I.

INTRODUCTION Angina, or angina pectoris, is the medical term used to describe the temporary chest discomfort that occurs when the heart is not getting enough blood. The heart is a muscle (myocardium) and gets its blood supply from the coronary arteries. Blood carries the oxygen and nutrients the heart muscle needs to keep pumping. When the heart does not get enough blood, it can no longer function at its full capacity. When physical exertion, strong emotions, extreme temperatures, or eating increase the demand on the heart, a person with angina feels temporary pain, pressure, fullness, or squeezing in the center of the chest or in the neck, shoulder, jaw, upper arm, or upper back. This is angina, especially if the discomfort is relieved by removing the stressor and/or taking sublingual (under the tongue) nitroglycerin. The discomfort of angina is temporary, meaning a few seconds or minutes, not lasting hours or all day. An episode of angina is not a heart attack. Having angina means you have an increased risk of having a heart attack. A heart attack is when the blood supply to part of the heart is cut off and that part of the muscle dies (infarction). Prolonged or unchecked angina can lead to a heart attack or increase the risk of having a heart rhythm abnormality. Either of those could lead to sudden death. Angina pectoris is a common manifestation of coronary artery disease. The pain is caused by reduced blood flow to a segment of heart muscle (myocardial ischemia). It usually lasts for only a few minutes, and an attack is usually quickly relieved by rest or drugs (such as nitroglycerin). Also, it is possible to have myocardial ischemia without experiencing angina. Typically, angina is described as a "pressure" or "squeezing" pain that starts in the center of the chest and may spread to the shoulders or arms (most often on the left side, although either or both sides may be involved), the neck, jaw or back. It is usually triggered by extra demand on the heart: exercise, an emotional upset, exposure to cold, digesting a heavy meal are common examples. Some people experience angina while sleeping or at rest. This type of angina may be caused by a spasm in a coronary artery, which most commonly occurs at the site of atherosclerotic plaque in a diseased vessel. Most people with angina learn to adjust their lives to minimize attacks. There are cases, however, when the attacks come frequently and without provocation - a condition known as unstable angina. This is often a prelude to a heart attack and requires special
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treatment, primarily with drugs. Angina affects both men and women, usually in middle age. Men are much more likely than women to experience it before age 60. It may develop weeks, months or even years before a heart attack, or may be experienced only after a heart attack has occurred. Angina symptoms include: Chest pain or discomfort Pain in your arms, neck, jaw, shoulder or back accompanying chest pain Nausea Fatigue Shortness of breath Sweating Dizziness The chest pain and discomfort common with angina may be described as pressure, squeezing, fullness or pain in the center of your chest. Some people with angina symptoms describe angina as feeling like a vise is squeezing their chest or feeling like a heavy weight has been placed on their chest. For others, it may feel like indigestion. Characteristics of stable angina Develops when your heart works harder, such as when you exercise or climb stairs Can usually be predicted and the pain is usually similar to previous types of chest pain you've had Lasts a short time, perhaps five minutes or less Disappears sooner if you rest or use your angina medication Characteristics of unstable angina (a medical emergency) Occurs even at rest Is a change in your usual pattern of angina Is unexpected Is usually more severe and lasts longer than stable angina, maybe as long as 30 minutes May not disappear with rest or use of angina medication Might signal a heart attack

Characteristics of variant angina (Prinzmetal's angina) Usually happens when you're resting Is often severe May be relieved by angina medication In the United States, 10.2 million are estimated to experience angina with approximately 500,000 new cases occurring each year. Angina is more often the presenting symptom of coronary artery disease in women than in men

Specific Objectives: The student nurses aim to achieve the following objectives in 2hours of case presentation:

1. Accurately present a thorough general assessment of the client which includes physical assessment and family history taking. 2. Effectively discuss and elaborate actual signs and symptoms of disease exhibited by the client. 3. Thoroughly discuss, explain, and elaborate the nature of the disease process. 4. Provide appropriate and proper nursing diagnosis in line with the clients medical condition. 5. Formulate nursing care plans for the different problems identified. 6. Provide nursing intervention according to the standards of nursing practice. 7. Apply the learned concepts and theories of disease. 8. Appraise the effectiveness and efficacy of nursing interventions rendered to the client. 9. Showcase the outcome of the rendered nursing interventions. 10. Convey the significance of clients response to the rendered nursing interventions. 11. Provide concise and concrete information to the audience with regards to the patients disease condition. 12. Provide appropriate environment for learning for the audience.

SCOPE AND LIMITATION This Grand Case Presentation will attempt to cover and discuss the disease process and present condition of the patient as assessed in the three days of assessment and duty, at Polymedic General Hospital, Station 5. It will also present the nursing and medical care as provided during the 32 hours duty (December 5-6, 2013). This case presentation will be limited to the patients verbalizations and significant other who partly served as informant, laboratory results, signs and symptoms and doctors order as evidenced by and observed from the patient within the engaged days.

II. PATIENTS PROFILE

Name: Sibuyan, Maria Lilia Trabado Sex: Female Birthday: June 14, 1960 Age: 53 years old Address: Upper Bontong, Camaman-an, Cagayan de Oro City Religion: Roman Catholic Nationality: Filipino Occupation: MLhuiller Manager Civil status: Married Spouse name: Jesus Sibuyan Occupation: Businessman Educational Attainment: High School Graduate Date & Time of admission: December 2, 2013/ 05:00AM Diagnosis: Angina Pectoris

Heredo-Familial Disease Patient explained that both her grandparents is hypertensive and that Hypertension is a big number of cases within their family and her father is also Diabetic that makes Diabetes Mellitus as one of her heredo-familial disease.

Gynaecological History Patient stated that she has her menarche at the age of 13 years old, she has four children (2 male & 2 female) and her youngest child is 17 years old. She is already in her Post-menopausal stage.

Food and Drug allergy Patient has no known food and drug allergies.

Diet and Lifestyle Patient states that she is not a picky eater and she usually eat foods that are readily available in fastfood chains. She also said that she drinks soft drinks almost everyday. She eats vegetables and fruits only when she is at home and has a longer time for prepare for their meal. She also admits that she has history of drinking alcoholic beverages in her younger years.

CHIEF COMPLAINT AND HISTORY OF PRESENT ILLNESS

She was previously admitted at Polymedic Medical Plaza in December 2011due to Myocardial Infarction. Her condition was triggered by Bagyong Sendong in which they were greatly affected.

In 2012, patient has episodes of chest pain.

12 hours prior to admission, patient had sudden onset of chest pain and shortness of breath with Pain Scale of 10/10 and 1 hour prior to admission patient had occurrence. Patients chief complaint is Chest Pain & Shortness of Breath.

III.

DEVELOPMENTAL DATA Erik Erickson 8 Stages of Development Young Adulthood: 35 to 55 Ego Development Outcome: Generativity vs. Stagnation Basic Strengths: Work & Parenthood Work is most crucial. Erikson observed that middle-age is when we tend to be occupied with creative and meaningful work and with issues surrounding our family. Also, middle adulthood is when we can expect to "be in charge," the role we've longer envied.

The significant task is to perpetuate culture and transmit values of the culture through the family (taming the kids) and working to establish a stable environment. Strength comes through care of others and production of something that contributes to the betterment of society, which Erikson calls generativity, so when we're in this stage we often fear inactivity and meaninglessness. As our children leave home, or our relationships or goals change, we may be faced with major life changes the mid-life crisis and struggle with finding new meanings and purposes. If we don't get through this stage successfully, we can become self-absorbed and stagnate. Significant relationships are within the workplace, the community and the family. Robert J. Havighurst (Middle Adult 30 years old 60 years old) *Assisting teenage children to become responsible and happy adults. * Achieving adult social and civic responsibility. * Reaching and maintaining satisfactory performance in ones occupational career. *Developing adult leisure time activities. * Relating oneself to ones spouse as a person. * To accept and adjust to the physiological changes of middle age. *Adjusting to aging parents. INTERPRETATION
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The information listed above made by these two famous theorist are being exhibited by our patient. Basing on what we have assessed and upon interviewing we have known that some characteristics that a normal 53 year old are present. On the first developmental theory which is from Eric Erickson wherein the major conflict a person may encounter when he will reach this stage is Generativity versus Stagnation, our patient has successfully entered this stage. In this stage, she was able establish her career working productively as a manger of MLhuiller. She has her own family in which she is living harmoniously with her husband and four children. She happily shared to us that she was able to guide her children in which path to take for them to be able have a better future. She appears so proud of her children and feels loved as we can see her children reciprocate it to the way on how they care on their mother during her hospitalization. She also shared that she is happy in joining activities that can help the lives of others.

On the second theory by Robert Havighurst, people tend to exhibit the characteristics of parenting much time. They act us a protector and a guide to their children by leading them to the right attitude in order for their children to become a good person when they grow. so that people will not blame the parents. Their major role is to guide their children so that they will not be misled to something that is inappropriate, it always reflect on how the parents have raised their children. She shared to us that even though she is busy with work and she also has time to have her leisure time with her children. She finds time to be with them and spend some quality time but the fact that she is workaholic it can never be changed. Her officemates are telling her to take a rest but she refused for it saying that she is needed in the office.

IV. MEDICAL MANAGEMENT

a. Medical Orders with Rationale

DATE/TIME 12/2/13 DOCTORS ORDER >Please admit the patient under Dr. Go-See RATIONALE To verify that the patient admitted in the hospital under the care of Dr. Go-see For legal purposes and hospital protocol To let the GI tract rest To maintain fluid and electrolyte balance To have a quantitative data for basis of patients diagnosis and treatment To further asses the patients condition To monitor Myocardial Infarction Relaxes vascular smooth muscle and prevention of angina pectoris Prevents situation that may cause angina attacks To assess the patients condition every 4 hours. To monitor fluid and electrolyte balance To provide medical management fitted for the patient. To endorse patients condition to physician if there are any changes or unusuallities in patients condition. To let the patient rest and to not increase the cardiac workload. To avoid sodium and fat intake that may result to increase in blood pressure thus increases cardiac workload. To maintain fluid and electrolyte balance To have a quantitative data for 9

5 AM BP= 150/90 => 140/80 HR= 68 RR= 20

>Secure Consent >NPO temporarily >IVF: D5W 500cc @ KVO Labs: CBC with PC , ECG , Na, K, CPK-MB, SGPT

TEMP= 36.2 O2 Sat= 97 % (+) Chest pain (-) SOB

U/A . HGT now Ca , CK-MB , Trop-T >Meds: Isodril 10mg tab now then BID P.O

(-) Diaphoresis

Vasterl MR 4 tabs now then 1 tab BID >Monitor v/s q4 >I/O q shift >AP informed >Refer accordingly

>Complete bed rest

12/2/13

>DAT Low salt, low fat

>IVF TF : D5W 250 cc @ KVO Dx: Acute MI >FBS, Lipid profile , UA, SGPT tom. am

>Clopidrogel (Plogrel) 75mg tab OD >Lipitor 80mg OD HS >Clexane 0.4cc SQ now then q12

>Start Dobutamine Single concentrate

D5W 250cc *1 amp 10 cc/hr close monitoring while on Dobu drip

(+) minimal

>Hold Isodril if BP < 90/60

Chest pain

>For 2D echo w/ color droppler once stable

>Continue vastarel >Hold Isodril >Possible ICU admission >Refer to Dr. Oporto for co-management >Complete bed rest w/o bathroom privileges >v/s to q2 >Start NTG patch now then OD

basis of patients diagnosis and treatment Treatment pf pts. At risk for ischemic eventshistory of MI. It lowers the level of cholesterol in the blood. To prevent ischemic complications of unstable angina and non-Q-wave MI w/ oral aspirin therapy. Short-term treatment of cardiac decompensation cause by depressed contractility. To maintain fluid and electrolyte balance To maintain adequate cardiac output, blood pressure and heart rate. To prevent further decrease in blood pressure that may lead to cardiogenic shock. To have a visual diagnosis of the patients heart for further assessment. Prevents situation that may cause angina attacks To stop the stimulation of decreasing the BP of the pt. For monitoring the patients condition. For further evaluation of patients condition. To let the patient rest and to not increase the cardiac workload. To assess the patients condition every 2 hours. To prevent episode of angina.

>Algesia tab BID >Celebrex 400mg cap OD

>Mucosta 100mg tab TID

Management of moderate to severe pain Management of acute pain & treatment of acute long term of s/s of rheumatoid arthritis & osteoarthritis. To increase gastric blood flow, prostaglandin biosynthesis and 10

>Omeprazole 40mg cap tab OD

>CKMB in AM 12/2/13 (tel. order 2pm) 12/2/13 >Duavent I neb q 8

decrease free oxygen radicals Treatment of heartburn of symptoms of gastroesophageal reflux (GERD) To monitor Myocardial Infarction Treatment of obstructive airway disease To maintain adequate cardiac output, blood pressure and heart rate because dobutamine increases the force of contraction of the heart

>Side drip D5W250cc + I amp Dobu in cycle

(text.order 11pm) 12/3/13 2pm

>Continue meds. >IVF : D5W250cc + 1amp Dobutamine x 10cc/hr

Short-term treatment of cardiac decompensation cause by depressed contractility. Lowering the bodys production of triglycerides To increase contracting power of the heart thus maintain adequate BP To monitor Myocardial Infarction Prevents situation that may cause angina attacks

(-) chest pain >Omacor I cap OD >Taper Dobu drip by 2micro gtts qhr. Target SBP 90-110 mmhg >Repeat CKMB in AM >Vastarel MR Vastarel MR 35mg 1 tab BID

12/4/13 3PM 1:20 PM

>Continue meds. >Duavent 1 neb q12

Treatment of obstructive airway disease To have visual view of the heart for further assessment Short-term treatment of cardiac decompensation cause by depressed contractility. To monitor Myocardial Infarction Promoting healing & improving skin tone and are non-reviewed natural alternatives to use for anxiety &insomnia

3PM

>ff.up 2d echo result >Taper Dobu by 1micro gtt q2 , then D/C

>Repeat CKMB in AM >Aminovita 1 cap OD

12/5/13

>Continue meds. >IVFTF : D5W250cc @KVO

To maintain fluid and electrolyte 11

>D/C O2

>Encourage Ambulation >Refer for any signs of dizzines >For possible discharge tomorrow

balance To improve patients independence from supplemental oxygen To improve circulation in the body To evaluation of patients capability of performing ADL If there is no change in patients condition patient can go home tomorrow

12/6/13

>No new orders

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b. Drug Study

Generic Name: Date Ordered: Classification: Dose/Frequency/Route: Mechanism of Action:

(Paracetamol + Tramadol) Algesia December 2, 2013 Non-Opioid Analgesic 1tab/BID/PO Inhibition of cyclooxygenase (COX) an enzyme responsible for the production of prostaglandins, which are important mediators of inflammation, pain and fever. Binds to mu-opioid receptors. Inhibits the reuptake of serotonin and norepinephrine in the CNS

Specific Indication: Contraindication: Side Effects:

Moderate to severe pain Acute intoxication with opioids or psychoactive drugs CNS: Sedation, Dizziness, Headache, and Confusion CV: Hypotension, Tachycardia, Bradycardia Dermatologic: Sweating

Nursing Precaution:

Administer with food if GI upset occurs; Monitor patient response, Give the drug before the pain becomes intense.

Generic Name: Date Ordered: Classification:

Celecoxib (Celebrex) December 2, 2013 NSAID, Analgesic (nonopioid), Specific COX-2 enzyme blocker

Dose/Frequency/Route: Mechanism of Action:

400mg/OD/PO It inhibits the conversion of arachidonic acid to prostaglandins while having no effect on the
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formation of prostaglandins that mediate the normal homeostasis in the GI tract, kidneys and platelets catalyzed by COX-1. Specific Indication: Contraindication: Management of acute pain Hypersensitivity including those in whom attacks of angioedema, rhinitis and urticaria have been precipitated by aspirin, NSAIDs or sulfonamides. Severe hepatic impairment; severe heart failure; inflammatory bowel disease; peptic ulcer; renal impairment (CrCl <30 ml/min); pregnancy and lactation. Abdominal pain, diarrhea, nausea, edema, dizziness, headache, insomnia, upper respiratory tract infections; rash Nursing Precaution: a. Administer drug with food or after meals if GI upset occurs. b. Administer drug with grapefruit juice while taking this drug it alters the metabolism of the drug leading to increased level& increased side effects c. Instruct patient to report sore throat, fever, rash, itching, weight gain, swelling in ankles or fingers; changes in vision.

Side Effects:

Generic Name: Date Ordered: Classification:

Rebamipide (Mucosta) December 2, 2013 Antacids, Anti-reflux agents & Anti-ulcerants

Dose/Frequency/Route: 100mg /TID/PO Mechanism of Action: A mucosal protective agent and is postulated to increase gastric blood flow, prostaglandin biosynthesis and decrease free oxygen radicals. Protects the walls of the G.I tract Prevention of NSAIDS induced gastropathy Discontinue if markedly increase fever, rash &

Specific Indication: Contraindication:

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hypersensitivity reaction PREGNANCY, lactation. Side Effects Nursing Precaution: Rash, pruritus, constipation, diarrhoea, nausea Watch for signs of dizziness.

Generic Name: Date Ordered: Classification:

Omeprazole December 2, 2013 Proton pump inhibitor

Dose/Frequency/Route: 40mg/OD/PO Mechanism of Action: An anti-secretory compound that is a gastric acid pump inhibitor. Suppresses gastric acid secretion by inhibiting the H+, K+, ATPase enzyme system in the partial cells. Specific Indication: Suppresses gastric acid secretion relieving gastrointestinal distress and promoting ulcer healing.. Contraindication: Long-term use for gastro esophageal reflux disease, duodenal ulcer. Side Effects:

Nausea, vomiting, diarrhea, stomach pain Headache, dizziness Sleep problems (insomnia) Malaise, vertigo and fatigue.

Nursing Precaution:

a. Report sore, throat, fever, bleeding, tarry stool, confusion. b. Give with or without food, simultaneous administration does not appear to reduce absorption or serum. c. Administer adjunctive antacid treatment 2h before or after drug.

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Generic Name: Date Ordered: Classification: Dose/Frequency/Route: Mechanism of Action:

Omacor December 2, 2013 Antipyretic 1gram capsule/OD/PO Reducing the amount of triglycerides made in the liver, inhibition of the esterification of other fatty acids, and the inhibition of diacylglycerol O-acyltransferase, which is an enzyme that catalyzes the final step of triglyceride synthesis.

Specific Indication: Contraindication:

Treatment to hypertriglyceridemia. Contraindicated in patients who are under 18 years of age, pregnant or nursing mothers, patients with bleeding disorders or who are on anticoagulation therapy, and with liver disease. Patients demonstrating an allergy to the drug or components that make up the drug should not take this medication.

Side Effects:

Rash, possible increase in LDL levels, belching (often called a fish burp), upset stomach, an increase in the AST and ALT liver enzymes, prolongation of bleeding time, changes in taste, and flu-like symptoms.

Nursing Precaution:

a. It should be taken with meals.

Generic Name: Date Ordered: Classification: Dose/Frequency/Route: Mechanism of Action:

Ipratropium Bromide + Salbutamol (Duavent) December 4, 2013 Anti-cholinergic Bronchodilator 1neb/BID/inh Ipratropium bromide blocks the action of acetylcholine at parasympathetic sites in bronchial smooth muscle causing bronchodilation.

16

Specific Indication: Contraindication:

Treatment to Obstructive Airway Diseases Contraindicated in patients hypersensitive to drug. Use cautiously in patients with long term alcohol use because therapeutic doses cause hepatotoxicity in these patients.

Side Effects:

Dry mouth, urinary retention, buccal ulceration, paralytic ileus, headache, nausea, constipation, paradoxical bronchospasm, immediate hypersensitivity reactions (urticaria, angioedema), acute angle-closure glaucoma, nasal dryness and epistaxis (nasal spray).

Nursing Precaution:

a. Position patient on high back rest position. b. do back tapping after you nebulizer the patient. c. do not give a food immediately, it can cause vomiting.

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Generic Name: Date Ordered: Classification: Dose/Frequency/Route: Mechanism of Action:

Isosorbide Dinitrate December 2, 2013 Cardiovascular Agent; Anti-angina 10mg tab/BID/PO Isordil relaxes vascular smooth muscle with a resultant decrease in venous return and decrease in arterial BP, which reduces left ventricular workload and decreases myocardial oxygen consumption. Treatment and prevention of angina pectoris Contraindicated with allergy to nitrates, severe anemia, head trauma, cerebral hemorrhage, hypertrophic cardiomyopathy, narrow-angle glaucoma, postdural hypotension Use cautiously with pregnancy, lactation, acute MI, CHF. Headache

Specific Indication: Contraindication:

Side Effects:

Flushing Swelling of hands & feet Give oral preparations on an empty stomach, 1 hr before or 2 hr after meals; take with meals if severe, uncontrolled headache occurs. Give sublingual preparations under the tongue or in the buccal pouch; discourage the patient from swallowing. Report blurred vision, persistent or severe headache, rash, more frequent or more severe angina attacks, fainting. Make position changes slowly, particularly from recumbent to upright posture, and dangle feet and ankles before walking. Lie down at the first indication of light-headedness or faintness.

Nursing Precaution:

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Generic Name: Date Ordered: Classification: Dose/Frequency/Route: Mechanism of Action:

Clopidogrel December 2, 2013 Anticoagulant 75mg tab/OD/PO Irreversible inhibitor of platelet aggregation, acts by inhibiting ADP formation inhibits beta oxidation of fatty acid in blood vessels Treatment to Angina Pectoris Contraindicated in patients hypersensitive to drug. Peptic ulcer intracranial hemorrhage or coagulation disorder contraindicated to hypersensitivity of the drug.

Specific Indication: Contraindication:

Side Effects:

Bleeding Hemorrhage

Nursing Precaution:

Monitor liver function studies: AST,ALT,bilirubin, creatinine if patient is on long-term therapy Monitor blood studies: CBC,Hgb, Hct, protime,cholesterol if the patient is on long-term therapy; thrombocytopenia and neutropenia may occur.

Generic Name: Date Ordered: Classification: Dose/Frequency/Route: Mechanism of Action:

Atorvastatin Calcium (Lipitor) December 2, 2013 Antihyperlipidimecs 80mg tab/OD/PO Inhibits HMG-CoA reductase, the enzyme that catalyzes the first step in the cholesterol synthesis pathway, resulting in a decrease in serum cholesterol, serum LDLs (associated with increased risk of CAD), and increases serum HDLs (associated with decreased risk of CAD); increases hepatic LDL recapture sites, enhances reuptake and catabolism of LDL; lowers triglyceride levels Reduction of Elevated Total Cholesterol & LDL
19

Specific Indication:

Cholesterol Contraindication: Contraindicated in patients hypersensitive to drug. Peptic ulcer intracranial hemorrhage or coagulation disorder contraindicated to hypersensitivity of the drug. Side Effects:

Myalgia Headache Insomnia Pruritus Muscle Cramps Avoid intake of alcohol. Monitor Vital Signs especially Blood Pressure. It should be taken with or after meals. Monitor Creatinine Phosphokinase Transaminase elevation.

Nursing Precaution:

and

Generic Name: Date Ordered: Classification: Dose/Frequency/Route: Mechanism of Action:

Trimetazidine (Vastarrel MR) December 3, 2013 Anti-angina 35mg tab/BID/PO Selective inhibition of an enzyme of fatty acid -oxidation: the long-chain 3-ketoacyl CoA thiolase (3-KAT).This inhibition results in: Reduction in fatty acid oxidation; Stimulation of glucose oxidation. Preventive treatment for episodes of angina pectoris (Chronic stable angina).

Specific Indication:

Contraindication:

Do not take Vastarel MR if you are allergic to any of the constituents.This drug is generally not recommended during breast feeding.

Side Effects: Nursing Precaution:

Nausea, Vomiting, Headache, Edema Monitor blood pressure and pulse rate before and after giving the meds. Notify prescribing signs of heart failure such as swelling of hands and feet or SOB. Advise patient of the side effects of the drug.
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c. Laboratory Results COMPLETE BLOOD COUNT DECEMBER 02, 2013

It is a series of screening test, which consist of Hemoglobin and Hematocrit. It is used routinely to screen for, to help diagnose and to monitor variety of condition. It provides a complete evaluation of all formed elements of the blood. It can supply a great deal of information necessary to diagnosed hematopoetic system and helps to evaluate the strategies and prognosis of certain disease.

Test Total WBC

Results 6.5

Reference (5.0 10.0)x10^9/L

Rationale Within Normal

Total RBC Hemoglobin

3.7 *10.4

(3.69-5.90) x10^2/L (11.70-14.00)g/dL

Within Normal May indicate anemia

Hematocrit

*32.5

(34.10-44.00)%

May indicate anemia, loss of

MCV

88.8

(70.0-97.00)fL

blood, nutritional deficiency bone, marrow problems

MCH MCHC

28.4 32.0

(26.10-33.30)pg (3.0 35.0)g/dl

Within Normal Within Normal

Platelet count Neutrophils Lymphocytes Monocytes Eosinophils Basophils RDW- CV

*440 60.00 30.20 7.50

(150-390)x10^9/L (55.0-62.0)% (20.00 40.00) % (4.0-10.0)%

Within Normal Within Normal Within Normal Within Normal

2.00 0.30 12.8

(1.0-6.0)% (0.00-1.00)% (11.5-14.5)%

Within Normal Within Normal Within Normal

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X-RAY REPORT DECEMBER 02, 2013

Chest X ray

A chest x ray is a procedure used to evaluate organs and structures within the chest for symptoms of disease. Chest x rays include views of the lungs, heart, and small portions of the gastrointestinal tract, thyroid gland and the bones of the chest area. X rays are a form of radiation that can penetrate the body and produce an image on an xray film.

There are no active pulmonary infiltrates. The heart is magnified. The aorta is tortuous and calcific. The trachea is midline. The pulmonary vascular markings are within normal. Both hemidiaphragms and both costophrenic sulci are intact. The rest of the osseous and soft tissue structures are unremarkable.

IMPRESSION: ATHEROSCLEROTIC AORTA

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BLOOD CHEMISTRY RESULT DECEMBER 02, 2013 Blood chemistry testing is defined simply as identifying the numerous chemical substances found in the blood. The analysis of these substances will provide clues to the functioning of the major body systems. It measures measure many chemical substances in the blood that are released from body tissues or are produced during the breakdown (metabolism) of certain substances.

Test Potassium Sodium SGPT (ALT) CPK-MB Creatinine

Results 4.15mEq/L

Reference 3.50-5.50

Rationale Within Normal Within Normal Within Normal Within Normal

145.30mEq/L 135.00-155.00 15.11U/L 11.81U/L 9.00-36.00 0.000-25.000

*0.61mgs/dl 0.70-1.30 May indicate muscle injury, burns, carbon monoxide poisoning, hypothyroidism 50-100 0.000-50.000 Within Normal

Cardiac-T

*Between 50ng/L and 100ng/L Acute myocardial infarction possible, repeat the test to detect rising troponin T levels in context of clinical assessment.

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DECEMBER 2, 2013 BLOOD CHEMISTRY Test Magnesium Sodium Urea Nitrogen Pro-BNP D-DIMER Results 1.96mgs/dl 147.00mEq/L 21.13mgs/dl 105.0pg/mL 0.5ug/ml Reference 1.90-2.50 135.00-155.00 4.70-23.00 0.000-125.000 0.000-0.500 Rationale Within normal Within normal Within normal Within normal Within normal

DECEMBER 2, 2013 IONIZED CALCIUM TEST An ionized calcium test checks the amount of calcium that is not attached to protein in the blood. The level of ionized calcium in the blood is not affected by the amount of protein in the blood.

Test Ionized Calcium

Results 1.2mEq/L

Reference 1.15-1.33

Rationale Normal

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DECEMBER 2, 2013 BLOOD CHEMISTRY Test CPK-MB Uric Acid Lipid Profile <240.00 <200.00 30.00-85.00 <150.00 Build up of cholesterol in the arteries Within Normal Slightly high fat in blood Within Normal Results *56.06U/L 5.27mgs/dl Reference 0.000-25.000 2.4-5.70 Within Normal Rationale
Elevation may suggest acute MI

Cholesterol Triglycerides HDL LDL

*242.95mgs/dl 154.65mgs/dl *26.32mgs/dl *185.70mgs/dl

VLDL Chol/HDL Ratio Fasting Blood Sugar

30.93mgs/dl 9.23mgs/dl 94.35mgs/dl

0.00-40.00

70.00-99.00

Within Normal

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Test CPK-MB Lipid Profile

Results *27.19U/L

Reference 0.000-25.000

Rationale
Elevation may suggest acute MI

Cholesterol Triglycerides HDL LDL VLDL Chol/HDL Ratio Fasting Blood Sugar

*334mgs/dl 191mgs/dl *26.32mgs/dl 266.39mgs/dl 32.96mgs/dl 9.29mgs/dl 90.35mgs/dl

<240.00 <200.00 30.00-85.00 <150.00 0.00-40.00

Slightly high fat in blood Within Normal

Within Normal

70.00-99.00

Within Normal

ELECTROCARDIOGRAPHY December 3, 2013 An echocardiogram (also called an echo) is a type of ultrasound test that uses highpitched sound waves that are sent through a device called a transducer. The device picks up echoes of the sound waves as they bounce off the different parts of the heart. An echocardiogram is a test that uses sound waves to create a moving picture of the heart. The picture is much more detailed than a plain x-ray image and involves no radiation exposure. QUALITATIVE The study was done in Sinus Rhythm. Normal left ventricular size and wall thickness with mildy hypokinesia of the mid to apical segments of the interior and anterior left ventricular free wall and interventricular septum. The rest of the visualized left ventricular segments contract adequately.

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Normal: left atrium, right atrium, right ventricle, main pulmonary artery segment and aortic root dimension. Thickened aortic valve cusps with no restriction of motion. Structurally normal mitral valve, tricuspid valve and pulmonic valve. No intracardiac thrombus and pericardial effusion noted. COLOR FLOW AND DOPPLER STUDY Abnormal colorflow display noted across the mitral valve and tricuspid valve during systole. Pulmonary artery pressure of 19mmHg by pulmonary acceleration time. CONCLUSION Normal left ventricular dimension with multi segmental wall motion abnormality but with adequate systolic function. Aortic valve sclerosis. Structurally normal mitral valve with mild mitral regurgitation. Structurally normal tricuspid valve with mild tricuspid regurgitation. Structurally normal pulmonic valve. Normal pulmonary artery pressure.

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V. ANATOMY and PHYSIOLOGY The Cardiovascular System The heart and circulatory system make up the cardiovascular system. The heart works as a pump that pushes blood to the organs, tissues, and cells of the body. Blood delivers oxygen and nutrients to every cell and removes the carbon dioxide and waste products made by those cells. Blood is carried from the heart to the rest of your body through a complex network of arteries, arterioles, and capillaries. Blood is returned to your heart through venules and veins. The one-way circulatory system carries blood to all parts of your body. This process of blood flow within your body is called circulation. Arteries carry oxygen-rich blood away from your heart, and veins carry oxygen-poor blood back to your heart. In pulmonary circulation, though, the roles are switched. It is the pulmonary artery that brings oxygen-poor blood into your lungs and the pulmonary vein that brings oxygenrich blood back to your heart. In the diagram, the vessels that carry oxygen-rich blood are colored red, and the vessels that carry oxygen-poor blood are colored blue. Twenty major arteries make a path through your tissues, where they branch into smaller vessels called arterioles. Arterioles further branch into capillaries, the true deliverers of oxygen and nutrients to your cells. Most capillaries are thinner than a hair. In fact, many are so tiny, only one blood cell can move through them at a time. Once the capillaries deliver oxygen and nutrients and pick up carbon dioxide and other waste, they move the blood back through wider vessels called venules. Venules eventually join to form veins, which deliver the blood back to your heart to pick up oxygen. The heart weighs between 7 and 15 ounces (200 to 425 grams) and is a little larger than the size of your fist. By the end of a long life, a person's heart may have beat (expanded and contracted) more than 3.5 billion times. In fact, each day, the average heart beats 100,000 times, pumping about 2,000 gallons (7,571 liters) of blood.
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Your heart is located between your lungs in the middle of your chest, behind and slightly to the left of your breastbone (sternum). A double-layered membrane called the pericardium surrounds your heart like a sac. The outer layer of the pericardium surrounds the roots of your heart's major blood vessels and is attached by ligaments to your spinal column, diaphragm, and other parts of your body. The inner layer of the pericardium is attached to the heart muscle. A coating of fluid separates the two layers of membrane, letting the heart move as it beats, yet still be attached to your body. Your heart has 4 chambers. The upper chambers are called the left and right atria, and the lower chambers are called the left and right ventricles. A wall of muscle called the septum separates the left and right atria and the left and right ventricles. The left ventricle is the largest and strongest chamber in your heart. The left ventricle's chamber walls are only about a half-inch thick, but they have enough force to push blood through the aortic valve and into your body. The Heart Valves Four types of valves regulate blood flow through your heart: The tricuspid valve regulates blood flow between the right atrium and right ventricle. The pulmonary valve controls blood flow from the right ventricle into the pulmonary arteries, which carry blood to your lungs to pick up oxygen. The mitral valve lets oxygen-rich blood from your lungs pass from the left atrium into the left ventricle. The aortic valve opens the way for oxygen-rich blood to pass from the left ventricle into the aorta, your body's largest artery, where it is delivered to the rest of your body. The Conduction System Electrical impulses from your heart muscle (the myocardium) cause your heart to contract. This electrical signal begins in the sinoatrial (SA) node, located at the top of the right atrium. The SA node is sometimes called the heart's "natural pacemaker." An electrical impulse from this natural pacemaker travels through the muscle fibers of the atria and ventricles, causing them to contract. Although the SA node sends electrical impulses at a certain rate, your heart rate may still change depending on physical demands, stress, or hormonal factors.

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SYSTEMIC AND PULMONARY CIRCULATION

Figure 1-3 Systemic and Pulmonary Circulation In the systemic circulation, arteries bring oxygenated blood to the tissues of the body. The pulmonary circulation (for arterial blood sent to the lungs) is excluded from this definition. As blood circulates through the body, oxygen diffuses from the blood into cells surrounding the capillaries, and carbon dioxide diffuses into the blood from the capillary cells. Veins bring deoxygenated blood back to the heart. A heartbeat is a two-part pumping action that takes about a second. As blood collects in the upper chambers (the right and left atria), the heart's natural pacemaker (the SA node) sends out an electrical signal that causes the atria to contract. This contraction pushes blood through the tricuspid and mitral valves into the resting lower chambers (the right and left ventricles). This part of the two-part pumping phase (the longer of the two) is called diastole. The second part of the pumping phase begins when the ventricles are full of blood. The electrical signals from the SA node travel along a pathway of cells to the ventricles, causing them to contract. This is called systole. As the tricuspid and mitral valves shut tight to prevent a back flow of blood, the pulmonary and aortic valves are pushed open. While blood is pushed from the right ventricle into the lungs to pick up oxygen, oxygenrich blood flows from the left ventricle to the heart and other parts of the body. After blood moves into the pulmonary artery and the aorta, the ventricles relax, and the pulmonary and aortic valves close. The lower pressure in the ventricles causes the tricuspid and mitral valves to open, and the cycle begins again. This series of contractions is repeated over and over again, increasing during times of exertion and decreasing while you are at rest. The heart normally beats about 60 to 80 times a minute when you are at rest, but this can vary. As you get older, your resting heart rate rises. Also, it is usually lower in people who are physically fit. Source: Snell, Richard S. Clinical Anatomy by Regions. 8th Edition. Lipincott Williams & Wilkins. 530 Walnut Street, PA. 2008.
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Nursing assessment I
Name: Sibuyan, Maria Lilia T. Date: Dec. 4, 2013 Vital Signs: Pulse: 80bpm RR: 20 cpm BP: 100/60 mmHg Temp: 36 C Height: 54 Weight: 45 Kg. EENT: [ ] impaired vision [ ] blind [ ] pain redden [ ] drainage Headache [ ] gums [ ] hard of hearing [ ] deaf [ ] burning [ ] edema [ ] lesion [ ] teeth Assess eyes ears nose throat for abnormality x [x] No problem RESP: Chest pain 6/10 [ ] asymmetric [ ] tachypnea [ ] barrel chest [ ] bradypnea [ ] shallow [ ] rhonchi [ ] sputum [ ] diminished [ ] dyspnea [ ] orthopnea [ ] labored [ ] wheezing [ ] pain [ ] cyanotic Localized pain at IVF Assess resp. rate, rhythm, depth, pattern, site Infiltrated breath sounds, comfort [x] no problem CARDIOVASCULAR: [ ] arrhythmia [ ] tachycardia [ ]numbness [ ] diminished pulses [ ] edema [X] fatigue [ ] irregular [ ] bradycardia [ ] murmur [ ] tingling [ ] absent pulses [X] pain Assess heart sounds, rate rhythm, pulse, blood Pressure, circ., fluid retention, comfort [X] no problem GASTROINTESTINAL TRACT: [ ] obese [ ] distention [ ] mass [ ] dyspagea [ ] rigidity [ ] pain [ ] LBM Assess abdomen, bowel habits, swallowing, bowel sounds, comfort [X] no problem GENITO URINARY AND GYNE [ ] pain [ ] urine color [ ] vaginal bleeding [ ] hematuria [ ] discharge [ ] nocturia Assess urine frequency, control, color, odor, comfort, gyne bleeding, discharge [ x ] no problem NEURO: [ ] paralysis [ ] stuporous [ ] unsteady [ ] seizures [ ] lethargic [ ] comatose [ ] vertigo [ ] treamors [ ] confused [ ] vision [ ] grip Assess motor function, sensation, LOC, strength, grip, gait, coordination, orientation, speech [ x ] no problem MUSCULOSKELETAL and SKIN: [ ] appliance [ ] stiffness [ ] itching [ ] petechiae [ ] hot [ ] drainage [ ] prosthesis [ ] swelling [ ] lesion [ ] poor turgor [ ] cool [ ] deformity [ ] wound [ ] rash [ ] skin color [ ] flushed [ ] atrophy [ ] pain [ ] ecchymosis [ ] diaphoretic [ ]moist Assess skin color, texture, turgor, integrity [x] no problem

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Nursing Assessment II SUBJECTIVE COMMUNICATION [ ] hearing loss [ ] visual changes [ ]denied

Comment:ok raman akong panan-aw ug pang dungog as verbalized by the patient.

OXYGENATION: [ ]dyspnea Comments: [ ]smoking history [ ] cough [ ]sputum [ ]denied CIRCULATION [X]chest pain Comments: [ ] leg pain [ ] numbness of extremities [ ] denied

Wala man koy problema ana tanan imu ge ingun as verbalized by pt

Sakit gyud akong dughan as verbalized by the patient

OBJECTIVE [ ] glasses [ ]languages [ ] contact lens [ ] hearing aide R 2-3mm L 2- 3mm Pupil size: 2-3 mm Reaction: Pupil equally round reactive to light and accommodation Resp. [ x]regular []irregular Describe: The patient has a regular respiratory rate is within normal range. R: Right lung symmetrical to the Left lung. L: Left lung symmetrical to the Right lung.

Heart rhythm [X] regular [ ] irregular Ankle Edema: Bipedal pitting edema 1+ present Carotid Radial Dorsal Pedis Femoral R: + 80bpm + not taken L: + 80bpm + not taken Comments: Pulses are palpable and heart rhythm is regular. [ ]dentures Full Upper [] Lower [] [x]none partial [] [] with patient [] []

NUTRITION: Comments: Diet: Low Salt &Low Fat okay man akong [ x] N [x ] V kaon, isda g iCharacter sinabaw nga utan [ ] recent change in weight og protas ra ako and appetite gikaon as [ ] swallowing difficulty verbalized by the [x]denied patient. ELIMINATION Usual bowel pattern Urinary frequency Once a day_____ ____5 times a day [ ]constipation [ ]urgency [ ] diarrhea [ ]dysuria Date of last BM [ ] hematuria December 3, 2013 ] incontinence [ ] polyuria [ ] folly in place [ ] denied MGT. OF HEALTH & ILLNESS: [ ] alcohol [ ]denied (amount frequency) ________ [X] SBE last Pap smear: cant recall LMP:

Comments: Patient has a normal bowel sounds and a regular urine output. Bowel sounds: Normoactive Abdominal Distention: Present [ ] yes [x] No Urine (color, consistency, odor) No foley foley bag catheter in placed * if foley bag catheter is in place N/A Briefly, describe the patients ability to follow treatments (diet, meds, etc.) for chronic health problems (if present). Patient has able to complied the meds. To be taken as well as with the diet, as prescribed by the Physician. 36

SKIN INTEGRITY: [ ] dry [ ] itching [x] other [ ] denied

Comments :

sakit akong kamot tungod sa dextrose as verbalized by the patient naa raku perme sa katre kay ipapahulay man ko as verbalized by pt.

[ ] dry [ ]cold [ ] flushed [ ]warm

[ ] pale [ ]moist [ ]cyanotic

*rashes, ulcers, decubitus (describe size, location, drainage) post operative wound/incision.

ACTIVITY/SAFETY: [ ] convulsion Comments : [ ] dizziness [ ] limited motion of joints [ ] ambulate [ ] bathe self [x] other [ ] denied

[ ] LOC and Orientation: the client is awake and coherent. [ ] Gait [ ] walker [ ] care [] others [x] steady [ ] unsteady [ ]Sensory and motor losses in face or extremities No problems observed in the patients sensory and motor function [ ] ROM limitations: The patient has limited ROM due to Abdominal pain

COMFORT/SLEEP/AWAKE: katulgon pa kayo [ ] pain (location, ko sayo ko nag mata frequency, Comments: kay nag inum ko remedies) tambal as [ ] nocturia verbalized by yhe [ x ] sleep difficulties patient [ ] denied

[x] facial grimace [ ] guarding [ ] other signs of pain: post operative pain. [ ] side rail release form signed (60 + years) Not applicable.

COPING: Occupation: Mlhuilier Employee (30 years) Members of household: 6 Most supportive person: Jesus Sibuyan (husband)

Observed nonverbal behavior: Patient participate well during the interview. Person (phone Number): Jesus Sibuyan 09174451905

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VII. NURSING MANAGEMENT

PROGRESS NOTES

FIRST DAY We had our first assessment and visited as a team last December 5, 2013 Thursday at Polymedic General Hospital Station 5. Upon arrival, patient was awake sitting up on bed with #1 D5W 500cc at 320cc level regulated at KVO rate. We had done our head to toe assessment and assessed patients health status through inspection, auscultation, palpation and percussion. Assessment findings included: Verbalization of anxiety at moderate level and she said she cant sleep properly due to some environmental stimuli (ventilation, space and noise). We also determined the patients diet and we found out that she had a good apetite. Vital signs we re within normal range. With the assessment presented, we prioritized problems and planned interventions based on the existing problems manifested by the patient. Interventions planned were focused on providing comfort to the patient. The following were the interventions rendered and health teachings given: 1. 2. 3. 4. 5. 6. 7. 8. Obtained and recorded vital signs. Instructed to avoid food rich in cholesterol such fried foods and egg. Encouraged adequate rest periods Encouraged to do deep breathing exercise during onset of pain. Placed patient to comfortable position. Encouraged to do diversional activities like listening to music. Instructed significant others to assist the patient in doing daily activities. Emphasized compliance of prescribed medications.

SECOND DAY We had our second assessment last December 6, 2013 Friday at Polymedic General Hospital Station 5. Upon arrival, patient was awake, sitting up on bed with the same IVF and infusion rate. We did our head-to-toe assessment. Assessment findings included: We found that the patient was conscious and coherent. No complaint of chest pain was noted. But the patient complained about having a headache.
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With the assessment presented, we prioritized problems and planned interventions based on the existing problems manifested by the patient. Interventions planned were focused on enhancing activity and promotion of comfort. The following were the interventions rendered and health teachings given: 1. 2. 3. 4. 5. 6. 7. Obtained and recorded vital signs. Elevated head of the bed. Instructed the significant others not to leave the patient alone. Encouraged adequate rest periods. Instructed to increase exercise and activity gradually Placed patient in a comfortable position. Encouraged patient to verbalize feelings on how shes doing

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A. IDEAL NURSING MANAGEMENT

DIAGNOSIS Acute Pain related to increase cardiac workload and oxygen consumption

INTERVENTIONS Independent Instruct client to notify nurse immediately when chest pain occurs

RATIONALE Pain and decreased cardiac output may stimulate the sympathetic nervous system to release excessive amounts of norepinephrine, which increases platelet aggregation and release of thromboxane A2. Provides information about disease progression. Aids in evaluating effectiveness of interventions and may indicate need for change in therapeutic regimen. Helps differentiate chest pain and aids in evaluating possible progression to unstable angina. Stable angina usually lasts 3 -15 minutes and is often relieved by rest and sublingually nitrogycerin. Reduces myocardial oxygen demand to minimize risk of tissue injury and necrosis

Assess and document client response and effects of medication

Identify precipitating event, frequency, duration, intensity, and location of pain

Place client at complete bed rest during angina episodes

Dependent Provide supplemental oxygen as indicated

Increases oxygen available for myocardial uptake and reversal of ischemia

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NURSING DIAGNOSIS Risk for decreased Cardiac Output related prolonged myocardial ischemia and effects of medications

INTERVENTIONS Independent Monitor Vital Signs and cardiac rhythm

RATIONALE Tachycardia and changes in blood pressure may be present because of pain, anxiety, hypoxemia, and reduced cardiac output. ECG changes reflecting ischemia and dysrhythmias indicate need for additional evaluation and therapeutic invtervention S3, S4 or crackles may occur with cardiac decomposatuin or some medications, especially beta blockers, development of murmurs may reveal a valvular cause for chest pain, such as aortic or mitral stenosis or papillary muscle rupture. Valsalvas manuever causes bradycardia, which may be followed by rebound tachycardia, both of which may impair cardiac output Angina is only a symptom of underlying pathology causing myocardial ischemia. Disease may compromise cardiac function to point of decomposition Increases oxygen available for myocardial uptake to improve contractility, reduce ischemia, and reduce lactic acid levels

Auscultate breath sounds and heart sounds. Listen for murmurs

Stress importance of avoiding straining and bearing down, especially during defecation Assess for signs and symptoms of heart failure

Dependent Administer supplemental oxygen as needed.

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NURSING DIAGNOSIS Anxiety related underlying to pathophysiological response

INTERVENTIONS Independent Explain purpose of tests and procedures

RATIONALE Reduces anxiety attributable to fear of unknown diagnosis and prognosis Unexpressed feelings may create internal turmoil and affect self- image. Verbalization of concerns reduces tension, verifies level of coping and facilitates dealing with feelings. Presence of negative self-talk can increase level of anxiety and may contribute to exacerbation of angina attacks Reassures client that role in the family and business has not been altered Encourages clients to test symptom control such as no angina with certain levels of activity, to increase confidence in medical program and to integrate abilities into perceptions of self

Promote expression of feelings and fears such as denial, depression, and anger. Let client or SO know these are normal reactions. Note statement of concern such as Heart Attack is inevitable

Encourage family and friends to treat client as before Tell client the myocardial regimen has been designed to reduce or limit future attacks and increase cardiac stability

Dependent Administer sedatives and tranquilizers as indicated

May be desired to help client relax until physically able to re-establish adequate coping strategies

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B. ACTUAL NURSING MANAGEMENT

S O

Galain lage ako dughan murag gasakit usahay Pain Scale of 6/10 Facial Grimace

A P

Acute Pain related to decreased myocardial blood flow Short Term: After 3-4 hours of nursing interventions, the patients pain will decrease from 67to 3 as verbalized by the patient. Long Term: After 2-3 days of nursing interventions, the patient will demonstrate activities and behaviors that will prevent the recurrence of pain.

1. Assessed patient pain for intensity using a pain rating scale, for location
and for precipitating factors. 2. Assessed the response to medications every 5 minutes 3. Provided comfort measures such as listening to music. 4. Established a quiet environment. 5. Elevated head of bed. 6. Monitored vital signs especially pulse and blood pressure, every 5 minutes until pain subsides.

7. Taught patient relaxation techniques and how to use them to reduce

stress.

After 4 hours of nursing interventions, the patient demonstrated behaviors to alleviate pain and he reported pain scale of 3.

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Katulgon pa kaayo ko. Sayo kaayo ko ni mata kay nag inom kog tambal. as verbalized by the patient.

Objective: No complaint of chest pain Conscious and coherent Vital signs: BP = 100/60 mmHg PR = 80 RR = 20 T = 36.1 C

Disturbed Sleeping Pattern related to environmental factors

At the end of 8 hours of nursing intervention, the patient will have adequate rest sleep.

1. Place patient in a comfortable position with head of bed elevated 2. Maintain a quiet and comfortable environment I 3. Schedule bedside care to minimize contact with patient 4. Instruct the patient and significant others to limit visitors

At the end of 8 hours of nursing intervention, the patient was able to have adequate rest and sleep.

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No subjective cues

Objective: Weak in appearance No complaint of chest pain Vital signs: BP = 100/70 PR = 68 RR = 18 T = 36 C Readiness for enhanced therapeutic regimen

At the end of 8 hours nursing intervention, the patient will be able to demonstrated or show wellness.

1. Place on position of comfort 2. Encourage ambulation as tolerated I 3. Impart health teachings about compliance of medication, importance of having adequate rest, and healthy lifestyle 4. Keep back dry for the patient to feel comfortable

At the end 8 hours of nursing intervention, the patient was able to demonstrate and showed wellness as evidenced by her verbalization of comfort.

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Ga labad akong ulo oy! as verbalized by the patient.

Objective: Conscious and coherent No complaint of chest pain Restlessness Activity Intolerance related to bed rest and immobility

At the end of 8 hours nursing intervention, the patient will be able to use identified techniques to enhance activity.

1. Instruct patient to increase exercise and activity gradually 2. Educate the patient and significant others to have rest periods in between exercise and activity I 3. Encourage expression of feelings contributing to clients condition 4. Provide and maintain a comfortable environment

At the end 8 hours of nursing intervention, the patient was able to use identified techniques to enhance activity.

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VII. REFERRAL AND FOLLOW-UP HEALTH TEACHINGS Name: Sibuyan, Ma. Lilia T.

Client was reminded of the name and purpose of Medications: prescribed drugs; and was instructed to take medications as prescribed and reminded him of the consequences of not doing so, which is exacerbation of his condition. Instructed to take medicines as prescribed by the physician, such as: Exercise: Mucosta 100mg 1tab 3x a day Clopidogrel 75mg 1tab once a day Vastarel 35mg 1tab twice a day Lipitor 80mg 1tab ince a day Duavent 1neb q12h Encouraged client to stay as active as he can; a mild exercise regimen was suggested (helps decrease symptoms and improve heart function). Stretching in the morning and active ROM exercises was recommended. Walking around the house or outside with friends once a day for 15-30 minutes if tolerated was advised. Heavy lifting and strenuous activities should be avoided. Rest in between any activity and to rest when tired (or experiencing shortness of breath) was emphasized. Outpatient: Explained the purpose and importance of a follow-up check-up. Return 3 days after discharged to Dr. Sandra Oliveros clinic at

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COMC, Room 214 at 10:00am. Advised the client and the caregiver to seek consult in the nearest health care facility when any signs of complications occur: fever, chills, pain or feeling of fullness in the chest, restlessness, decrease in the amount of urine and frequency of urination, rapid respirations, bloody sputum, palpitations and warmth pain numbness tingling on extremities Diet: Instructed the client to limit intake of sodium by avoiding canned and processed goods, cheese, seasonings, sauces and condiments; also to refrain adding too much salt to foods when cooking. Encouraged recommended dietary restrictions: a low-fat, low-cholesterol diet to avoid the risk for any advanced heart problems.

(Recommended foods: high fiber food items like green leafy vegetables and whole wheat bread. Foods to be avoided: fats like butter, coconut oil, fried food, cakes, ice creams, ham, bacon, yolk of egg, red meat, organ meats, crab, shrimps, cheese, cream) Instructed client to not skip meals, to eat in small, frequent feedings and to rest before, after and even while eating so as not to cause sudden increases in the workload of the heart.

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PROGNOSIS

Score Legend: 1 Poor Prognosis 2 Good Prognosis 3 Very Good Prognosis CRITERIA SCORE ANAYSIS/IMPLICATION 12 hours prior to admission A.ONSET OF ILLNESS 1 patient has experienced 10/10 chest pain. Detection of the disease B. DURATION OF ILLNESS 1 condition was delayed for attaining prevention. Patient already had a related condition prior to this. The increasing age of the patient, the gender and her C. PRECIPITATING AND PREDISPOSING FACTOR 3 diet which is mostly rich in salty and high in cholesterol diet predisposed her and put her at risk for obtaining such condition. Such factor manifest by the patient cannot already be altered and prevented. Unfortunately, manifestations showed up but were diagnosed too late for her to prevent from the condition. Thus strictly following the treatment regimen would help her prevent from further complication and faster 49

recovery The patients admission and 3 D. ATTITUDE & WILLINGNESS TO TAKE TREATMENT adherence regimen may medication somehow

proved that the patient is very willing to follow treatment. Patient is financially capable for her was able to pay the

E. FINANCIAL CAPABILITY

entire medical and hospital bills by the help of family

member and phil. Health. A daily progressive sign of relief from the experienced pain, G.PAIN MANAGEMENT 2 she she stated takes that the

whenever

medication the pain subsided but during missed dose she experienced pain. Her family was very

H. FAMILY SUPPORT 3

supportive that her husband and she were always

accompanied by either her husband or her children

during admission. This is why patients prognosis is very important for patient having such condition vary greatly on the health, the extent of damage, the regimen given and the patients adherence to it, and most importantly the detection of the disease. Most noted prognosis in the chart shows good prognosis but the detection of the symptoms were too late for her to prevent and to be able treated.

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IX.

EVALUATION

During the initial assessment, patient X was in a sustaining pain in the chest. She was anxious, restless at first but the support of his family really gave her the courage that they can overcome this trial Diet was a low salt and low fat. The patient was restless due to difficulty in breathing and complaints of chest pain. In response to his condition, care was given to her. Her vital signs were monitored every 4 hours and I & 0 every shift. Medications due for her were given every day. Advocacy in nursing was definitely applied in her care, accepting her minute requests so as to alleviate her suffering as much as possible. His temperature was also monitored because of some changes due to her condition. During the last two visit condition. In caring for patient X, we have not only contributed to the betterment of her health, but also to the improvement of ourselves as student nurses. Any circumstance during the time of caring for patient X added to the skills, knowledge and attitude which will surely be beneficial in the future. to our patient, there was an improvement in her

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X.

DOCUMENTATION

BIBLIOGRAPHY BOOKS DRUG HANDBOOK Lippincott Williams & Wilkins Nursing 2004 24th edition. MIMS PHILIPPINES. 123rd edition 2012, Philipine Index Of Medical Specialties Establishment. 1968 Ben Yeo, Lippincott Manulal of Nursing 8th edition, Lipincott Williams & Wilkins PATHOPHYSIOLOGY Lippincott Williams &Wilkins A2-in-1 reference for nurses. Fundamentals of nursing Concepts. Process and Practices 11th edition. Upper Saddle, Kozier, B. etal New Jersey, 2007. Nursing Care Plans, Nursing Diagnosis and Intervention 6th edition, by Gulanick/Myers WEBSITES WWW.MEDICINENET.COM/CHOLE/ARTICLE.HM www.who.int/topics/chole www.mursingcribs.com www.youtube.com www.google.com www.MIMS.com www.PIMS.com

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