics, as acceptable indiv
pain indicated, to level of pain. idual
scale maximum Notify situa
from dosage, as physician if tion.
8/10 to needed. regimen is
5/10 as inadequate to Short term:
0 as no meet pain That after
pain control goal. 1-2 hours
and 10 of nursing
as interventio
severe ns, patient
pain. was able
3. Demonst to:
rate 1. Repor
appropr t
iately pain
interve is
ntions relie
individ ved
ually. or
55
contr
Long Term: olled
That after 1- .
2 days of 2. Reduc
nursing e
interventions pain
, patient scale
will be able from
to: 8/10
1. Perform to
appropr 5/10
ite as 0
regimen as no
individ pain
ually and
to 10 as
relieve sever
pain. e
2. Report pain.
pain is 3. Demon
relieve strat
d. e
3. Reduce appro
pain priat
scale ely
from inter
8/10 to venti
0/10 as ons
0 as no indiv
pain idual
and 10 ly.
as
severe Long Term:
pain That after
1-2 days of
nursing
interventio
56
ns, patient
was able
to:
1. Perfo
rm
appro
prite
regim
en
indiv
idual
ly to
relie
ve
pain.
2. Repor
t
pain
is
relie
ved.
3. Reduc
e
pain
scale
from
8/10
to
0/10
as 0
as no
pain
and
10 as
sever
e
pain.
57
Name: BV Physician: Dr. MRJS Year Level: BSN 3
Age: 76 years old Clinical Instructor: Mr. Persee James Baybay,RN Date of duty:3/16/11
Sex: female Clinical Area: Upper Annex-NOPH Time of Duty: 7-3 pm
Impression: Acute Coronary Syndrome, Student’s Name: Sydney Colina
Subjective Objective Cues Nursing Diagnosis Scientific Planning Interventions Rationale Evaluation
Cues Analysis
“ Sakit - Verbalizes Ineffective tissue Ineffective That after -Note -provides That after 2-3
akong pain at the perfusion related Tissue Perfusion 2-3 hours of customary comparison hours of
dughan dai chest when interruption of is when there is nursing baseline data with nursing
kung moubo coughing blood flow a decrease of intervention current intervention
ko” as oxygen going to the patient findings the patient
verbalized - Creatinine: the tissues will be able will be able
by the .93 mg/dL (Lewis,2008). to: -to to:
patient When there is determine
- Poor -review
blockage or - Verbalize location or - Verbalize
capillary Definition: results of
vasoconstriction understan severity of understand
refill diagnostic
Decrease in oxygen in the ding of of ing of
studies
resulting in the myocardium there condition condition condition,
failure to nourish will be decrease , therapy therapy
regimen, -decreased regimen,
the tissues at the oxygen supply
side glomerular side
capillary level. going to the
effects filtration effects of
(Tissue perfusion myocardial -Auscultate rate may
problems can exist cells, so the of medication
BP, ascertain increase
without decreased there will be medicatio , and when
clients usual renin
cardiac output; cellular n, and to contact
range release and
however, there may starvation. When when to healthcare
contact raise Blood provider.
be a relationship the cells will
58
between cardiac starve, healthcar Pressure - Demonstrat
output and tissue anaerobic e e
perfusion). metabolism provider. -may be behaviors/
happens, and the altered by lifestyle
by product of - Demonstra increased changes to
anaerobic te BUN/Creatin improve
metabolism is behaviors ine circulatio
lactic acid /lifestyl -note n
Source: - for
which causes the e changes mentation
to baseline Demonstrate
Doenges, M.E., pain in the
improve data increased
Moorhouse, M.F & chest.Alteration
Murr, A.C.( 2008). in creatinine circulati perfussion as
Nurse’s pocket level indicates on individually
guide: Diagnoses, kidney problem. appropriate .
- Demonstra
prioritized
te -Evaluate
interventions,
increased vital signs,
and rationales
Source: perfussio -may
(11th ed.). p. noting changes
Lewis, S.L., n as reflect
705.Philadelphia, in BP, heart
Heitkemper, individua developing
Pennsylvania: F.A. rate and
M.M., Dirksen, abdominal
lly respirations
Davis Company. S.R., O’Brien,
appropria compartment
P.G., & Bucher,
te . -Ivestigate syndrome.
L.2008.Medical
surgical in reports of
-
Nursing. (7th pain out of
ed.) Vol. 1. restriction
proportion to
Elsevier of protein
degree of
Singapore helps limit
injury
BUN.
-Provide for
diet
restrictions,
as indicated,
59
while
providing
adequate
calories to
meet the
body’s needs. -to
increase
-elevate head
gravitation
of bed
al blood
flow when
at risk for
embolus
-smoking
causes
vasoconstri
ction and
may further
-encourage compromise
smoking perfusion.
cessation,
provide
information or -to
refer to stop decrease
smoking tension
programs level
-encourage use
of relaxation
techniques.
60
Sex: female Clinical Area: Upper Annes-NOPH Time of Duty: 7-3 pm
Impression: Acute Coronary Syndrome, Student’s Name: Sydney Colina
Subjective Objective Cues Nursing Diagnosis Scientific Planning Interventions Rationale Expected
Cues Analysis outcomes
“ Ga lisud -dyspnea Decreased cardiac In myocardial Immediate: -evaluate -to assess Immediate:
ko ug output related to infarction the client for signs
ginhawa -prolonged altered muscle heart pumps out That after 30 reports/eviden of poor That after 30
day”, as capillary refill contractility as not enough blood minutes to 1 ce of extreme ventricular minutes to 1
verbalized evidenced by the to supply the hour of fatigue, function hour of
-decreased nursing nursing
by the objective cues. body due to intolerance and or
peripheral intervention, intervention,
patient. altered activity, impending
pulses the patient the patient
myocardial sudden or cardiac
activity.So will be able progressive failure will be able
-fatigue Defintion:
there is no to: weight gain, to:
-Creatinine Inadequate blood enough blood to swelling of
-Demonstrate -Demonstrate
level of .93 pumped by the supply the extremities
adequate adequate
mg/dl(.57-.9 heart to meet the myocardium so and
cardiac cardiac output
mg/dl) metabolic demands the patient will progressive
output as as evidenced
of the body.In a manifest shortness of
evidenced by blood
hypermetabolic decreased breath
by blood pressure and
state, although peripheral
pressure and -determine pulse rate and
cardiac output may pulses and
pulse rate vital signs rhythm within
be within normal prolonged
and rhythm normal
range, it may capillary
within normal parameters for
still be refill. Death of
61
inadequate to meet the cells brings parameters client.
the needs of the about the for client.
body’s tissues. release of Short term:
Cardiac Output and certain enzymes Short term: That after 4
tissue perfusion that enter the That after 4 hours of
are interrelated, general hours of nursing
although there are circulation and nursing intervention
differences. When this includes intervention -provides the patient
cardiac output is the creatinine the patient baselin for will be able
decreased, tissue which will will be able comparisson to:
perfusion problems elevate due to to: to folow
-Review -Report or
will develop; decreased trens and
-Report or diagnosticstud demonstrate
however, tissue perfusion to the evaluate
demonstrate ies decreased
perfusion problems kidneys. response to
decreased episodes of
can exist without interventio
episodes of dyspnea,
decreased cardiac ns
dyspnea, angina,and
output
angina,and dysrrhythmias.
dysrrhythmias -Keep client
. on bed or -helps -Demonstrate
chair rest in determine an increase
-Demonstrate position of underlying activity
Source: an increase comfort. cause. intolerance.
activity
Doenges, M.E., intolerance. -decreases -Verbalize
Moorhouse, M.F & oxygen knowledge of
Murr, A.C.( 2008). -Verbalize -monitor consumption the disease
Nurse’s pocket knowledge of cardiac rhythm and risk of process,
guide: Diagnoses, the disease continuosly decompensat individual
prioritized process, ion risk factors,
interventions, individual an treatment
and rationales risk factors, pain.
(11th ed.). p. an treatment
-to note -Participate
62
145.Philadelphia, pain. effectivene in avtivities
Pennsylvania: F.A. ss of that reduce
Davis Company. -Participate medication the workload
in avtivities and of the heart
that reduce
the workload /or That after 1
-administer
of the heart assisstive day of nursing
high flow of
devices intervention
Long term: oxygen via
the patient
mask
Reference: will be able
That after 1
to:
Source: day of -to
Lewis, S.L., nursing increase -Identify
Heitkemper, intervention oxygen signs of
M.M., Dirksen, the patient available
S.R., O’Brien, cardiac
will be able for cardiac decompenation,
P.G., & Bucher,
L.2008.Medical to: function/ alter
surgical in tissue activities,
-Identify -restrict or
Nursing. (7th perfusion and seek help
signs of administer
ed.) Vol. 1. appropriately.
Elsevier cardiac fluids (IV or
Singapore decompenation PO)
, alter -to allow
activities, for timely
and seek help alterations
-Provide
appropriately in
fluids and
. therapeutic
electrolytes
regimen
-to
-encourage minimize
relaxation dehydration
skills and
dysrhythmia
63
s
-to reduce
anxiety
64
Sex: female Clinical Area: NOPH – Upper Annex Time of Duty: 7-3 pm
Impression: Acute Coronary Syndrome, Student’s Name: Ailyn Chua
Subjective Objective Cues Nursing Diagnosis Scientific Planning Intervention Rationale Expected
Cues Analysis Outcome
“Kamo rai -Pallor noted Activity Patient with That after 30 Independent: That after 30
tiwas tubag on nail beds. Intolerance cardiac minutes to 1 -Monitor vital -To obtain minutes to 1
ana nila related to problems/respirat hour of signs baseline hour of
-Hct = 34.9% accurately. data.
kay kapoy imbalance oxygen ory problems will nursing nursing
na”, as with a normal supply and demand experienced interventions, -Note presence -Fatigue interventions,
verbalized range of secondary to heart alteration in the patient will of actors affects patient was
by the 37.0%-47.0%. problems. delivery of be able to: contributing both able to:
patient. oxygen. In to fatigue. patient’s
-Poor myocardial 1. Identify actual and 1. Identify
capillary infarction there negative perceived negative
Definition: factors ability to factors
refill more is cell death or
affecting participat affecting
than 3 Insufficient necrosis which e in
seconds. can alter the activity activity
physiological or activities
activity of the tolerance . tolerance
psychological
-Pale pink myocardial cells. and and
energy to endure
conjuctiva, Since the main eliminate -Evaluate -Provides eliminate
or complete
oral and nasal function of the or reduce patient’s comparativ or reduce
required or
their actual and e baseline their
mucosa noted. desired daily heart is to pump
effects perceived and effects
activities. or regulate blood limitations/de provides
-slight throughout the when when
gree of informatio
weakness body (Lewis, possible. deficit in n about possible.
noted. 2008). If theres light of usual needed
2. Use status. education/ 2. Use
problem in the
identifie interventi identifie
heart/lungs, some
d ons d
organs in the
65
body will receive technique regarding technique
inadequate s to quality of s to
Source: blood/oxygen enhance life. enhance
supply which can activity activity
Doenges, M.E., -Note -Symptoms
cause weakness to tolerance patient’s may be tolerance
Moorhouse, M.F &
an individual. . report of result .
Murr, A.C.( 2008).
There is weakness weakness, of/or
Nurse’s pocket 3. Participa 3. Participa
because the body fatigue, pain, contribute
guide: Diagnoses, te te
deprived oxygen. difficulty in to
prioritized willingly accomplishing intoleranc willingly
interventions, in tasks, and/or e of in
and rationales necessary insomnia. activity. necessary
(11th ed.). p. 70- Source: /desired /desired
73.Philadelphia, Lewis, S.L., -Assess -To
activitie ability to determine activitie
Pennsylvania: F.A. Heitkemper, M.M.,
Dirksen, S.R., s. stand and move current s.
Davis Company.
O’Brien, P.G., & about and status and
Bucher, 4. Report degree of needs 4. Report
L.2008.Medical measurabl assistance associated measurabl
surgical in e necessary/use with e
Nursing. (7th ed.) increase of equipment. participat increase
Vol. 1. Elsevier in ion in in
Singapore activity needed/des activity
ired
tolerance activities tolerance
. . .
5. Demonstra -Adjust -To 5. Demonstra

te a activities. prevent te a
decrease overexetio decrease
in n. in
physiolog physiolog
ical -Plan care to -To ical
carefully prevent
signs of balance rest fatigue. signs of
intoleran periods with intoleran
66
ce. activities. ce.
-Encourage -To
expression of protect
feelings patient
contributing from
to/resulting injury.
from
condition.
-Assist with -To

activities and enhance
provide/monito ability to
r patient’s participat
use of e in
assistive activities
devices. .
-Promote
comfort
measures and
provide for
relief of
pain.
67
CHAPTER 5:
XIV. PROGRESS NOTES
Date Problem Medical/Surgical Nursing Outcome

Interventions Intervention
04/14/11 Chest pain -Imdur 60 mg 1 -given by -pain
tablet/nasogastric nurse on decreases
tube once a day duty from 10/10
(Hold once Isoket to 7/10 (0
drip started) as no pain
and 10 as
severe pain)
- #1 D5W90 cc + 1 -IVF -IVF patent

Isoket insertion by and infusing
-#1 PLNSS 1 liter nurse on well at the
@10 gtts min duty of #1 left radial
PLNSS 1 vein
liter @ 10
gtts/ minute
with a side
drip of #1
D5W 90 cc +
1 ampule
isoket ,
regulated
well and
infusing
well at the
left radial
vein
-difficulty - nasogastric -attached by -patent

in tube: OF 1,600 cal nurse on
swallowing in 6 divided by duty
feeding as ordered
by the physician
-shortness -oxygen therapy @ -oxygen -decreased
of breath 2 liters per therapy @ 2 shortness of
minute via nasal liters per breath
canula minute via
nasal
canula. Kept
rested
-difficulty -Foley bag - Foley bag
in catheter attached catheter
urinating to urobag attached to
urobag,
draining
well
-blood chemistry -blood -Result:
chemistry BUN,
68
taken by Creatinine,
laboratory FBS and SGPT
personnel are
increased,
Troponin T
>2.0 ng/ml
positive
-Urinalysis -urine -Result
sample shows
taken, abnormal
endorsed to color which
nurse on is clear and
duty and transparent,
taken by glucose and
laboratory protein and
personnel bacteria are
present.
04/16/11 -nasogastric -patient
tube, foley kept rested.
bag catheter
removed by
nurse on
duty
XV. DISCHARGE PLANNING
Medication:
 Clopidogrel 75 mg 4 tablet once a day
69
 Imdur 60 mg 1 tablet per orem
 Amiodarone 250 mg twice a day per orem
 Metformin 500 mg three times a day per orem

 Ciprofloxacin 500 mg 1 tablet two times a day
Exercise:
 Advice significant others to instruct the patient and tell
the patient to have non-strenuous and non-jarring exercise
such as walking.
 Tell client to initiate exercise through repetitive low
intensity exercises first.
 Advice his family to have or maintain safe, clean,
comfortable and calm environment.
 Advice significant others to be supportive to the patient.
 Encourage the patient to stay active as tolerated and as

possible and build into his schedule structured rest
periods.
Health Teachings:
 Stress the importance of eating a well balance diet.
 Adequate rest and proper hygiene.

 Return for follow up care and evaluation.
 Explain the disease process, causative factors, signs and

symptoms and treatment to the patient and significant
others.
 Follow the prescribe dosage of the medications everyday.
 Teach client on avoiding stress.

 Counseling can help in emotional condition.
 Avoid strenuous activities, heavy lifting and vigorous

exercise.
 Encourage family to help the patient cope with her recent
condition.
 Avoid cigarette smoking.
 Encourage slow deep breathing exercises to promote
effective breathing pattern.
Out-Patient:
70
Contact Physician for the following problems:
 Pain that is not relieved by medication.
 Difficulty breathing even though medication is taken.

 Allergic or other reactions to the medication.
 Anxiety, depression, and trouble sleeping.

 Nagging cough or hoarseness
Diet:
 Full diet, decreased salt diet
Spiritual Care:
 Encourage patient and significant others to attend Sunday
masses to strengthen the faith in God.
 Encourage the patient to pray rosary to ask guidance from
God and good health.
71
XVI. RECOMMENDATION
After studying this case, we the researchers came up with the

following recommendations:
a. To the Healthcare Team:
 Thorough assessment of the patient is very important for
them to render appropriate intervention and any
abnormalities found from the patient should be referred
immediately to the attending physician.
b. To the future student nurses:
 Baseline data of the patient should be obtained for
comparison to note any progress or rule out complications.
Understanding the disease process of patient’s condition is
very important to be able to care the patient properly and
manage the signs and symptoms the will be occurring.
c. To the patient:
 Compliance of the medication is very important and
cigarette smoking should be avoided so that condition may
not worsen.
d. To the significant others:
 Family support is very important most especially in the
process of her recovery.
72
XVII. CONCLUSION
Thorough studying the case of the patient, the medications that

is being given, the treatment that is being rendered to the patient
and the interaction between the researchers and the patient, we, the
researchers was able to come up with a clinical paper of the said
disease.
From the start until the end of this clinical paper, the
researchers were able to meet the objectives that were being
formulated.
The researchers had realization and learning during the making of
this clinical paper. First, the researchers were able to gather
information from the patient to be able to trace the condition that
the patient is having. Secondly, the researchers were able to fully
understand the anatomy and physiology of the respiratory and
cardiovascular system which are affected on the client’s condition,
Acute Coronary Syndrome, Inferior Wall Myocardial Infarction, ST
elevatum, Killip 2. Third, the researchers were motivated to read lots
of references to gather information to support the said case and come
up with an appropriate pathophysiology in relation to the client’s
case. Fourth, the researchers were able to prioritized 5 Nursing care
plans in relation to the client’s condition. Fifth, the researchers
were able to rationalize the interventions being rendered to the
patient. Lastly, the researchers was able to formulate discharge
planning that is applicable to the patient’s condition which includes
the medications, exercise, health teachings, out-patient, diet and
spiritual care.
73
XVIII. BIBLIOGRAPHY
74

Clinical Paper

Hochgeladen von

Dokumentinformationen

Originalbeschreibung:

Copyright

Verfügbare Formate

Dieses Dokument teilen

Dokument teilen oder einbetten

Freigabeoptionen

Stufen Sie dieses Dokument als nützlich ein?

Sind diese Inhalte unangemessen?

Copyright:

Verfügbare Formate

Clinical Paper

Hochgeladen von

Copyright:

Verfügbare Formate

ACKNOWLEDGMENT

Ours is a place of countless, amazing individuals who do

b. REASON FOR SEEKING HEALTH CARE

c. CURRENT HEALTH STATUS

Hospitalization: It was her first time to be admitted in the hospital

Serious Injuries: None

Serious/Chronic Illness: Myocardial Infarction, Diabetes Mellitus

Immunization: Patient could no longer remember.

Allergies: Patient had no allergies in foods, drugs, and environment.

Travel: From Tanjay City to Dumaguete City

Female + Deceased Asthma

Alive and Well Myocardial Infarction Acute Coronary Syndrome

MATERNAL SIDE PATERNAL SIDE

Typical Day: Patient usually wakes up at 4:00 or 5:00 on the morning.

Nutritional Health Pattern: Patient usually eats vegetables and fish.

Sleep and Rest Pattern: Patients usually had 5 to 6 hours of sleep.

Elimination Pattern: Patient could no longer remember how many times

Occupational Health Pattern: Patient works in a farm with fresh and

Environmental Health Pattern: Patient lives in peaceful environment

VII. REVIEW OF SYSTEM

Systems Inspection Palpation Percussion Auscultati

• Skin -Uniform -Skin is

• Hair -Hairs are -Scalp is

HEAD ,FACE AND

• Head and -symmetrical -TMJ smooth,

EYE AND EAR

• Chest *we are not -trachea is *we are

• Carotid -Carotid -Negative

• Veins and -skin color

• Breast -breast -Breast soft

• Abdomen -abdominal -abdomen soft -bowel *we are

• Posture *we are not

• Cranial -CN II, III,

Random Blood Sugar (RBS)

BLOOD CHEMISTRY 04/14/11

Component Result Reference Range Significance

BLOOD CHEMISTRY 04/14/11

Component Result Reference Range Significance

• Na+ 142.4 mmol/L 135-148 mmol/L Normal

Blood Urea Nitrogen (BUN)

Fasting Blood Sugar (FBS)

Chol_HDL (High Density Lipoprotein)

Chol_LDL (Low Density Lipoprotein)

Serum Glutamic-Pyruvic Transaminase (SGPT)

BLOOD CHEMISTRY 04/15/11 10:13 am

Components Result Reference Significance

BLOOD CHEMISTRY 04/15/11 02:25 pm

Component Result Reference Range Significance

• Troponin T >2.0 ng/mL <0.03

MACROSCOPIC EXAMINATION 04/14/11 9:40 am

Component Result Normal Significance

MICROSCOPIC EXAMINATION 04/14/11 9:40 am

Component Result Reference Range Significance

• Pus Cells 6.10/hpf 5-10/hpf Normal

• Pro Time 14 secs

d. Diagnostic Clinical Laboratory

White Blood Cells (WBC)

Component Result Reference Range Significance

• WBC- 15.9 K/uL 4.0-11.0 K/uL High

Components Result Reference Range Significance

• Lymphocyte 8 20-45 Low

IX. DIAGNOSTIC STUDIES

THE CARDIOVASCULAR SYSTEM

• Chest we are not -trachea is we are