angina cpa

8/13/2019 Angina Cpa

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I. INTRODUCTION

Angina, orangina pectoris, is the medical term used to describe the temporary chestdiscomfort 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 theheart muscle needs to keeppumping. When the heart does not get enough blood, it can no longer function at its fullcapacity.

When physical exertion, strong emotions, extreme temperatures, or eating increase thedemand on the heart, a person with angina feels temporary pain, pressure, fullness, orsqueezing in the center of the chest or in the neck, shoulder, jaw, upper arm, or upperback. This is angina, especially if the discomfort is relieved by removing the stressorand/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 aheart attack.Having angina means you have an increasedrisk 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 themuscle dies (infarction).

Prolonged or unchecked angina can lead to a heart attack or increase the risk of havinga heart rhythm abnormality. Either of those could lead to sudden death.

Angina pectoris is a common manifestation of coronary artery disease. The pain iscaused by reduced blood flow to a segment of heart muscle (myocardial ischemia). Itusually lasts for only a few minutes, and an attack is usually quickly relieved by rest ordrugs (such as nitroglycerin). Also, it is possible to have myocardial ischemia withoutexperiencing angina.

Typically, angina is described as a "pressure" or "squeezing" pain that starts in thecenter of the chest and may spread to the shoulders or arms (most often on the leftside, although either or both sides may be involved), the neck, jaw or back. It is usuallytriggered 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 becaused by a spasm in a coronary artery, which most commonly occurs at the site ofatherosclerotic 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 knownasunstable angina. This is often a prelude to aheart attack and requires special
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treatment, primarily with drugs. Angina affects both men and women, usually in middleage. Men are much more likely than women to experience it before age 60. It maydevelop weeks, months or even years before aheart attack, or may be experiencedonly after aheart attack has occurred.

Angina symptoms include: Chest pain or discomfortPain in your arms, neck, jaw, shoulder or back accompanying chest pain

NauseaFatigue

Shortness of breathSweatingDizziness

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 aheavy weight has been placed on their chest. For others, it may feel like indigestion.

Characteristics of stable anginaDevelops when your heart works harder, such as when you exercise or climb stairsCan usually be predicted and the pain is usually similar to previous types of chest painyou've hadLasts a short time, perhaps five minutes or lessDisappears sooner if you rest or use your angina medication

Characteristics of unstable angina (a medical emergency)Occurs even at restIs a change in your usual pattern of anginaIs unexpectedIs usually more severe and lasts longer than stable angina, maybe as long as 30minutesMay not disappear with rest or use of angina medicationMight signal a heart attack

Characteristics of variant angina (Prinzmetal's angina)Usually happens when you're restingIs often severeMay 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
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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 otherwho partly served as informant, laboratory results, signs and symptoms and doctorsorder as evidenced by and observed from the patient within the engaged days.


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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.


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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.


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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.


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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 transmitvalues 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 Adult30 years old60 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.


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IV. MEDICAL MANAGEMENT

a. Medical Orders with Rationale

DATE/TIME DOCTORS ORDER RATIONALE

12/2/13 >Please admit the patient under Dr. Go-See To verify that the patientadmitted in the hospital under

the care of Dr. Go-see

5 AM >Secure Consent For legal purposes and hospital

protocol

BP= 150/90 =>

140/80

>NPO temporarily To let the GI tract rest

HR= 68 >IVF: D5W 500cc @ KVO To maintain fluid and electrolyte

balance

RR= 20 Labs: CBC with PC , ECG , Na, K, CPK-MB, SGPT To have a quantitative data for

basis of patients diagnosis and

treatmentTEMP= 36.2 U/A . HGT now To further asses the patients

condition

O2 Sat= 97 % Ca , CK-MB , Trop-T To monitor Myocardial Infarction

(+) Chest pain >Meds:

(-) SOB Isodril 10mg tab now then BID P.O Relaxes vascular smooth muscle

and prevention of angina

pectoris

(-) Diaphoresis Vasterl MR 4 tabs now then 1 tab BID Prevents situation that may

cause angina attacks

>Monitor v/s q4 To assess the patients condition

every 4 hours.>I/O q shift To monitor fluid and electrolyte

balance

>AP informed To provide medical management

fitted for the patient.

>Refer accordingly To endorse patients condition to

physician if there are any

changes or unusuallities in

patients condition.

>Complete bed rest To let the patient rest and to not

increase the cardiac workload.

12/2/13 >DATLow salt, low fat To avoid sodium and fat intake

that may result to increase in

blood pressure thus increases

cardiac workload.

>IVF TF : D5W 250 cc @ KVO To maintain fluid and electrolyte

balance

Dx: Acute MI >FBS, Lipid profile , UA, SGPT tom. am To have a quantitative data for


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basis of patients diagnosis and

treatment

>Clopidrogel (Plogrel) 75mg tab OD Treatment pf pts. At risk for

ischemic eventshistory of MI.

>Lipitor 80mg OD HS It lowers the level of cholesterol

in the blood.>Clexane 0.4cc SQ now then q12 To prevent ischemic

complications of unstable angina

and non-Q-wave MI w/ oral

aspirin therapy.

>Start Dobutamine Single concentrate Short-term treatment of cardiac

decompensation cause by

depressed contractility.

D5W 250cc *1 amp To maintain fluid and electrolyte

balance

10 cc/hr close monitoring while on Dobu drip To maintain adequate cardiac

output, blood pressure and heart

rate.

(+) minimal >Hold Isodril if BP < 90/60 To prevent further decrease in

blood pressure that may lead to

cardiogenic shock.

Chest pain >For 2D echo w/ color droppler once stable To have a visual diagnosis of the

patients heart for further

assessment.

>Continue vastarel Prevents situation that may


>Hold Isodril To stop the stimulation of

decreasing the BP of the pt.

>Possible ICU admission For monitoring the patientscondition.

>Refer to Dr. Oporto for co-management For further evaluation of

patients condition.

>Complete bed rest w/o bathroom privileges To let the patient rest and to not

increase the cardiac workload.

>v/s to q2 To assess the patients condition

every 2 hours.

>Start NTG patch now then OD To prevent episode of angina.

>Algesia tab BID Management of moderate tosevere pain

>Celebrex 400mg cap OD Management of acute pain &

treatment of acute long term of

s/s of rheumatoid arthritis &

osteoarthritis.

>Mucosta 100mg tab TID To increase gastric blood flow,

prostaglandin biosynthesis and


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decrease free oxygen radicals

>Omeprazole 40mg cap tab OD Treatment of heartburn of

symptoms of gastroesophageal

reflux (GERD)

>CKMB in AM To monitor Myocardial Infarction

12/2/13 >Duavent I neb q 8 Treatment of obstructive airway

disease

(tel. order 2pm)

12/2/13 >Side drip D5W250cc + I amp Dobu in cycle To maintain adequate cardiac

output, blood pressure and heart

rate because dobutamine

increases the force of

contraction of the heart

(text.order

11pm)

12/3/13 2pm >Continue meds.

>IVF : D5W250cc + 1amp Dobutamine x 10cc/hr Short-term treatment of cardiac



(-) chest pain

>Omacor I cap OD Lowering the bodys production

of triglycerides

>Taper Dobu drip by 2micro gtts qhr.

Target SBP 90-110 mmhg

To increase contracting power of

the heart thus maintain

adequate BP

>Repeat CKMB in AM To monitor Myocardial Infarction

>Vastarel MR Vastarel MR 35mg 1 tab BID Prevents situation that may


12/4/13 3PM >Continue meds.

1:20 PM >Duavent 1 neb q12 Treatment of obstructive airway

disease

3PM >ff.up 2d echo result To have visual view of the heart

for further assessment

>Taper Dobu by 1micro gtt q2 , then D/C Short-term treatment of cardiac



>Repeat CKMB in AM To monitor Myocardial Infarction>Aminovita 1 cap OD Promoting healing & improving

skin tone and are non-reviewed

natural alternatives to use for

anxiety &insomnia

12/5/13 >Continue meds.

>IVFTF : D5W250cc @KVO To maintain fluid and electrolyte


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balance

>D/C O2 To improve patients

independence from

supplemental oxygen

>Encourage Ambulation To improve circulation in the

body>Refer for any signs of dizzines To evaluation of patients

capability of performing ADL

>For possible discharge tomorrow If there is no change in patients

condition patient can go home

tomorrow

12/6/13 >No new orders


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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: Management of acute pain

Contraindication: Hypersensitivity including those in whom attacks ofangioedema, rhinitis and urticaria have beenprecipitated by aspirin, NSAIDs or sulfonamides.Severe hepatic impairment; severe heart failure;inflammatory bowel disease; peptic ulcer; renalimpairment (CrCl


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hypersensitivity reaction PREGNANCY, lactation.

Side Effects Rash, pruritus, constipation, diarrhoea, nausea

Nursing Precaution: Watch for signs of dizziness.

Generic Name: Omeprazole

Date Ordered: December 2, 2013

Classification: 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: Omacor


Classification: Antipyretic

Dose/Frequency/Route: 1gram capsule/OD/PO

Mechanism of Action: 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: Treatment to hypertriglyceridemia.

Contraindication: 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 theAST 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: Ipratropium Bromide + Salbutamol (Duavent)


Classification: Anti-cholinergic BronchodilatorDose/Frequency/Route: 1neb/BID/inh

Mechanism of Action: Ipratropium bromide blocks the action of acetylcholine atparasympathetic sites in bronchial smooth musclecausing bronchodilation.


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Specific Indication: Treatment to Obstructive Airway Diseases

Contraindication: 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, paralyticileus, headache, nausea, constipation, paradoxicalbronchospasm, 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: Isosorbide Dinitrate


Classification: Cardiovascular Agent; Anti-angina

Dose/Frequency/Route: 10mg tab/BID/PO

Mechanism of Action: 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.

Specific Indication: Treatment and prevention of angina pectoris

Contraindication: 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.Side Effects: Headache

Flushing

Swelling of hands & feet

Nursing Precaution: 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 fromrecumbent to upright posture, and dangle feet andankles before walking.

Lie down at the first indication of light-headedness orfaintness.


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Generic Name: Clopidogrel


Classification: Anticoagulant

Dose/Frequency/Route: 75mg tab/OD/PO

Mechanism of Action: Irreversible inhibitor of platelet aggregation, acts by

inhibiting ADP formation inhibits beta oxidation of fatty

acid in blood vessels

Specific Indication: Treatment to Angina Pectoris


Peptic ulcer intracranial hemorrhage or coagulation

disorder contraindicated to hypersensitivity of the drug.

Side Effects: Bleeding

Hemorrhage

Nursing Precaution: Monitor liver function studies: AST, ALT, bilirubin, creatinineif 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: Atorvastatin Calcium (Lipitor)


Classification: Antihyperlipidimecs

Dose/Frequency/Route: 80mg tab/OD/PO

Mechanism of Action: 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), andincreases serum HDLs (associated with decreased risk

of CAD); increases hepatic LDL recapture sites,

enhances reuptake and catabolism of LDL; lowers

triglyceride levels

Specific Indication: Reduction of Elevated Total Cholesterol & LDL


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Cholesterol


Peptic ulcer intracranial hemorrhage or coagulation

disorder contraindicated to hypersensitivity of the drug.

Side Effects: Myalgia

Headache

Insomnia

Pruritus

Muscle Cramps

Nursing Precaution: Avoid intake of alcohol.

Monitor Vital Signs especially Blood Pressure.

It should be taken with or after meals. Monitor Creatinine Phosphokinase and

Transaminase elevation.

Generic Name: Trimetazidine (Vastarrel MR)


Classification: Anti-angina

Dose/Frequency/Route: 35mg tab/BID/PO

Mechanism of Action: Selective inhibition of an enzyme of fatty acid -oxidation: thelong-chain 3-ketoacyl CoA thiolase (3-KAT).This inhibition

results in: Reduction in fatty acid oxidation; Stimulation of

glucose oxidation.

Specific Indication: Preventive treatment for episodes of angina pectoris (Chronic

stable angina).

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: Nausea, Vomiting, Headache, Edema

Nursing Precaution: Monitor blood pressure and pulse rate before and after givingthe 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 acomplete evaluation of all formed elements of the blood. It can supply a great deal ofinformation necessary to diagnosed hematopoetic system and helps to evaluate the strategiesand prognosis of certain disease.

Test Results Reference Rationale

Total WBC

Total RBC

6.5

3.7

(5.010.0)x10^9/L

(3.69-5.90) x10^2/L

Within Normal

Within Normal

Hemoglobin *10.4 (11.70-14.00)g/dL May indicate

anemia

Hematocrit

MCV

MCH

MCHC

Platelet count

*32.5

88.8

28.4

32.0

*440

(34.10-44.00)%

(70.0-97.00)fL

(26.10-33.30)pg

(3.035.0)g/dl

(150-390)x10^9/L

May indicate

anemia,loss of

blood, nutritional

deficiency bone,

marrow problems

Within Normal

Within Normal

Within Normal

Neutrophils 60.00 (55.0-62.0)% Within Normal

Lymphocytes

Monocytes

Eosinophils

BasophilsRDW- CV

30.20

7.50

2.000.30

12.8

(20.0040.00) %

(4.0-10.0)%

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

(11.5-14.5)%

Within Normal

Within Normal

Within NormalWithin Normal

Within Normal
http://www.medicinenet.com/anemia/article.htmhttp://www.medicinenet.com/anemia/article.htm


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X-RAY REPORT

DECEMBER 02, 2013

Chest Xray

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 x-

ray 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.


Potassium 4.15mEq/L 3.50-5.50 Within Normal

Sodium 145.30mEq/L 135.00-155.00 Within Normal

SGPT (ALT) 15.11U/L 9.00-36.00 Within Normal

CPK-MB 11.81U/L 0.000-25.000 Within Normal

Creatinine *0.61mgs/dl 0.70-1.30 May indicate muscle injury,

burns,carbon monoxide poisoning,hypothyroidism

Cardiac-T 50-100 0.000-50.000 Within Normal

*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


Magnesium

Sodium

Urea Nitrogen

Pro-BNP

D-DIMER

1.96mgs/dl

147.00mEq/L

21.13mgs/dl

105.0pg/mL

0.5ug/ml

1.90-2.50

135.00-155.00

4.70-23.00

0.000-125.000

0.000-0.500

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.


Ionized Calcium 1.2mEq/L 1.15-1.33 Normal


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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. Blooddelivers 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. Arteriescarry oxygen-rich blood away

from your heart, and veinscarry 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 oxygen-

rich 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 thebody. Thepulmonary circulation (for arterial blood sent to the lungs) is excluded fromthis 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 thecapillary cells.Veins bring deoxygenated blood back to the heart.

A heartbeat is a two-part pumping action that takes about a second. Asblood 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. Theelectrical 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, oxygen-

rich 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 anddecreasing 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. 8 thEdition. Lipincott Williams &

Wilkins. 530 Walnut Street, PA. 2008.
http://en.wikipedia.org/wiki/Arterieshttp://en.wikipedia.org/wiki/Pulmonary_circulationhttp://en.wikipedia.org/wiki/Veinhttp://texasheart.org/HIC/Anatomy/blood.cfmhttp://texasheart.org/HIC/Anatomy/blood.cfmhttp://en.wikipedia.org/wiki/Veinhttp://en.wikipedia.org/wiki/Pulmonary_circulationhttp://en.wikipedia.org/wiki/Arteries


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Nursing assessment I

Name: Sibuyan, Maria Lilia T. Date: Dec. 4, 2013Vital Signs: Pulse: 80bpm RR: 20 cpm BP: 100/60 mmHg Temp: 36 CHeight: 54 Weight: 45 Kg.EENT:

[ ] impaired vision [ ] blind[ ] pain redden [ ] drainage[ ] gums [ ] hard of hearing [ ] deaf[ ] burning [ ] edema [ ] lesion [ ] teethAssess eyes ears nose throat for abnormality x[x] No problemRESP:[ ] asymmetric [ ] tachypnea [ ] barrel chest[ ] bradypnea [ ] shallow [ ] rhonchi[ ] sputum [ ] diminished [ ] dyspnea[ ] orthopnea [ ] labored [ ] wheezing[ ] pain [ ] cyanoticAssess resp. rate, rhythm, depth, pattern,breath sounds, comfort [x] no problemCARDIOVASCULAR:[ ] arrhythmia [ ] tachycardia [ ]numbness[ ] diminished pulses [ ] edema [X] fatigue[ ] irregular [ ] bradycardia [ ] murmur[ ] tingling [ ] absent pulses [X] painAssess heart sounds, rate rhythm, pulse, bloodPressure, circ., fluid retention, comfort [X] no problemGASTROINTESTINAL TRACT:[ ] obese [ ] distention [ ] mass[ ] dyspagea [ ] rigidity [ ] pain [ ] LBMAssess abdomen, bowel habits, swallowing, bowel sounds,comfort [X] no problemGENITOURINARY AND GYNE

[ ] pain [ ] urine color [ ] vaginal bleeding[ ] hematuria [ ] discharge [ ] nocturiaAssess urine frequency, control, color, odor, comfort,gyne bleeding, discharge [ x ] no problemNEURO:[ ] paralysis [ ] stuporous [ ] unsteady [ ] seizures[ ] lethargic [ ] comatose [ ] vertigo [ ] treamors[ ] confused [ ] vision [ ] gripAssess 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 [ ]moistAssess skin color, texture, turgor, integrity [x] no problem

Headache

Chest pain 6/10

Localized pain at IVF

site Infiltrated


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36

Nursing Assessment II

SUBJECTIVE OBJECTIVE

COMMUNICATION

[ ] hearing loss

[ ] visual changes

[ ]denied

[ ] 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

OXYGENATION:

[ ]dyspnea Comments:

[ ]smoking history

[ ] cough

[ ]sputum

[ ]denied

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.

CIRCULATION

[X]chest pain Comments:[ ] leg pain

[ ] numbness of extremities

[ ] denied

Heart rhythm [X] regular [ ] irregular

Ankle Edema: Bipedal pitting edema 1+ presentCarotid Radial Dorsal Pedis Femoral

R: + 80bpm + not taken

L: + 80bpm + not taken

Comments: Pulses are palpable and heart rhythm is

regular.

NUTRITION: Comments:

Diet: Low Salt &Low Fat

[ x] N [x ] V

Character

[ ] recent change in weightand appetite

[ ] swallowing difficulty

[x]denied

[ ]dentures [x]none

Full partial with patient

Upper [] [] [ ]

Lower [] [] [ ]

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

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

MGT. OF HEALTH & ILLNESS:

[ ] alcohol [ ]denied

(amount frequency) ________

[X] SBE last Pap smear: cant recall

LMP:

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.

Comment:ok raman

akong panan-aw ug pang

dungog as verbalized by

the patient.

Wala man koy

problema ana

tanan imu ge

ingun as

verbalized by pt

Sakit gyud akong

dughan as

verbalized by the

patient

okay man akong

kaon, isda g i-

sinabaw nga utan

og protas ra akogikaon as

verbalized by the


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SKIN INTEGRITY:

[ ] dry Comments :

[ ] itching

[x] other

[ ] denied

[ ] dry [ ]cold [ ] pale

[ ] flushed [ ]warm [ ]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 dueto Abdominal pain

COMFORT/SLEEP/AWAKE:

[ ] pain (location,

frequency, Comments:

remedies)

[ ] nocturia

[ x ] sleep difficulties

[ ] 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

sakit akong

kamot tungod

sa dextrose

as verbalized

b the atient

naa raku

perme sa

katre kay

ipapahulay

man ko as

verbalized by

t.

katulgon pa kayo

ko sayo ko nag mata

kay nag inum ko

tambal as

verbalized by yhe


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38

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 sleepproperly 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 were 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. Obtained and recorded vital signs.

2. Instructed to avoid food rich in cholesterol such fried foods and egg.

3. Encouraged adequate rest periods4. Encouraged to do deep breathing exercise during onset of pain.

5. Placed patient to comfortable position.

6. Encouraged to do diversional activities like listening to music.

7. Instructed significant others to assist the patient in doing daily activities.

8. Emphasized compliance of prescribed medications.

SECOND DAY

We had our second assessment last December 6, 2013 Friday at PolymedicGeneral 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. Obtained and recorded vital signs.2. Elevated head of the bed.3. Instructed the significant others not to leave the patient alone.4. Encouraged adequate rest periods.5. Instructed to increase exercise and activity gradually6. Placed patient in a comfortable position.7. Encouraged patient to verbalize feelings on how shes doing


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NURSING DIAGNOSIS INTERVENTIONS RATIONALERisk for decreased Cardiac

Output related prolonged

myocardial ischemia and effects

of medications

Independent

Monitor Vital Signs and

cardiac rhythm

Auscultate breath sounds

and heart sounds. Listen for

murmurs

Stress importance of

avoiding straining andbearing down, especially

during defecation

Assess for signs and

symptoms of heart failure

Dependent

Administer supplemental

oxygen as needed.

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 befollowed 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


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NURSING DIAGNOSIS INTERVENTIONS RATIONALE

Anxiety related underlying to

pathophysiological response

Independent

Explain purpose of tests and

procedures

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

Reduces anxiety

attributable to fear of

unknown diagnosis andprognosis

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 anxietyand 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

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 Galain lage ako dughan murag gasakit usahay

O Pain Scale of 6/10

Facial Grimace

A Acute Pain related to decreased myocardial blood flow

P 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.

I 1. Assessed patient pain for intensity using a pain rating scale, for locationand for precipitating factors.

2. Assessed the response to medications every 5 minutes

3. Provided comfort measures such as listening to music.. 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 reducestress.

E After 4 hours of nursing interventions, the patient demonstrated

behaviors to alleviate pain and he reported pain scale of 3.


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47

VII. REFERRAL AND FOLLOW-UP

HEALTH TEACHINGS

Name: Sibuyan, Ma. Lilia T.

Medications:Client was reminded of the name and purpose of

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:

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

Exercise: 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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PROGNOSIS

Score Legend:

1Poor Prognosis

2Good Prognosis

3Very Good Prognosis

CRITERIA SCORE ANAYSIS/IMPLICATION

A.ONSET OF ILLNESS 1

12 hours prior to admission

patient has experienced 10/10

chest pain.

B. DURATION OF

ILLNESS 1

Detection of the disease

condition was delayed for

attaining prevention. Patient

already had a related

condition prior to this.

C. PRECIPITATING AND

PREDISPOSING

FACTOR

3

The increasing age of the

patient, the gender and her

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


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50

recovery

D. ATTITUDE &

WILLINGNESS TO

TAKE TREATMENT

3

The patients admission and

adherence medication

regimen may somehow

proved that the patient is very

willing to follow treatment.

E. FINANCIAL

CAPABILITY

3

Patient is financially capable

for her was able to pay the

entire medical and hospital

bills by the help of family

member and phil. Health.

G.PAIN MANAGEMENT

2

A daily progressive sign of

relief from the experienced

pain, she stated that

whenever she takes the

medication the pain subsided

but during missed dose she

experienced pain.

H. FAMILY SUPPORT

3

Her family was very

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 adherenc e 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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51

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 to our patient, there was an improvement in her

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.


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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 8thedition, 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 6thedition, 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
http://www.medicinenet.com/CHOLE/ARTICLE.HMhttp://www.who.int/topics/cholehttp://www.mursingcribs.com/http://www.youtube.com/http://www.google.com/http://www.mims.com/http://www.pims.com/http://www.pims.com/http://www.mims.com/http://www.google.com/http://www.youtube.com/http://www.mursingcribs.com/http://www.who.int/topics/cholehttp://www.medicinenet.com/CHOLE/ARTICLE.HM

angina cpa

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