A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips 1, Diabetes Mellitus Type II - Uncontrolled

d I. INTRODUCTION Acute Coronary Syndrome is defined as a spectrum of conditions involving chest discomfort or other symptoms caused by lack of oxygen to the heart muscle (the myocardium). The unification of these manifestations of coronary artery disease under a single term reflects the understanding that these are caused by a similar pathophysiology (sequence of pathologic events) characterized by erosion, fissuring, or rupture of a pre-existing plaque, leading to thrombosis (clotting) within the coronary arteries and impaired blood supply to the heart muscle. It encompasses a range of thrombotic coronary artery diseases, including unstable angina and both ST-segment elevation and nonST-segment elevation myocardial infarction. Diagnosis requires an electrocardiogram and a careful review for signs and symptoms of cardiac ischemia. In acute coronary syndrome, common electrocardiographic abnormalities include T-wave tenting or inversion, ST-segment elevation or depression (including J-point elevation in multiple leads), and pathologic Q waves. If prompt actions are not done complications such as Myocardial Infarction may take place. (http://www.mayoclinic.com/health/acutecoronary-syndrome/DS01061/DSECTION=symptoms) The risk factors for acute coronary syndrome are similar to those for other types of heart disease. It includes Older age (older than 45 for men and older than 55 for women), high blood pressure, high blood cholesterol, cigarette smoking, lack of physical activity, type 2 diabetes, family history of chest pain, heart disease or stroke. Signs and symptoms include Chest pain (angina) that feels like burning, pressure or tightness and lasts several minutes or longer, Pain elsewhere in the body, such as the left upper arm or jaw (referred pain), nausea, vomiting, shortness of breath (dyspnea), and sudden, heavy sweating (diaphoresis) (http://www.mayoclinic.com/health/acute-coronary syndrome/DS01061/DSECTION=symptoms) According to the morbidity rate, taken from the records of the Department of Health for region X, the occurrence of cardiovascular diseases per 100,000 populations is 3,356. This data is taken from the 2001-2005, a 5 year-average record. While the occurrence rate for cardiovascular disease for region X by 2006 is recorded to be 4,373 per 100,000 populations.(http://www.dh.gov.uk/en/index.htmhttp://www.dh.gov.uk/en /index.htm) On the other hand, Diabetes Mellitus is a condition in which the pancreas no longer produces enough insulin or cells stop responding to the insulin that is produced, so that glucose in the blood cannot be absorbed into the cells of the body. Symptoms include frequent urination, lethargy, excessive thirst, and hunger. The treatment includes changes in diet, oral medications, and in some cases, daily injections of insulin.
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A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips 1, Diabetes Mellitus Type II - Uncontrolled The most common form of diabetes is Type II, It is sometimes called age-onset or adult-onset diabetes, and this form of diabetes occurs most often in people who are overweight and who do not exercise. Type II is considered a milder form of diabetes because of its slow onset (sometimes developing over the course of several years) and because it usually can be controlled with diet and oral medication. The consequences of uncontrolled and untreated Type II diabetes, however, are the just as serious as those for Type I. This form is also called noninsulin-dependent diabetes, a term that is somewhat misleading. Many people with Type II diabetes can control the condition with diet and oral medications, however, insulin injections are sometimes necessary if treatment with diet and oral medication is not working. Diabetes is the third leading cause of death in the United States after heart disease and cancer. (http://www.medicinenet.com/diabetes_mellitus/page4.htm#tocf)

A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips 1, Diabetes Mellitus Type II - Uncontrolled II. SCOPE AND LIMITATIONS OF THE STUDY This case study tackles about Acute Coronary Syndrome specifically on the case of patient JB. It includes essential concepts in relation to the said condition such as the patients profile and health history, nursing assessment and clinical manifestations, drug study and diagnostic exams done. The anatomy and physiology is also included as well as the pathophysiology of Acute Coronary Syndrome with its associated factors. The Medical and Nursing Management along with the discharge plans and other relevant data are also being covered. The scope of the plan encompasses during the course of duty last June 29, 30 and July 1 of year 2011 wherein the assigned students who have assessed the client with cumulative interaction and good rapport to the patient and significant others. Nursing Management covers the above mentioned dates which encompasses the clients Recovery Phase. Data gathering about the Laboratory results covers from June 29 to 30, 2011 The areas of concerns are limited to the discussions of Acute Coronary Syndrome with uncontrolled diabetes type II and the quality of Nursing Care to the patient. The quantity and quality of the information are limited to the data gathered from the client, significant others and his medical records.

OBJECTIVES OF THE STUDY The study aims to explore the concepts about the condition and the quality of nursing care being rendered to our client that was diagnosed with Acute Coronary Syndrome and uncontrolled diabetes type II. In order to learn more about the health condition of the patient, the study wants to fathom about the predisposing and precipitating factors, anatomy and physiology and the pathophysiology of the condition experienced by the client. Basically, the main goal of this study in relation to knowledge is to identify the nursing interventions after the condition of patient. The study aims to critically analyze the qualitative and quantitative data gathered in order to establish connection between the different manifestations experienced by the patient with that of the disease process. To be able to improve skills, the students also endeavors to come up with nursing care plans that will alleviate patients condition. The presentors also intend to compare and contrast the ideal management for Acute

A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips 1, Diabetes Mellitus Type II - Uncontrolled Coronary Syndrome with that of the actual management. In addition, the study seeks to disseminate essential information to everybody for awareness. Furthermore, by this study, the provider will be able to exercise that attitude of determination and in order to come up with a successful study

SIGNIFICANCE OF THE STUDY The study is significant to the following people: the client, the clients family, and nursing students The study is significant to the client, because it enlightens the clients queries and doubts regarding her condition. Allowing him to understand the situation of his present state, this would allow him to be more aware of the importance of following the treatment regimen. Clients family must also be aware of the condition of the client. With the study, the clients family will be able to participate in the clients treatment, and they will be able realize the importance of the support system in participating in the clients care. The study is also important to the nursing students, since it allows them to explore the clients condition, giving them firsthand experience in observing the manifestations of the disease condition and allowing them to apply theoretical knowledge regarding nursing managements for the manifested signs and symptoms.

A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips 1, Diabetes Mellitus Type II - Uncontrolled III. CLIENTS PROFILE A. Socio-demographic Date Patient JB is a 54-year old male, Protestant, married to his 50-year old wife and is currently residing at Opol, Misamis Oriental was admitted last June 29, 2011 due to chest pain at Northern Mindanao Medical Center Intensive Coronary Care Unit. B. Vital Signs Upon assessment, the patients vital signs were: BP: 110/80 mmHg, Temperature: 36.2 degree Celsius, PR: 58 beats per minute (bradycardia), and RR: 25 cycles per minute (tachypnea) and 27 cycles per minute (tachypnea) upon exertion. The patient weighs 62 kilograms and is 160 centimeters tall C. Health Pattern Assessment Aside from the current condition, patient also complained of non-productive cough and prostate enlargement. Generally, he looks normal and able to ambulate and change positions as well. There was no history of tobacco and illicit drug use as well as alcohol consumption yet hes taking a cupful of coffee everyday for almost 30years. No allergies were reported.

Past Medical History Client JB has been previously hospitalized twice. First was last July 2009 at Cagayan de Oro Medical Center with the diagnosis of Myocardial Infarction and the second admission was in Northern Mindanao Medical Center last November 2009 due to left cerebrovascular disease. He also has the family history of Diabetes Mellitus on both maternal and paternal side and taking metformin 500mg to control increase blood glucose level taken BID. He was also diagnosed to have Benign Prostate Hypertrophy (BPH) and was given tamsulosin hydrochloride 400mg OD taken every morning.

History of Present Illness Client JB was climbing the stairs upon reaching the second plight of it, he felt intense pain on his left chest that radiated to his left shoulder associated with shortness of breathing. He was then brought to the Emergency Room subsequently, thus caused him to be admitted last June 29, 2011. His diagnosis was Acute Coronary Syndrome, ST Elevation,

A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips 1, Diabetes Mellitus Type II - Uncontrolled Myocardial Infarction (STEMI) Anterior Wall, Killips-1, Diabetes Mellitus Type II - Uncontrolled.

Physical Assessment Client JB has an oxygen inhalation @ 2 LPM via nasal cannula and an intravenous fluid of PNSS1L regulated at 10 cc per hour infusing well at the right arm. Capillary Blood Glucose Monitoring was also done to the patient: on the first day, he has blood glucose of 172mg/dl then the next day it became normal with a value of100mg/dl.

HEENT: Head, hair and scalp Eyes: sclera, pupils Normocephalic with fine hair and clean scalp. Sclerae are anicteric, pupils are equal in size and reaction to light. Periorbital region is not sunken or edematous. Cornea and lens are not opaque Ears and tympanic membrane Nose and conjunctiva is pale. Equal in size with no discharges and has equal auditory function. Intact tympanic membrane. No nasal flaring noted. Septum is medial. Mucosa is pink in color. Gross smell is normal and symmetrical. Mouth, lips, tongue, teeth and Lips are pink but oral mucosa is pale. No lesions oral mucosa Throat and neck Facial movements noted in the mouth. Tongue is midline. Teeth are complete with plaques noted. Gums are pinkish. Trachea and uvula are midline. Thyroids are non palpable. Tonsils are not inflamed. Symmetrical.

Cognitive/ Neurological Assessment Conscious, coherent and responsive Oriented to time, place and person Calm, but upon exertion he feels dizzy and answers questions inappropriately. Visayan College graduate of Criminology at Ateneo de Davao University

Level of consciousness Orientation Emotional state Primary language Educational attainment

Nutritional and Metabolic Pattern At home, Client JB usually eats three times a day with red meat and rice, but after he was diagnosed with stroke and myocardial infarction

A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips 1, Diabetes Mellitus Type II - Uncontrolled he was consuming fish, vegetables, and rice with good appetite yet still cannot resist fatty foods and sweets too. He drinks water and other fluids at most 10 glasses a day. He takes no vitamins or mineral supplement at all. Upon hospital stay, his diet was on low salt low fat, full diabetic diet with no nausea and vomiting reported.

Elimination Pattern Patient JB usually follows a pattern in defecating, he used to defecate once every morning; his stool appears soft in consistency, yellow to brown in color and in minimal amount with no discomforts upon defecating. He urinates at about 6-8 times a day with amber to yellow colored urine and in moderate amount and with no difficulty. He has an enlarged prostate and had difficulty urinating before but it subsided after taking due medications.

Abdominal configuration Bowel sounds Percussion

Symmetrical, no superficial veins, with no lesions and scars Normoactive upon auscultation Tympanic and dullness noted on right upper quadrant

Activity-Exercise Pattern He used to be very active before but after the diagnosis of myocardial infarction, his activities and exercises were restricted but he could still walk for no more than one kilometer and can perform tolerable exercises. Upon overexertion, pain is felt radiating to the left shoulders with a pain scale of 6/10 sometimes felt at night which takes for a minute. His leisure activities include watching TV and socializing with his children and friends.

CARDIOVASCULAR STATUS Chest pain, radiation

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Positive chest pain at the left side that radiates to the

A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips 1, Diabetes Mellitus Type II - Uncontrolled left shoulder, palpitations noted at some times Point of maximal impulse, 5th intercostal space, midclavicular line Precordial area Heart sounds Peripheral pulses Capillary refill time Flat Distinct and regular, no murmurs noted Regular and symmetrical 2 seconds, no clubbing noted

RESPIRATORY STATUS Breathing pattern Lung expansion Vocal/tactile fremitus Percussion Breath sounds Cough Irregular (tachypnea) Symmetrical Symmetrical Resonant Rales crackles at inspiration Non - productive with colorless sputum, minimal in amount and viscous in consistency

Sleep and Rest Pattern Client JB usually sleeps about 6-8hours a day with naps during day time. He said this number of hours is adequate enough for his activities the following day. He does not have any history of sleep disturbances but he prays and meditates before sleeping to promote a good and sound sleep.

Role and Relationship Pattern Client JB is married to his 50- year old healthy wife and a father to two healthy kids. The eldest is 20 years old and has graduated Computer Science Studies and the second age 14 who is currently a fourth year high school student. He lives with his family. Client JB reported to have a Diabetes Mellitus in both maternal and paternal side but confused why he has developed Myocardial Infarction.

Value and Belief Pattern Client X is a Protestant; in fact he is a community facilitator of their church. He strongly believes that without God he will be nothing. He gets his strength in facing his condition from his faith that gives him hope. He believes his hospitalization interferes with his religious rites but he finds ways to communicate with God through prayers as an alternative. Moreover, he considers his church mates as his support group and they visited him quite often.

A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips 1, Diabetes Mellitus Type II - Uncontrolled

A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips 1, Diabetes Mellitus Type II - Uncontrolled

REVIEW OF SYSTEMS

Pale conjunctiva

Copious nonproductive cough

Pale oral mucosa

Abnormal increase of RR of 25 cpm (at rest) and 27cpm (upon exertion)

Pain radiating to shoulders

Chest pain of 6/10

Prostate Enlargement

CBG shows abnormal increase of blood glucose of 172mg/dl (first day) and normal 10 blood glucose of 100mg/dl (second day)

Abnormal decrease of heart rate of 58 bpm (bradycard ia)

A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips 1, Diabetes Mellitus Type II - Uncontrolled IV. ANATOMY AND PHYSIOLOGY

Every cell in the human body needs energy in order to function. The bodys primary energy source is glucose, a simple sugar resulting from the digestion of foods containing carbohydrates (sugars and starches). Glucose from the digested food circulates in the blood as a ready energy source for any cells that need it. Insulin is a hormone or chemical produced by cells in the pancreas, an organ located behind the stomach. Insulin bonds to a receptor site on the outside of cell and acts like a key to open a doorway into the cell through which glucose can enter. Some of the glucose can be converted to concentrated energy sources like glycogen or fatty acids and saved for later use. When there is not enough insulin produced or when the doorway no longer recognizes the insulin key, glucose stays in the blood rather entering the cells. Anatomy of the pancreas: The pancreas is an elongated, tapered organ located across the back of the abdomen, behind the stomach. The right side of the organ (called the head) is the widest part of the organ and lies in the curve of the duodenum (the first section of the small intestine). The tapered left side extends slightly upward (called the body of the pancreas) and ends near the spleen (called the tail). The pancreas is made up of two types of tissue: Exocrine tissue
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A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips 1, Diabetes Mellitus Type II - Uncontrolled o The exocrine tissue secretes digestive enzymes. These enzymes are secreted into a network of ducts that join the main pancreatic duct, which runs the length of the pancreas. Endocrine tissue o The endocrine tissue, which consists of the islets of Langerhans, secretes hormones into the bloodstream. Functions of the pancreas: The pancreas has digestive and hormonal functions: The enzymes secreted by the exocrine tissue in the pancreas help break down carbohydrates, fats, proteins, and acids in the duodenum. These enzymes travel down the pancreatic duct into the bile duct in an inactive form. When they enter the duodenum, they are activated. The exocrine tissue also secretes bicarbonate to neutralize stomach acid in the duodenum. The hormones secreted by the endocrine tissue in the pancreas are insulin and glucagon (which regulate the level of glucose in the blood), and somatostatin (which prevents the release of the other two hormones.

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A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips 1, Diabetes Mellitus Type II - Uncontrolled

CARDIOVASCULAR SYSTEM

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A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips 1, Diabetes Mellitus Type II - Uncontrolled The right and left coronary arteries most often arise independently from individual ostia in association with the right and left aortic valve cusps. The left anterior descending (LAD) and left circumflex (LCX) coronary arteries arise at the left main coronary artery bifurcation; they supply the anterior LV, the bulk of the interventricular septum (anterior two thirds), the apex, and the lateral and posterior LV walls. The right coronary artery (RCA) generally supplies the right ventricle (RV), the posterior third of the interventricular septum, the inferior wall (diaphragmatic surface) of the left ventricle (LV), and a portion of the posterior wall of the LV (by means of the posterior descending branch). When the posterior descending coronary artery (PDA), which supplies the posterior interventricular septum, arises from the LCX artery, the circulation is called left dominant. Most often, the PDA arises from the RCA; this anatomy is called rightdominant circulation. In two thirds of patients, the first branch of the RCA is the conus artery, which supplies the conus arteriosus (RV outflow tract); occasionally the conus arteriosus arises from a separate orifice. In 60% of patients, the sinus node artery arises from the proximal RCA, and in 40% of patients, it arises from the LCX artery. The anterior branches supply the free wall of the RV, and the acute marginal branches supply the RV. When the RCA extends to the crux (the origin of the PDA), it supplies the atrioventricular (AV) node (90%); otherwise, the AV node is supplied by the LCX. Therefore, obstruction of the RCA commonly affects the sinus node and the AV node, resulting in bradycardia, with or without heart block. Not surprisingly, RCA occlusion frequently manifests with sinus bradycardia, AV block, RV myocardial infarction, and/or inferoposterior myocardial infarction (of the LV).Heart is a hollow muscular organ that pumps blood through the body. The heart, blood, 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 system's power supply. It must beat ceaselessly because the body's tissues-especially the brain and the heart itself-depend on a 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
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A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips 1, Diabetes Mellitus Type II - Uncontrolled 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 years, the heart will beat nearly 2.8 billion times and move 169 million liters (179 million quarts) of blood. STRUCTURE OF THE HEART The human heart has four chambers. The upper two chambers, the right and left atria, are receiving chambers for blood. The atria are 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 sides of the heart. Each side pumps blood through a different circuit of 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 two 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 the blood to the lungs, where it picks up a fresh supply of oxygen and eliminates carbon dioxide. The blood that is oxygen-rich returns to the heart through the pulmonary veins, which empty into the left atrium. 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. A. THE HEART VALVES Four valves within the heart prevent blood from flowing backward in the heart. The valves open easily in the direction of blood flow, but when blood pushes against the valves in the opposite direction, the valves close. Two valves, known as atrioventricular valves, are located between the atria and ventricles. The right atrioventricular valve is formed from three flaps of tissue and is called the tricuspid valve. The left atrioventricular valve has two flaps and is called the bicuspid or mitral valve. The other two heart valves are located between the ventricles and arteries. They are called semilunar valves because they each consist of three half-moon-shaped flaps of tissue.
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A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips 1, Diabetes Mellitus Type II - Uncontrolled The right semilunar valve, between the right ventricle and pulmonary artery, is also called the pulmonary valve. The left semilunar valve, between the left ventricle and aorta, is also called the aortic valve. B. 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. C. 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 two 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. D. THE ENDOCARDIUM The inner surfaces of the heart's chambers are 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 flow smoothly and prevents blood clots from forming inside the circulatory system. E. THE CORONARY ARTERIES The heart is nourished not by the blood passing through its chambers but by a specialized network of blood vessels. Known as the coronary arteries, these blood vessels encircle the heart like a crown. About 5 percent of the blood pumped to the body enters the coronary arteries, which branch from the aorta just above where it emerges from the left ventricle. Three main coronary arteries-the right, the left circumflex, and the left anterior descending-nourish different regions of the heart muscle. From these three arteries arise smaller branches that enter the muscular walls of the heart to provide a constant supply of oxygen and nutrients. Veins running through
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A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips 1, Diabetes Mellitus Type II - Uncontrolled the heart muscle converge to form a large channel called the coronary sinus, which returns blood to the right atrium. 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.

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A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips 1, Diabetes Mellitus Type II Uncontrolled Predisposing Factors: V. PATHOPHYSIOLOGY Sedentary Lifestyle Eating habits consuming organ meats and fatty foods Age (54 years old) Gender (male) Family History of DM Precipitating Factors: Poor compliance to medication LEGEND: Increased cell division causing further mutations Predisposing Factors Precipitating Factors Disease Process Activation of the k-ras oncogene Management Administered metformin (Glucophage) 500mg 1 tab. OD BID Diagnostic Examination Increase blood glucose level within the serum Signs and symptoms prevent apoptosis P53 mutations which Compensatory Mechanism Prolong lifespan of affected cells

Abnormal increase in blood glucose level of 139mg/dl

Beta cells response poorly to hyperglycemia

Continuous replication of affected cells Scanty amount of insulin being released Increase glucagon release Increases number of malignant cells Administered atorvastatin Increase breakdown of (Lipitor) lipids 80mg, 1 tab, PO, OD at HS

CBG shows blood glucose level of `72mg/dL

Continuous increase in serum blood glucose

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A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips 1, Diabetes Mellitus Type II Uncontrolled ===========================> Increase hydrostatic pressure on the coronary artery Increase blood concentration which leads to its viscosity Chest pain radiating to the shoulders Pain scale of 6/10 Abnormal Presence of decrease NPO state surgical Possible in wound. increase in lymphocyt acid and es 7.1 production 7.9 within the GI lining

Sluggish flow going to the heart

Intravenous PNSS at 10cc/hr

Lactic acid production

Clot formation and lipid deposition on the anterior coronary artery

Anaerobic metabolism is initiated

Ischemia on the myocardium Plaque formation in the intimal lining of the anterior coronary artery Still insufficient to supply blood to the heart The fibrous cap (plaque) protrude in the intimal lining Collateral circulation is stimulated to help perfuse the myocardium Partial blockage of the anterior coronary artery Patient JB climbed two flights of stairs
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Ketoste Susceptible Activation of ril 1cap. to infection pain PO BID 1.omeprazol mediators e 20mg PO Increase respiratory rate of every 6 25cpm (at rest) and 27cpm hours (upon exertion) 1. celecoxib 2. ranitidine 1.5gm IVTT every 6 hours 500mg IVTT every 8 hrs. 2. paracetamol 60mg IVTT every 6 hours 3. oxygen Provide ketorolac 30mg IVTT every 8 hours inhalation at 2LPM via nasal cannula 4. tramadol 500mg IVTT every 6 hours

A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips 1, Diabetes Mellitus Type II Uncontrolled

Plaque ruptures

Pale mucosa Pale conjunctiva

Platelet adhesion to subendothelial matrix

Release of Thromboxane A2, Serotonin and other platelet aggregatory agent

Enhanced affinity to fibrinogen

Exposure of subendohelial matrix

Abnormal decrease of RBC (3.58), Hct (31.5) , Platelet aggregation and Hgb (11.1)

Hardening of the coronary artery

Platelet activation

Converts fibrinogen to fibrin Plasma Coagulation System activation Formation of thrombin Stabilization of fibrin clot Enhances platelet aggregation

Change in platelet shape

Platelet degranulation

Expression of Platelet GP IIb/IIIa

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A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips 1, Diabetes Mellitus Type II Uncontrolled Impaired repolarization of the myocardium O2 inhalation Decrease perfusion to the system Decrease cardiac contractility

Abnormal decrease of blood pressure of 58bpm Coronary occlusion Decrease cardiac output Infarction on the myocardium takes place Further deprivation of oxygen supply to the myocardium

Abnormal ST elevation seen in the ECG

1. Administered enoxaparin (Clexane) 0.4cc SC every 12 hours Decrease ventricular function 2. clopidogrel (Plavix) 75 mg, 1 tab PO at HS 3. aspirin (Atria SR) 80mg, 1tab, PO, OD after PC

VI. LABORATORY RESULTS Hematology Report (06/29/11) TEST Hgb RESULTS 11.1 REFERENCE VALUES 13.7-16.7 g/dL INTERPRETATION A decrease in rbc may also decrease hemoglobin since rbc carries oxygen to the blood. A Low hemoglobin may also indicate anemia.
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A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips 1, Diabetes Mellitus Type II Uncontrolled Hct 31.5 37.0- 47.0 gm% A low hematocrit level indicates that a person does not have a sufficient volume of red blood cells. WBC 12, 300 5,000-10,000 cell/mm3 A high blood count indicates is not a specific disease by itself but indicates infection, systemic illness, inflammation, allergy, leukemia and tissue injury. DIFFERENTIAL COUNT: Segmenters Lymphocytes Monocytes Platelet count 55 40 5 329, 000 45-70% 18-45% 4-8% 144,000-372,000 cell/mm3 Within Normal Range Within Normal Range Within Normal Range Within the normal range which connotes the clotting factor is good. RBC 3.58 4.7-6.1 10^6/uL A decrease Red blood cell production may indicate anemia and low oxygen levels due to poor heart or lung function. MCV MCH MCHC 81.6 30 25.2 80.0-96.0 fL 27.0-31.0 pg 32.0-36.0% Within Normal Range Within Normal Range A low MCHC number might indicate the presence of anemia, but other factors will be measured as well before making this diagnosis. The mean corpuscular
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A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips 1, Diabetes Mellitus Type II Uncontrolled volume indicates the size of the red blood cells in a person's body.

Hematology Report (06/30/11) TEST Hgb Hct WBC RESULTS 14.0 39.6 11,000 REFERENCE VALUES 13.7-16.7 g/dL 37.0- 47.0 gm% 5,000-10,000 cell/mm3 INTERPRETATION Within the Normal Range. Within Normal Range It is beyond normal range. Increase in the WBC count may indicate infection. DIFFERENTIAL COUNT: Segmenters 56 45-70% Within the Normal Range

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A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips 1, Diabetes Mellitus Type II Uncontrolled Lymphocytes Monocytes Platelet count RBC MCV MCH MCHC 20 5.0 376, 000 4.0 83.6 28.0 36.0 18-45% 4-8% 144,000-372,000 cell/mm3 4.7-6.1 10^6/uL 80.0-96.0 fL 27.0-31.0 pg 32.0-36.0% Within the Normal Range Within the normal range. Within the normal range thus, the clotting factor is good. Within the normal Range Within the Normal Range Within the Normal Range Within the Normal Range

Others Laboratory Examinations (06/29/11) Diagnostic/Laboratory Procedures/Tests Purposes Result Analysis and Interpretation

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A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips 1, Diabetes Mellitus Type II Uncontrolled 1. ECG The electrocardiogram (ECG or ST segment elevation EKG) 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. These conditions can vary from minor to life threatening. Myocardial injury causes the T wave to become enlarged and symmetric. As the area of injury becomes ischemic, myocardial repolarization is altered and delayed, causing T wave to invert. The injured myocardial cells depolarize normally but repolarize more rapidly than normal cells, causing the ST segment to rise at least 1 mm above isoelectric line.

2. CK-MB

CK-MB is a more sensitive marker 2 ng/mL (Reference Value: 0- NORMAL of myocardial injury than total CK 3 ng/mL) activity, because it has a lower basal level and a much narrower normal range. It is the most specific index for the diagnosis of

3. Creatinine

acute MI. The test is done to evaluate kidney 1.9 mg/dL (Reference Value: Any condition that impairs the function of the function. Creatinine is removed 0.59-1.21) from the body entirely by the kidneys. If kidney function is abnormal, creatinine levels will kidneys will probably raise the creatinine level in the blood. The most common reasons for developing raised creatinine levels will be when the filtration mechanism

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A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips 1, Diabetes Mellitus Type II Uncontrolled increase in the blood (because less creatinine is released through 4. Glucose becomes gradually damaged by long-term raised blood pressure or diabetes. abnormal level increases decrease denotes which of the results the blood

your urine). The test is done to evaluate the 139 mg/dL (Reference Value: The blood glucose within the 59.9 110.1) circulation.

glucose blood

so-called to its

hyperglycemia where the concentration of viscosity.

VII. DRUG STUDY

DRUG ORDER (Generic name, brand name, classification, dosage, route, frequency) GENERIC NAME: atorvastatin BRAND NAME: Lipitor
26

MECHANISM OF ACTION

INDICATIONS

CONTRAINDICATIONS

ADVERSE EFFECTS OF THE DRUG

NURSING RESPONSIBILITIES/ PRECAUTIONS 1. Confirm patient through asking looking bracelet. his on name his and name

Inhibit an enzyme, 3- Secondary hydroxy3methylglutarylcoenzyme A prevention cardiovascular

Patients hypersensitive of to atorvastatin and active liver disease or

CNS: headache, weakness EENT: rhinitis CV: chest

dizziness, insomnia,

(HMG- disease (decrease unexplained persistent

CoA) reductase, which risk of MI, stroke, in aspartate

pain, 2. Obtain a dietary history,

A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips 1, Diabetes Mellitus Type II Uncontrolled is in responsible the synthesis for revascularization of angina, CHF) with in aminotransferase (AST) or alanine and aminotransferase (ALT) patients clinically peripheral edema Resp: bronchitis GI: abdominal cramps, constipation, flatulence, nausea GU: erectile dysfunction diarrhea, heartburn, especially with regard to fat consumption. 3. levels during, Evaluate before and serum initiating, after the

CLASSIFICATION: Lipid-lowering agents HMG-CoA inhibitor DOSAGE: 80mg 1 tab ROUTE: PO FREQUENCY: ONCE A DAY TIMING : 8pm

catalyzing an early step procedures, cholesterol. hospitalizations for

cholesterol and triglyceride

elevated liver enzyme,

evident CHD.

therapy, if possible. 4. Explain to the patient what the drug is for. 5. Administer drug before patient goes to sleep.

27

A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips 1, Diabetes Mellitus Type II Uncontrolled

28

A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips 1, Diabetes Mellitus Type II Uncontrolled DRUG ORDER (Generic name, brand name, classification, dosage, route, frequency) GENERIC NAME: clopidogrel bisulfate BRAND NAME: Plavix CLASSIFICATION: Antiplatelet agent Platelet inhibitor DOSAGE: 75mg 1 tab ROUTE: PO FREQUENCY: Once a
29

MECHANISM OF ACTION

INDICATIONS

CONTRAINDICATIONS

ADVERSE EFFECTS OF THE DRUG

NURSING RESPONSIBILITIES/ PRECAUTIONS

Inhibits aggregation irreversibly platelet thereby, occurrence

platelet Reduction by atherosclerotic

of 1.

Hypersensitivity

to CNS: dizziness, fatigue

depression, 1. Confirm patient through headache, asking his name and looking on his name bracelet. 2. Explain to the patient what the drug is for. 3. Administer drug before

clopidogrel bisulphate 2. Pathologic bleeding (e.g. peptic ulcer, intracranial hemorrhage 3. Severe

inhibiting events in patients receptors decreases of

the binding of ATP to with MI.

EENT: epistaxis CV: chest pain, edema, hypertension GI: GI

liver Resp: cough, dyspnea abdominal diarrhea, pain, dyspepsia,

atherosclerotic events.

impairment 4. Patients with rare

bleeding, patient goes to sleep. 4. Monitor the vital signs prior, during and after therapy. 5. Ensure patients safety

aggregation

galactose intolerance

gastritis, constipation Derm: rashes, purpura, pruritus, bruising neutropenia Metabolic:

Hematology: bleeding, through side rails up. 6. Keep patients skin intact by positioning patient every

A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips 1, Diabetes Mellitus Type II Uncontrolled Day TIMING: HS (8PM) hypercholesterolemia Muskuloskeletal: arthralgia, back pain Miscellaneous: fever, hypersensitivity reaction 2 hrs.

30

A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips 1, Diabetes Mellitus Type II Uncontrolled DRUG ORDER (Generic name, brand name, classification, dosage, route, frequency) MECHANISM OF ACTION INDICATIONS CONTRAINDICATIONS ADVERSE EFFECTS OF THE DRUG NURSING RESPONSIBILITIES/ PRECAUTIONS

31

A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips 1, Diabetes Mellitus Type II Uncontrolled GENERIC NAME: aspirin BRAND NAME: Artria S.R. CLASSIFICATION: antipyretics, analgesics salicylates DOSAGE:80mg 1 tab ROUTE: PO FREQUENCY: Once a Day TIMING: after lunch nonopioid Produce analgesia and Prophylaxis reduce the inflammation transient production of fever, and fever by inhibiting attacks prostaglandins and mild of 1. MI, to Hypersensitivity to EENT: tinnitus, GI: GI abdominal nausea, diarrhea, epigastric 1. Confirm patient through pain, on his name bracelet. vomiting, dyspepsia, distress, 2. Explain to the patient what the drug is for. 3. Assess pain: location,

ischemic clopidogrel bisulphate 2. Pathologic bleeding (e.g. peptic ulcer, intracranial hemorrhage 3. Severe

bleeding, asking his name and looking

moderate pain

liver anorexia, hepatotoxicity bleeding anemia,hemolysis Miscellaneous: allergic reactions; anaphylaxis and laryngeal edema

impairment 4. Patients with rare

Hematology: increase type, and intensity before time, and at the peak of drug action after administration. 4. Administer drug after

galactose intolerance

lunch. 5. Monitor the vital signs, especially temperature (for fever) prior, during and after therapy.

32

A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips 1, Diabetes Mellitus Type II Uncontrolled

33

A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips 1, Diabetes Mellitus Type II Uncontrolled DRUG ORDER (Generic name, brand name, classification, dosage, route, frequency) GENERIC NAME: enoxaparin sodium BRAND NAME: Clexane CLASSIFICATION: anticoagulants antithrombotics DOSAGE: 4000iu Potentiate the inhibitory Treatment of acute 1. effect of antithrombin STon factor Xa thrombin. preventing formation. Thus, prevention thrombus venous thromboembolism. (VTE) and elevation MI Hypersensitivity to CNS: CV: edema to GI: constipation, liver enzymes GU: urinary retention vomiting, nausea, MECHANISM OF ACTION INDICATIONS CONTRAINDICATIONS ADVERSE EFFECTS OF THE DRUG NURSING RESPONSIBILITIES/ PRECAUTIONS

dizziness, 1. Confirm patient through asking his name and looking on his name bracelet. 2. Explain to the patient what the drug is for. 3. Assess for signs of

segment- specific agents or pork headache, insomnia and products of 2. Hypersensitivity

enoxaparin sodium 3. Active bleeding

reversible increase in

bleeding and hemorrhage 4. History of heparin- Derm: ecchymosis, (bleeding gums, nosebleed, induced pruritus, rash, urticaria black tarry stools, thrombocytopenia Hematology: bleeding, hematuria). Notify physician anemia, thrombocytopenia Local: erythema if such manifestations occur.

(40mg) per 0.4 ml ROUTE: subcutaneous FREQUENCY:

34

at 4. Administer the drug in a manner, injection site, irritation, slow subcutaneously. pain, hematoma

A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips 1, Diabetes Mellitus Type II Uncontrolled Q 12H TIMING: 8am-8pm 5. Alternate injection site to avoid hypertrophy

35

A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips 1, Diabetes Mellitus Type II Uncontrolled DRUG ORDER (Generic name, brand name, classification, dosage, route, frequency) GENERIC NAME: omeprazole BRAND NAME: Prisolec CLASSIFICATION: Antiulcer agent Proton-pump inhibitor DOSAGE: 40mg Derm: itching, rash ROUTE: IVTT FREQUENCY: Q 24H TIMING: 8pm
36

MECHANISM OF ACTION

INDICATIONS

CONTRAINDICATIONS

ADVERSE EFFECTS OF THE DRUG

NURSING RESPONSIBILITIES/ PRECAUTIONS

Binds to an enzyme on Reduction of risk of 1. gastric parietal cells in GI gastric pH, preventing and bleeding the presence of acidic critically ill patients condition

Hypersensitivity

to CNS:

dizziness, 1. Confirm patient through on his name bracelet. 2. Obtain a skin test prior to pain, initial administration.

in omeprazole 2. Metabolic alkalosis

headache, drowsiness, asking his name and looking fatigue, weakness CV: chest pain GI: acid flatulence, vomiting abdominal

the final transport of where inhibition of 3. Hypocalcemia hydrogen ions in the gastric acid gastric lumen. secretion may be beneficial

regurgitation, 3. Explain to the patient diarrhea, what the drug is for. nausea, 4. Inform the patient that administration may cause pain on IV site.

constipation,

Miscellaneous: allergic 5. Administer the drug in a reaction slow manner, intravenously.

A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips 1, Diabetes Mellitus Type II Uncontrolled DRUG ORDER (Generic name, brand name, classification, dosage, route, frequency) MECHANISM OF ACTION INDICATIONS CONTRAINDICATIONS ADVERSE EFFECTS OF THE DRUG NURSING RESPONSIBILITIES/ PRECAUTIONS

37

A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips 1, Diabetes Mellitus Type II Uncontrolled GENERIC NAME: metoprolol BRAND NAME: Lopresor CLASSIFICATION: Antianginals, antihypertensive agent Beta blockers DOSAGE: 50mg 1 tab ROUTE: PO FREQUENCY: BID TIMING: 8am-6pm Unknown. A Selective beta blocker that selectively blocks betaadrenergic decreases output, oxygen secretion. receptors; cardiac peripheral consumption; Early intervention in 1. acute MI Hypersensitivity to CNS: fatigue, dizziness, 1. Confirm patient through drowsiness, anxiety, asking his name and looking weakness nervousness, on his name bracelet. nightmares, insomnia EENT: blurred vision, stuffy nose Resp: CV: peripheral vasoconstriction, bradycardia, Pulmonary edema GI: diarrhea, flatulence,gastric nausea, GU: dysfunction, frequency
38

metoprolol 2. Uncompensated CHF 3. Pulmonary edema 4. Cardiogenic shock 5. Bradycardia or heart block

2. Explain to the patient what the drug is for.

resistance, and cardiac and depresses rennin

bronchospasm, 3. Monitor vital signs before, during, and after hypotension, administration. Take apical pulse before administering. If HR is <60bpm, inform CHF, physician. 4. Monitor intake and output accurately. Monitor HGT as

wheezing

constipation,

pain, 5.

heartburn, dry mouth, prescribed. vomiting, erectile Derm: itching, rash 6. Administer drug with or after meals.

urinay 7. Assess for signs and symptoms of CHF

A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips 1, Diabetes Mellitus Type II Uncontrolled Derm: rashes Endo: MS: pain Miscellaneous: induced syndrome druglupus hypoglycaemia arthralgia, (dyspnea, venous occur. rales/crackles, distention) and

hyperglycemia, peripheral edema, jugular back prompt physician if these

39

A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips 1, Diabetes Mellitus Type II Uncontrolled DRUG ORDER (Generic name, brand name, classification, dosage, route, frequency) GENERIC NAME: lactulose BRAND NAME: Duphalac CLASSIFICATION: laxative osmotics DOSAGE: 3.3g/5ml 30 ml ROUTE: PO Increases water Prophylaxis avoid for 1. valsalva causing Hypersensitivity to GI: belching, cramps, 1. diarrhea Endo: hyperglycemia Confirm patient his MECHANISM OF ACTION INDICATIONS CONTRAINDICATIONS ADVERSE EFFECTS OF THE DRUG NURSING RESPONSIBILITIES/ PRECAUTIONS

content and softens pending the stool, lowers pH of to the colon, from inhibits ammonia thereby diffusion which maneuver

constipation lactulose 2. Galactosemia

distention, flatulence, through

asking

name and looking on his name bracelet. 2. Explain to the

of then more agitation to 3. Bowel obstruction the the patient.

colon into the blood, reducing blood ammonia.

patient what the drug is for. 3. Assess for bowel distention, presence of bowel normal sounds, pattern and of

bowel function. 3. Monitor vital signs before,

40

during,

and

A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips 1, Diabetes Mellitus Type II Uncontrolled FREQUENCY: HS TIMING: 8pm after administration. 4. Monitor HGT as ordered. 5. Monitor intake and output Assess amount produced. 6. Administer drug accurately. the of color, and stool

consistency,

before sleeping hours. 7. Provide safety

measures; keep side rails up at all times.

41

A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips 1, Diabetes Mellitus Type II Uncontrolled DRUG ORDER (Generic name, brand name, classification, dosage, route, frequency) MECHANISM OF ACTION INDICATIONS CONTRAINDICATIONS ADVERSE EFFECTS OF THE DRUG NURSING RESPONSIBILITIES/ PRECAUTIONS

42

A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips 1, Diabetes Mellitus Type II Uncontrolled GENERIC NAME: metformin HCl BRAND NAME: Glucophage CLASSIFICATION: Antidiabetics biguanides 6. Hepatic impairment DOSAGE: 500mg 1 tab ROUTE: PO FREQUENCY: TID TIMING: 8am-6pm 7. Renal dysfunction Decreases glucose decreases glucose and hepatic Management of type 2 1. production, diabetes mellitus intestinal absorption increases Hypersensitivity to GI: bloating, nausea, unpleasant taste. Endo: 4. Dehydration 5. Hypoxemia hypoglycaemia F and E: lactic acidosis Misc: decreased vitamin B12 levels abdominal 1. Confirm patient his

metformin 2. Metabolic acidosis 3. Sepsis

diarrhea, through

asking

vomiting, name and looking on metallic his name bracelet. 2. only hyperglycemia does not cure DM. 3. Assess for bowel distention, presence of bowel normal sounds, pattern and of Explain to the

sensitivity to insulin.

patient that metformin controls and

bowel function. 4. Monitor vital signs before, during, and after administration. 5. Administer

metformin with meals.

43

A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips 1, Diabetes Mellitus Type II Uncontrolled 6. Monitor HGT as ordered. 7. Monitor intake and output accurately.

ASESSMENT DATA (Subjective and Objective)

NURSING DIAGNOSIS (Problem and Etiology)

GOAL AND OBJECTIVES

NURSING INTERVENTIONS AND RATIONALE

EVALUATION

Subjective: Murag naai plemas nagpikit

44

Ineffective clearance retained sa akong

Airway Short-Term Goals: related to Within 3-5 minutes copious thorough

INDEPENDENT: of 1. Auscultate breath sounds. nursing R This will serve as a baseline

Short- Term Goals: Goals met. After 5 minutes of thorough nursing intervention

diri

A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips 1, Diabetes Mellitus Type II Uncontrolled tutunlan the patient. Objective: Abnormal increase of RR Non cough Abnormal sounds heard breath upon Long-Term Goals: of 25cpm productive (tachypneic) nga dili nako secretions in the intervention the patient will data for the effectiveness of the be able to: a) Improve respiratory (tachypneic) (12 22cpm) b) Expectorate gradually secretions. to back rest. promoting then proper exchange of gases. actions done. the patient was able to

magawas as verbalized by

tracheobronchial tract.

improve

respiratory

status

from 25cpm to a normal range expectorated secretions. Long-Term Goals: Goals partially met. After 8 hours of thorough nursing

status from 25cpm 2. Assist patient on moderate high of RR (22cpm) and gradually normal range of RR R To maximize lung expansion

3. Demonstrate and instruct proper interventions the client was and effective deep breathing and able to maintain the respiratory status within the normal range (12 22cpm). Although, there are clear breath sounds heard upon auscultation, there are times intake within the cardiac tolerance. all R This will soften the copious the that patient coughs After 8 hours of the course coughing exercises. of duty, the client will be R To effectively expectorate able to: a) Maintain respiratory within the status copious secretions lodge in the the airways.

auscultation (rales on inspiration)

normal 4. Instruct patient to increase fluid roughly which may denote the existence of secretions within the tracheobronchial tract. .

range (12 22cpm) b) Expectorate copious lodge within

secretions secretions for easy expectoration.

tracheobronchial tract 5. Do chest tapping at appropriate

45

A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips 1, Diabetes Mellitus Type II Uncontrolled as manifested by intervals. R To dislodge secretions from smaller airways to larger airways for easy expectoration. 6. Turn the patient into sides every 2 hours and/or appropriate intervals. R This will prevent respiratory complications and allows the release of pressure on the back especially on the sacral area and other bone prominences that may create ulceration. DEPENDENT: 1. Provide oxygen inhalation, as ordered, at 2LPM via nasal cannula. R - To adequately provide oxygen unto the client preventing then tachypnea.

clear breath sounds.

46

A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips 1, Diabetes Mellitus Type II Uncontrolled

47

ASESSMENT DATA on Acute Coronary Syndrome, GOAL AND OBJECTIVESInfarction, Anterior Wall, Killips ANDDiabetes Mellitus Type II NURSING DIAGNOSIS NURSING INTERVENTIONS 1, EVALUATION A Case Study ST Elevation Myocardial Uncontrolled (Subjective and Objective) (Problem and Etiology) RATIONALE

Subjective:

Decreased kay naa sa by pud by the kay the Output

Cardiac Short- Term Goals: related to

INDEPENDENT:

Short- Term Goals:

Usahay

gapitik-pitik verbalized patient.

altered preload as in decrease venous return secondary Elevation to ST Myocardial

Within 5 10 minutes of 1. Monitor Vital Signs frequently Goals met. After 10 minutes thorough be able to: a) Improve from (bradycardia) (60 100bpm). b) Improve from (tachypneic) (12 22cpm). Long- Term Goals: At the end of 16 hours of duty, the patient will be able to: respiratory 25cpm to status of the client heart rate 58bpm to nursing especially HR and RR. data for the effectiveness of the actions done. of thorough nursing intervention, the client will R This will serve as a baseline intervention, the client was able to improve heart rate from 58bpm to normal range of back rest. R To maximize lung expansion promoting then proper exchange of gases. 3. Provide quiet environment and decrease stimuli. R To promote adequate rest and to avoid agitation in the client decreasing then oxygen demand. 4. Allow client to rest in appropriate intervals. R This would decrease oxygen a) Maintain HR within consumption using it instead for the normal range (60 the myocardium for better cardiac Long- Term Goals: Goals partially met. After 16 hours of duty, the patient was able to maintain HR within the normal range (60 100bpm), maintain HR (67bpm), improve

akong dughan as

Usahay verbalized patient.

Infarction (STEMI)

gahanguson ko.. as

2. Assist client in moderate high respiratory status of the client from 25cpm to normal range of RR (22cpm).

normal range of HR

Objective: Abnormal decrease of HR of 58bpm (bradycardia) Abnormal increase of RR of 25cpm (tachypneic) ST elevation on the ECG of the client

normal range of RR

respiratory status of the client within the normal range (12 22cpm) but we werent able to see progress of the ECG because there was no followup order.

48

A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips 1, Diabetes Mellitus Type II Uncontrolled

49

ASESSMENT DATA on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips 1, Diabetes Mellitus Type II NURSING DIAGNOSIS GOAL AND OBJECTIVES NURSING INTERVENTIONS AND EVALUATION A Case Study Uncontrolled RATIONALE (Subjective and Objective) (Problem and Etiology) Subjective:

Ineffective perfusion

tissue Short-Term Goals:

INDEPENDENT:

Short- Term Goals: Goals Met. At the end of 8 hours able of to thorough nursing and intervention, the client was established

Usahay paspas ang pitik sah akong as the dughan ug mura ko ganerbioson verbalized patient. by

(cardiopulmonary) related blood blood Mellitus to flow sluggish due to

At the end of 8 hours of 1. Elevate peripheries or extremities thorough be able to:

a.) Establish

nursing R To promote venous return to

intervention, the client will the heart.

increase viscosity of circulation secondary to Diabetes

and 2. Demonstrate and assist patient in maintain normal vital signs of HR (67bpm) and RR (22cpm). Long Term Goals: Goals met. At the end of 16 hours appropriate improves of thorough nursing intervention, the client was establish and maintain normal blood glucose within the and and normal range (100mg/dL) from 172mg/dL 139mg/dL (CBG) (labs)

maintain normal vital active and passive range-of motion. signs of heart rate R To increase the blood flow by 60-100bpm 58bpm.
b.) Establish

Objcetive:

Abnormal decrease of heart rate of 58bpm Abnormal decrease of respiratory 25cpm rate of

from improving circulation and prevent formation of thrombus. and normal 3. from R Turn patient Bed at

maintain 12-22cpm 25cpm. Long-Term Goals:

respiratory rate of intervals. mobility circulation in the body. 4. Instruct patient to have a complete

Abnormal increase of blood glucose level of 172mg/dl. (CBG)

Abnormal increase in blood glucose level of 139mg/dL (labs)

At the end of 16 hours of bed rest without toilet privilege. thorough nursing R To prevent overexertion and intervention, the client will fatigue. be able to: a.) Establish maintain and DEPENDENT: Administer normal 1.

maintained heart rate (60 100bpm) and respiratory rate (12 22cpm) within the normal range.

50

metformin

blood glucose within (Glucophage) 50mg,p.o at TID as

ASESSMENT DATA on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips 1, Diabetes Mellitus Type II NURSING DIAGNOSIS GOAL AND OBJECTIVES NURSING INTERVENTIONS AND EVALUATION A Case Study Uncontrolled RATIONALE (Subjective and Objective) (Problem and Etiology) Subjective:
Gasakit

Acute pain (left chest) Short-Term usahay dughan by as the related blockage coronary secondary to to of partial the artery acute Within 10 - 15 minutes of nursing will: 1. Report controlled care the and patent interventions,

INDEPENDENT: altered when patient is in acute pain. R - Changes in vital signs may indicate discomfort. acute pain and

Short- Term Goals:

1. Monitor V/S which is usually Goals met After 15 minutes of Nursing interventions, the patient reported pain was relieved as evidenced by a pain scale of 0/10 and demonstrated relaxation techniques such as deep breathing exercise. Long-Term Goals: Goal partially met 3. Assist patient to find position of comfort. R - Position affects the patients ability to relax and rest/sleep After the 8-hour shift, the patient reported relieved pain with a pain scale of 0/10.

akong patient. Objective:

verbalized

coronary syndrome

Pain Scale :6/10 Restless Guarding on the left chest.

pain as evidenced 2. Provide comfort measures to the by a decreased pain patient such as providing appropriate scale from 6/10 to ventilation. 0/10. 2. Demonstrate use of relaxation skills. R - To promote relaxation.

Long-Term

After 8 hours of thorough effectively. nursing intervention, the 4. Teach patient deep-breathing client will be able to report relieved of pain.

exercise to help refocus attention and enhance coping abilities. R - This reduces muscle tension which reduces the intensity of the pain.

51

A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips 1, Diabetes Mellitus Type II Uncontrolled

ASESSMENT DATA (Subjective and Objective)

NURSING DIAGNOSIS (Problem and Etiology)

GOAL AND OBJECTIVES

NURSING INTERVENTIONS AND RATIONALE

EVALUATION

Subjective:

Activity na sa nako una (Level oxygen 1) imbalance

Intolerance Short-Term Goals: related supply

INDEPENDENT:

Short-Term Goals: Goals met. After 5 hours of nursing interventions, the need the for client will be able to verbalize acceptance activity modification, improved

Dili

to After 5 hours of nursing 1. Allow rest in between activities and be able to:
a.) Verbalize

mabuhat kayo akong gabuhaton nga wa by nagsakit verbalized patient.

between interventions, the client will R This will decrease oxygen consumption overexertion. the medical and gain and to avoid

pako demand secondary to as inability of the heart to the pump out adequate amount of blood.

acceptance need
b.) Improve

for

activity 2. Inform the client about the recent the respiratory status of the condition. client cooperation from to 27cpm normal (upon range clients the R This will clarify thought of the from along the way. (upon modification. ( i.e. meals, instead he exertion) (22cpm), coherent

modification.

Dali rako kapuyon ug kung masobraan, hanguson dayon ko, as verbalized by the patient.

respiratory status of clients the 27cpm client

improved by

responses from restless to answering

exertion) to normal 3. Assist client in doing activity questions appropriately and range (12 22cpm) of perform activities within the can cardiac tolerance.
c) Improve

Objective: Pallor
52

clients buying/cooking

mucosa

and

responses

from prepare the utensils and plates)

A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips 1, Diabetes Mellitus Type II Uncontrolled conjunctiva Abnormal decrease of RBC (3.58); Hgb (11.1); and Hct (31.5). Abnormal increase of RR of 27cpm upon exertion (tachypnea) Restless Long-Term Goals: After 16 hours of nursing provide be able to:
a. Maintain RR within

restless to coherent R This will encourage client in by questions appropriately.

d) Perform

answering his health management. In this manner, it would gain clients compliance to activities modification and this will be more the cardiac achievable rather than setting your own activities.

Long-Term Goals: Goals met. After 16 hours of interventions, the client will be able to maintain RR within the normal range (12 22cpm), maintained clients responses upon doing

activity nursing

within

tolerance.

4. Promote comfort measures and activities ( i.e. dont feel dizzy relief To of pain ability non- easily), to continuously do modified activities within the cardiac tolerance, improved clients laboratory results of RBC from 3.58 to normal gradually. (i.e from the bed to sitting normal range (14.0); and Hct clients position on the bed to chair and from 31.5 to normal range upon assist in ambulation) (39.6).

interventions, the client will pharmacologically. R enhance participate in activities. the normal

range 5. Increase exercise/activity levels range ( 4.0); Hgb from 11.1 to

(12 22cpm)
b. Maintain

responses

doing activities ( i.e. R To conserve energy and dont feel dizzy increase activity competency. easily)
c. Continuously 53

do 6. Assist client in Active and Passive

A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips 1, Diabetes Mellitus Type II Uncontrolled modified within the tolerance.
d. Improve

activities Range of Motion. cardiac R To initiate gradual; activity to the client. clients

laboratory results of DEPENDENT: RBC from 3.58 to 1. Provide oxygen inhalation at normal range ( 4.2 2LPM via nasal cannula, as per 5.4); Hgb from 11.1 doctors order to normal range R To give adequate oxygen flow (12.0 16.0); and especially during exertion. Hct from 31.5 to normal range (37.0 47.0)

54

ASESSMENT DATA (Subjective and Objective)

NURSING DIAGNOSIS (Problem and Etiology)

GOAL AND OBJECTIVES

NURSING INTERVENTIONS AND RATIONALE

EVALUATION

Risk factors: Dietary Intake (still consumes sweet, fatty salty, and

Risk Glucose

for Short term Goal: After 30 minutes of nursing interventions, to: Verbalize understandi ng of the patient will be able

INDEPENDENT: 1. Ascertain knowledge understanding needs. R: To know what are the information to be given

Short- Term Goals: clients Goal met. After 30 or minutes of nursing of intervention, verbalize understanding of the factors that may lead to unstable glucose the

Unstable Blood

condition and treatment patient was able to

carbohydraterich foods) Stress

as eating the 2. Provide information on such factors that balancing food intake and sweet, salty, fatty carbohydratemay lead to anti-diabetic agents. R: and unstable glucose such eating sweet, salty, and e-rich foods. as 3. Review to R: clients glucose Multiple common situations that fatty contribute instability. To enhance the efficacy of the medication Long term Goal: Goal met. After 16 hours of nursing the interventions, maintain a Normal level; CBG) glucose (indicate the rich foods.

Sedentary lifestyle (lack of exercise)

carbohydrat

factors can play a role at any time , such as missing infection 5. Encourage client to read labels and choose foods described as having low glycemic index, higher fiber, and low fat meals and

patient was able to

Long term Goal:

After 16 hours of a nursing interventions, to:

a.) Maintain

the content. a slower rise in blood a glucose 6. Discuss how clients 70- anti-diabetic medications work. R: Drugs and combinations of drugs

patient will be able R: These foods produce

normal glucose level; 110 mg.

IX. DISCHARGE PLANNING MEDICATIONS Discuss to the patient and family the dosage, frequency, and adverse effects of the drugs. Explain that the drugs used for effective control of elevated BP will likely produce adverse effect. Explain to the patient and family members the importance of taking medicines. The patient will able to take medications as what had been prescribed by the physician religiously and be able to follow directions as instructed by the nurse. In patients with self-administer insulin, demonstrate patient the appropriate preparation and administration techniques.

ECONOMIC STATUS Inform the patient to avail to some government programs such as philhealth. Explain to significant others that the rehabilitation may be prolonged to be able to for the family to prepare financial needs. Have occupational therapist to help re-learn everyday activities or ADL.

TREATMENT
Emphasized the importance of regular follow-up check-ups and as instructed by

physician.
Advised patient and family members to seek medical advise if any unusuality

arises
Reinforced the importance of having blood sugar checked every day.

Admit patient in cardiac rehabilitation, this is a monitored exercise and education program that can help the patient return to an active lifestyle.

HEALTH TEACHING

 Encouraged client to do at least 30 minutes of walking a day as a form of exercise. Encouraged client to quit smoking and offered nicotine replacement. Cessation of cigarette smoking reduces the progression of disease, as shown by lower rates of amputation and lower incidences of rest ischemia in patients who quit, and it reduces the risks of myocardial infarction and death from other vascular causes. Instructed to monitor blood sugar regularly. Adjustments in diet, medication and exercise can be made accordingly. Encouraged to stick to the monitoring protocol prescribed by the doctor. Generally, blood is monitored before meals and at bedtime. Safety precaution should be maintained to prevent foot injury such as do not wear open shoes or walk barefoot Teach to the patient signs and symptoms of diabetic neuropathy and emphasize the need for safety precautions because neuropathy decreased sensation can hide sense injuries. Adjust of activities to avoid over exertion and fatigue, allow rest periods

OUT-PATIENT The patient could avail his medication from government hospitals that he could get some benefits. He will also avail the services offered by the barangay health center and at the botikang bayan Instruct patient to seek regular medical check-up

DIET
Eat a variety of foods as recommended in the Diabetes Food Pyramid to get a

balanced intake of the nutrients your body needs - carbohydrates, proteins, fats, vitamins, and minerals. Reduce the amount of fat you eat by choosing fewer high-fat foods and cooking with less fat.

 Eat more fiber by eating at least 5 servings of fruits and vegetables every day. Eat fewer foods that are high in sugar like fruit juices, fruit-flavored drinks, sodas, and tea or coffee sweetened with sugar. Use less salt in cooking and at the table. Eat fewer foods that are high in salt, like canned and packaged soups, pickles, and processed meats.

SPIRITUALITY
Encouraged patient and Family members to go to church every Sunday and to

continue to seek Gods guidance and enlightenment.

Emphasized the importance of prayers in healing Encouraged

to

ask

for

divine

assistance

in

everything

and

to

encouragecontinuing to pray to God.

Encouraged to continue to have a positive outlook in life. Encouraged to keep faith in God and not to give up easily when hardtimes come

X. RELATED LEARNING EXPERIENCE

Taking up nursing course have entitled the group to become disciplined in everything that we do. As much as we want to think that the nursing life is easy to somehow lessen the stress and sometimes burden but its not working. This have made us realize that its better to accept the idea that nothing is easy and hence, molding ourselves to become disciplined is one way of passing this difficult road to success.

Our duty at the Intensive Care Unit of Northern Mindanao Medical Center is probably the busiest duty weve ever had unlike in CUMC Intensive Care Unit its opposite due to fewer patients admitted. But despite it, we have taken it as an opportunity to take advantage of our duty time in improving our clinical skills and as well as improving our knowledge. Weve learned a lot in the clinical area and so its definitely worth our exhaustion.

The entire process of making this case study may have not been easy for all of us but fortunately, weve manage to deal with the problems properly and thus, we were able to finish this case study in the best way we could. Whether the outcome of this case study is good or bad, we must take it as a lesson and a parameter to continue seeking knowledge and improving our skills.

This case study enabled the group to identify nursing intervention which are appropriate to promote the well-being of the patient and as well as the medical management for the case.

We would like to thank Mr. Hamed Fabre, for giving his best to teach us and to mold us in becoming good and competent nurses in the future. Furthermore, this rotation would have not been successful without the guidance of our almighty God!

XI. REFERENCE

BOOKS:
Doenges, M.E., Moorhouse, M.F., & Geissler, A.C, (2002). Nursing Care

Plans Guidelines for Individualizing Patient Care, (6th ed.). Thailand

Doenges, M.E., Moorhouse, M.F., & Geissler, A.C (2006). Nurses pocket

Guide; Diagnoses, Prioritized Interventions, and Rationales. (10thed.). Philadelphia, Pennsylvania

Smeltzer, Suzanne C., RN, Edd, FAAN, & Bare, Brenda G., RN, MSN,(2004).

Textbook of Medical-Surgical Nursing, (10th ed.), Philadelphia

Karch, Amy M. ; 2006 Lippincotts Nursing Drug Guide, 8th edition. Lippincott

Williams & Wilkins. Nurses Pocket Guide, 10th edition F.A. Davis. Nursing Care Plans, 7th edition F.A. Davis Doeuger, Moorhouse, Murr. Patients Chart
Black, Joyce M. et. al, Medical-Surgical Nursing: Clinical Management for

Positive outcome. 7th edition. Philadelphia, W.B. Saunders. 2005 Malseed, Roger T. ; Springhouse Nurses Drug Guide 2004, 5th edition.
Davis drug handbook, 10th edition

Drug handbook by Saunders

 Medical-Surgical Nursing (Clinical Management for Positive Outcomes) 8th

edition By: Joyce Black and Jane Hokanson Hawks Nursing Care of Infants and Children by Wong

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