final case study - cad
TRANSCRIPT
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ANGELES UNIVERSITY FOUNDATION
COLLEGE OF NURSING
S.Y. 2013 2014
CAS E S TUD Y ABOUT
COR ON OR Y AR TE R Y D I S E AS E W I THUN S TABLE AN GI N A
SUBMITTED BY:
BUENAFE, PATRICIA MARIE
MANALANG, MA. CLARELLE
SULA, JANNICA
BSN III 3 (GROUP 11)
SUBMITTED TO:
DENNISON JOSE C. PUNSALAN, RN, MN
CLINICAL INSTRUCTOR
OCTOBER 11, 2013
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I. INTRODUCTION
Every man's disease is his personal property.
-Alonzo Clark
A person should be able to take care of his body in order to maintain a healthy
life. It is becausehealth refers to the levels of functional or metabolicefficiency ofliving
beings. In humans, it is the general condition of a person's mind and body, usually
meaning to be free fromillness,injury or needlesspain.That is why the quote said that
a sick person is in his personality.
During the Ottawa Charter for Health Promotion in 1986, the WHO said that
health is a resource for everyday life, not the objective of living. Health is a positive
concept emphasizing social and personal resources, as well as physical capacities
(http://www.medicalnewstoday.com/articles/150999.php) but since health is a basic
need of a person and it does not mean that if you are not sick, you are healthy, it is now
presented as a complete physical, mental and social well-being and not merely the
absence of disease or infirmity or simply health is the wholeness of one person. As a
person is growing up, he or she cannot prevent a certain disease coming from his body
parts like the brain and heart. The etiology may be coming from the hereditary/genetics,
age or idiopathic. That is a disease is being manifested by a person whether it is
symptomatic or asymptomatic.
(http://www.medicalnewstoday.com/articles/150999.php)
Coronary Artery Disease happens when the arteries that supply blood to heart
muscle become hardened and narrowed. This is due to the buildup of cholesterol and
other material, called plaque, on their inner walls. This buildup is calledatherosclerosis.
As it grows, less blood can flow through the arteries. As a result, the heart muscle can't
get the blood or oxygen it needs. This can lead to chest pain (angina)or aheart attack.
Most heart attacks happen when ablood clot suddenly cuts off the hearts' blood supply,
causing permanent heart damage. Over time, this can also weaken the heart muscle
http://en.wikipedia.org/wiki/Healthhttp://en.wikiquote.org/wiki/Efficiencyhttp://en.wikiquote.org/wiki/Livinghttp://en.wikiquote.org/wiki/Humanshttp://en.wikiquote.org/wiki/Mindhttp://en.wikiquote.org/wiki/Meaninghttp://en.wikiquote.org/wiki/Illnesshttp://en.wikiquote.org/wiki/Injuryhttp://en.wikiquote.org/wiki/Painhttp://www.nlm.nih.gov/medlineplus/cholesterol.htmlhttp://www.nlm.nih.gov/medlineplus/atherosclerosis.htmlhttp://www.nlm.nih.gov/medlineplus/angina.htmlhttp://www.nlm.nih.gov/medlineplus/heartattack.htmlhttp://www.nlm.nih.gov/medlineplus/bloodclots.htmlhttp://www.nlm.nih.gov/medlineplus/bloodclots.htmlhttp://www.nlm.nih.gov/medlineplus/heartattack.htmlhttp://www.nlm.nih.gov/medlineplus/angina.htmlhttp://www.nlm.nih.gov/medlineplus/atherosclerosis.htmlhttp://www.nlm.nih.gov/medlineplus/cholesterol.htmlhttp://en.wikiquote.org/wiki/Painhttp://en.wikiquote.org/wiki/Injuryhttp://en.wikiquote.org/wiki/Illnesshttp://en.wikiquote.org/wiki/Meaninghttp://en.wikiquote.org/wiki/Mindhttp://en.wikiquote.org/wiki/Humanshttp://en.wikiquote.org/wiki/Livinghttp://en.wikiquote.org/wiki/Efficiencyhttp://en.wikipedia.org/wiki/Health -
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and contribute to heart failure and arrhythmias. Heart failure means the heart can't
pump blood well to the rest of the body. Arrhythmias are changes in the normal beating
rhythm of the heart.
The most common disease of the coronary arteries is arteriosclerosis, commonly
called "hardening of the arteries." Plaque a combination of cholesterol and other fats,
calcium and other elements carried in the blood builds up in the small blood vessels
that feed the heart. When this condition exists in other parts of the body, it is called
atherosclerosis.
This plaque buildup can, in time, narrow the arteries so severely that blood flow
to the heart is inadequate and symptoms of insufficient blood flow called angina
develop. Angina is a term meaning strangling or oppressive heaviness and pain, but it
has become synonymous with angina pectoris or chest pain caused by lack of oxygen
to the heart due to poor blood supply.
In addition to angina or chest pain, arteriosclerosis can produce fatigue,
shortness of breath and an abnormal heart beat or arrhythmia. Plaque also can tear the
artery walls and form blood clots that can lead to a heart attack. Often, there are no
symptoms of arteriosclerosis until a heart attack occurs.(http://www.ucsfhealth.org/conditions/coronary_artery_disease/signs_and_symptoms.ht
ml)
Arteriosclerosis is diagnosed through various tests including:
Coronary Angiography Coronary angiography, also called cardiac
catheterization, is a minimally invasive study that is considered the gold standard
for diagnosing coronary artery disease. This test is performed under local
anesthesia and involves injecting X-ray dye or contrast medium into the coronary
arteries via tubes called catheters. An X-ray camera films the blood flow to show
the location and severity of artery narrowing. This test can show if the blood
vessels in your heart have narrowed, your heart is pumping normally and blood is
flowing correctly and your heart valves are functioning properly. It also can
http://www.nlm.nih.gov/medlineplus/heartfailure.htmlhttp://www.nlm.nih.gov/medlineplus/arrhythmia.htmlhttp://www.ucsfhealth.org/conditions/coronary_artery_disease/signs_and_symptoms.htmlhttp://www.ucsfhealth.org/conditions/coronary_artery_disease/signs_and_symptoms.htmlhttp://www.ucsfhealth.org/conditions/coronary_artery_disease/signs_and_symptoms.htmlhttp://www.ucsfhealth.org/conditions/coronary_artery_disease/signs_and_symptoms.htmlhttp://www.nlm.nih.gov/medlineplus/arrhythmia.htmlhttp://www.nlm.nih.gov/medlineplus/heartfailure.html -
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identify any heart abnormalities you may have been born with or congenital
abnormalities.
Echocardiogram (ECHO) This non-invasive test translates sound waves from
your chest into pictures of your heart. It provides information about how the heart
is pumping, how blood flows in the heart and blood vessels, how large the heart
is and how the valves are working.
Electrocardiogram (ECG or EKG) The electrocardiogram records the heart's
electrical activity. Small patches called electrodes are placed on your chest, arms
and legs, and are connected by wires to the ECG machine. Your heart's electrical
impulses are translated into a wavy line on a strip of paper, enabling doctors to
determine the pattern of electrical current flow in the heart and to diagnose
arrhythmias and heart damage.
Stress Echocardiogram Stress tests are performed to see how the heart
performs under physical stress. The heart can be stressed with exercise on a
treadmill or in a few instances, a bicycle. If you can't exercise on a treadmill or
bicycle, medications can be used to cause the heart rate to increase, simulating
normal reactions of the heart to exercise. During the stress test, you will wear
ECG electrodes and wires while exercising so that the electrical signals of your
heart can be recorded at the same time.
Stress Thallium Test Stress thallium tests have two components a treadmill
stress test and heart scan after injection of a radionuclide material, such as
thallium, which allows doctors to see the coronary arteries and the shape and
function of the heart. It has been used in this manner safely for many years to
demonstrate the amount of blood the heart is getting under various conditions
rest and stress.
(http://www.ucsfhealth.org/conditions/coronary_artery_disease/diagnosis.html)
Medications and sometimes lifestyle changes, such as quitting smoking or losing
weight, can help improve heart efficiency to reduce angina but can't eliminate the
plaque blockages. Medications may include cholesterol-lowering drugs, Beta-
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blockers, nitroglycerin, calcium channel blockers, angiotensin-converting enzyme
inhibitors and others. These are the other management for CAD:
Plaque Removal - to remove plaque from arteries, the following procedures are
performed:
Angioplasty - also called percutaneous transluminal coronary angioplasty or
PTCA, involves inserting a long flexible tube called a catheter into a blood vessel
through a small incision in your skin. The catheter has a deflated balloon on its
tip. Once the catheter reaches the blocked blood vessel, the balloon is inflated
and compresses the plaque against the sides of the blood vessel. The balloon
may be inflated and deflated several times. Often, the procedure is done in
conjunction with a small metal tube called a stent that is left in the artery to serve
as a scaffold to keep the artery open and prevent the plaque from springing back
toward the center of the vessel.
Coronary Artery Bypass Graft surgery - an open-heart operation in which an
artery or a piece of vein taken from your leg is attached to the blood vessel to
detour blood around the blockage. During part of the operation, your heart will be
stopped and a heart-lung machine will be used to pump your blood and help you
breathe. As with most major large incision operations, it takes about six weeks to
recover. CABG is the most successful and most common major heart surgery in
the Western world.
Coronary Stent - a small, latticed, high-grade stainless steel tube that is used to
hold the coronary artery open and minimize the chance of abrupt closure after
angioplasty. It is placed in the coronary artery using the same procedure as the
angioplasty. The stent is typically positioned at the narrowed area of the artery.
When the catheter's balloon is inflated, the stent expands and is pressed againstthe vessel wall. The balloon is deflated and withdrawn, leaving the stent
permanently in place. After a stent is placed, you will be prescribed an
antiplatelet medication, Clopidogrel, also known as Plavix, for one month. This is
used to minimize the risk of clot formation in the stent while tissue grows around
the stent to incorporate it into the blood vessel wall. Within a month, the body no
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longer "sees" the stent, and the medication is no longer needed. You should
continue to take aspirin, if it has been prescribed, along with the Clopidogrel.
Rotational Atherectomy - widens narrowed arteries using a high-speed
rotational device to "sand" away plaque. This technique is used in particular
situations, such as with plaque with large amounts of calcium or to widen
blockages within a stent.
(http://www.ucsfhealth.org/conditions/coronary_artery_disease/treatment.html)
Although CAD can be a life-threatening condition, the outcome of the disease is
in many ways up to the patient. Damage to the arteries can be slowed or halted with
lifestyle changes, including smoking cessation, dietary modifications and regular
exercise, or by medications to lower blood pressure and cholesterol levels. Additionalgoals of treatment, which may involve medication and sometimes surgery, are to relieve
symptoms, ease circulation and prolong life.
(http://www.nlm.nih.gov/medlineplus/coronaryarterydisease.html)
A. Current trends
MANILA, Philippines - Recent data last July 9, 2012, from the National Statistics
Office (NSO) showed that five out of 10 deaths in the country were of cardiovascular
causes.
The NSO reported that 100,908 people died of heart diseases in 2009. This
accounted for 21 percent of all deaths in the country. It was followed by cerebrovascular
disease, which claimed 56,670 lives in the same year. It accounted for 11.8 percent of
all deaths in 2009. "Within three years (2007-2009), the top five causes of deaths
remained on their posts and proved to be fatal among other causes of deaths," the NSO
said. The World Health Organization (WHO) has said that an estimated 17 million
people die of cardiovascular diseases every year. Most of these were heart attacks and
strokes. "A substantial number of these deaths can be attributed to tobacco smoking,
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which increases the risk of dying from coronary heart disease and cerebrovascular
disease 23 fold. Physical inactivity and unhealthy diet are other main risk factors which
increase individual risks to cardiovascular diseases," the WHO said. The NSO also
reported that most females die in their older age compared to their male counterparts.
"It was noted that the most number of deaths was at the age of 80 and over with 85,705
or 17.8 percent. From these, 59.6 percent (51,074) were females while the remaining 40
percent (34,631) were males," the NSO said. The age group 10 to 14 had the least
number of deaths, accounting for only 1 percent of all total deaths. "It has been
observed that as the age increases, the rate of dying also increasing. From age group
10 onwards it shows that the number of deaths continuously increase though a slight
decrease were seen at ages 75-79 then it went up again at age 80 and over," the NSO
said. Deaths in 2009 reached 480,820, which was 4.2 percent higher than the previous
year. The most number of deaths in the country occurred in the National Capital Region,
which accounted for 75,019 or 15.6 percent of all deaths in the country. Learn about
coronary artery disease, its symptoms and about the latest developments in treatment.
Coronary artery disease is caused when plaque buildup creates blockages or
narrowing in the arteries. The blockages restrict blood flow and reduce the amount of
oxygen delivered to the heart, potentially putting a person at risk for a heart attack.
Common symptoms of coronary artery disease include chest pain, shortness of
breath, fatigue and overall weakness.
Simple lifestyle changes can help prevent and manage coronary artery disease.
These include managing obesity and high blood pressure, living an active lifestyle,
making healthy dietary choices and stopping smoking.
(http://www.philstar.com/breaking-news/2012/07/09/826043/5-out-10-filipinos-die-heart-
disease-nso)
Improved Treatments
Staying on top of the latest medical advances helps ensure you and loved ones
secure the best treatment available.
http://www.philstar.com/breaking-news/2012/07/09/826043/5-out-10-filipinos-die-heart-disease-nsohttp://www.philstar.com/breaking-news/2012/07/09/826043/5-out-10-filipinos-die-heart-disease-nsohttp://www.philstar.com/breaking-news/2012/07/09/826043/5-out-10-filipinos-die-heart-disease-nsohttp://www.philstar.com/breaking-news/2012/07/09/826043/5-out-10-filipinos-die-heart-disease-nso -
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Last March 28, 2013, a new treatment was found for patients with CAD. One
advancement in treatment is supported by new results from the FAME 2 Study funded
by St. Jude Medical and published in the New England Journal of Medicine. The study
found that use of a blood-flow measurement technology, called Fractional Flow Reserve
(FFR) during treatment of stable coronary artery disease will result in better health
outcomes.
FFR technology offers physicians a better assessment of where blood flow
blockages occur in the coronary arteries and whether treatment to open an artery
narrowing, along with medication, can help lower a patient's risk of chest pain and heart
attack.
From less likelihood of a patient being readmitted to the hospital for urgent care,
to a reduction in health care costs, FAME 2 research demonstrates that patients who
receive FFR-guided treatment experienced better outcomes than those treated with
medication alone.
The FAME 2 Study results offer further evidence that FFR should be considered
the standard of care for treating patients with coronary heart disease," said Frank J.
Callaghan, president of the Cardiovascular and Ablation Technologies Division at St.Jude Medical.
B. Statistics
Coronary artery disease (CAD) is the leading cause of death in the United
States, affecting over 5 million Americans. CAD is a narrowing of the coronary arteries,
the vessels that supply blood to the heart muscle, generally due to the buildup of
plaques in the arterial walls, a process known as atherosclerosis. Plaques are
composed of cholesterol-rich fatty deposits, collagen, other proteins, and excess
smooth muscle cells.
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Atherosclerosis, which usually progresses very gradually over a lifetime,
thickens and narrows the arterial walls, impeding the flow of blood and starving the
heart of the oxygen and vital nutrients it needs (also called ischemia). This can
cause muscle cramp-like chest pain calledangina.
Blood clots form more easily on arterial walls roughened by plaque deposits
and may block one or more of the narrowed coronary arteries completely and cause
a heart attack. Arteries may also narrow suddenly as a result of an arterial spasm.
(Spasms are most commonly triggered by smoking.)
Heart disease is the leading cause of death for both men and women. More
than half of the deaths due to heart disease in 2009 were in men. About 600,000
people die of heart disease in the United States every yearthats 1 in every 4
deaths. Coronary heart disease is the most common type of heart disease, killing
more than 385,000 people annually.Every year about 715,000 Americans have a
heart attack. Of these, 525,000 are a first heart attack and 190,000 happen in people
who have already had a heart attack. Coronary heart disease alone costs the United
States $108.9 billion each year. This total includes the cost of health care services,
medications, and lost productivity. (http://www.cdc.gov/heartdisease/facts.htm)
According to the latest WHO data published in April 2011 Coronary Heart
Disease Deaths in Philippines reached 57,864 or 13.73% of total deaths. The age
adjusted Death Rate is 121.63 per 100,000 of population ranks Philippines #79 in
the world. Review other causes of death by clicking the links below or choose the full
health profile. (http://www.worldlifeexpectancy.com/philippines-coronary-heart-
disease)
http://www.hopkinsmedicine.org/heart_vascular_institute/conditions_treatments/conditions/angina.htmlhttp://www.worldlifeexpectancy.com/philippines-coronary-heart-diseasehttp://www.worldlifeexpectancy.com/philippines-coronary-heart-diseasehttp://www.worldlifeexpectancy.com/philippines-coronary-heart-diseasehttp://www.worldlifeexpectancy.com/philippines-coronary-heart-diseasehttp://www.hopkinsmedicine.org/heart_vascular_institute/conditions_treatments/conditions/angina.html -
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C. Reason for choosing such case for presentation
The student nurses are hopeful for the realization of the essence of this study to
the involved and to those of which this study can be of any help. Since the case of
Coronary Artery Disease is very rampant, the student nurses would like to be of
service in decreasing the probability of what is fast occurring. The aim of the group is
not just to present what we have researched or learned from time to time but to put
into profession in order to be of great help to others, to increase awareness, to
educate, to prevent, to promote and to restore health.
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D. Objectives
Short Term
During the course of the study, the student nurse will be able to:
Establish rapport with the patient
Explain the purpose in conducting the interview
Collect information regarding the demographic data of the patient
Collect information regarding socio economic and cultural beliefs of the
patient and environmental factors
Collect data regarding the patients family health illness and history, post
and present illness
List the diagnostic procedures done and explain
Identify the different medical, surgical and nursing management
Emphasize the importance of health teaching
Long Term
After the completion of the study, the student nurse will be able to:
Associate abnormal diagnostic findings with his disease condition
Demonstrate nursing interventions for procedure done
Formulate recommendations to be imparted to patients same condition
Provide critical thinking skills necessary for providing safe and effective
nursing care.
Provide a comprehensive assessment and implement care base on our
knowledge and skills of the condition
Familiarize us with effective inter-personal skills to emphasized health
promotion and illness prevention.
Impart the learning experience from direct patient care.
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Short Term
During the course of the study, the patient will be able to:
Develop trust with the student nurse
Understand the purpose in conducting such interview
Provide information regarding his demographic data
Provide information regarding his socio economic and cultural beliefs
Demonstrate compliance to medical regimen
Identify risk factors
Long Term
After completion of the study, the patient will be able to:
Continue cooperating with physical assessment
Express feelings regarding his condition
Will be able to accept his situation and have sense of control
Understand his manifestation related to him condition
Gain the basic information concerning Coronary Artery Disease
Eradicate activities that may worsen his condition
Comply with the treatment given upon discharge
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II. NURSING PROCESS
A. Assessment
1. Personal History
a. Demographic Data
Our patients name is Mr. Corona D. Sease for the purpose of confidentiality and
he is 56 years old. He is approximately 52 feet in height and weighs 45 kilograms in
weight. He has a pale fair skin complexion. His eyes are round and his teeth are slightly
yellowish. His role in the family is to work for his family as a grass cutter at a certain
subdivision. He does have 6 children. He lives in Bulaon Rest City of San Fernando,
Pampanga. He was born on May 16, 1957 at their house in Del Paz Norte by Normal
Spontaneous Delivery. His nationality is a Filipino and ethnicity is a Kapampangan.
He was admitted September 17, 2013 at around 1:40 AM. His chief complaint
was difficulty of breathing and chest tightness. He is still admitted at a local hospital in
Pampanga. He was diagnosed with Coronary Artery Disease with Unstable Angina.
b. Socio-Economic and Cultural Factors
Mr. Corona D. Sease lives together with his wife and his 6 children and they are
pure Kapampangan. They are currently living at Bulaon Rest City of San Fernando,
Pampanga. Their house is made of sement and wood house in a 1 story building and
only has 1 window. They are still living there even a typhoon already flooded and
destroyed some of the parts of the house like the floors.
Mr. Corona D. Seaseswork is a grass cutter during weekdays from 7AM to 5PM
at a certain subdivision. He owns 5,200 pesos every month. They are categorized aspoor because each member receives 900 pesos only. According to NEDA 2004, a
family must have a total income of 2768.60 per family member to be classified as not
poor and meet the basic needs of each member.
(http://localweb.neda.gov.ph/regional.html)
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His wife budgets the money for their basic needs. They buy their food at a local
market. Their source of water is from a distilled water company. Their garbage is
collected once a week by the city government entities. According to Mr. Sease, their
food source comes from the maket and they dont have any electricity but they use
candles as their source of light. They buy things for their hygiene purposes like
shampoo, soap, tooth brush and tooth paste. They ride tricycles and jeepneys as
means of transportation. They save money that was left for emergency purposes like
medications. He gives money for his childrens projects and allowance. Some of his
income was given to his relatives since his relatives are asking.
Basic Needs Expenses (Per Week)
Food
Rice
Viand
900 pesos
800 pesos
Water Supply 140 pesos
No Electricity Suppy but for Candles 60 pesos
Hygiene Suppy 200 pesos
Transportation 112 pesos
Savings for Emergency purposes 500 pesos
Education for his children 500 pesos
For his relatives 1500 pesos
Others 488 pesos
Mr. Sease only reached Grade 5 as his highest educational attainment in a public
school. He was forced to stop her studies because of the financial constraint in the
family. They are affliated with Roman Catholic religion and they go to mass every
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Sunday. Regarding their cultural factors affecting health, they take herbal medicines
such as Malunggay and Bawang as an alternative of a medicine but they do not believe
in faith healers. If one of the family members got sick, they immediately go to a hospital.
Mr. Sease does not smoke but he drinks alcohol 4 times a week. He is fond of eating
vegetables and has a high fat diet.
TIME ACTIVITIES OF DAILY LIVING OF
MR. CORONA D. SEASE
4:00 AM6:00AM Freshen up including dressing up for 30
minutes, Cooking and Preparing their
Breakfast for 40 minutes, Breakfast for
30 minutes, Cleaning the Dishes for 15
minutes, Getting Ready for His Work
for 5 minutes
6:00 AM6:45 AM Travel Time Going to His Work
7:00 AM12:00 NN Working Hours
12:00 NN1:00 PM Lunch Break
1:00 PM5:00 PM Working Hours
5:00 PM5:45 PM Travel Time Going Back to His House
6:00 PM6:30 PM Rest for 30 minutes
6:30 PM7:00 PM Dinner
7:00 PM7:30 PM Doing Household Chores
7:30 PM10:00 PM Bonding with Family for 30 minutes,
Going to His Friends House and Drinks
Alcohol for 2 Hours
10:00 PM4:00 AM Sleeping Hours
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C. Environmental Factors
Seases family live in Bulaon Rest, City of San Fernando, Pampanga. Theirhouse is a sement and wood type of house. It is a 1-storey building house. They have 1
window and 1. They are still living their even there was a typhoon that flooded the
house. His wife cleans the house every week.
3. History of Past Illness
Mr. Corona D. Sease is complete with his immunizations when he was 1 year old
at the year of 1958. He experienced tigdas at the age of 10 years old at the year of
1967 and did not have any chicken pox and mumps during his childhood years. He
does not have any allergies like in dust, pollens and foods such as shrimps or chickens.
Sometimes, he experience fever. His highest temperature when he experiences his
fever on October 2005 was 38.5 degree Celsius. His wife only did tepid sponge bath
and bed rest. When he has cough and colds and flu, he drinks Lagundi as his
alternative medicine when they lack of financial resources. If he is severe ill, he
immediately goes to the hospital.
4. History of Present Illness
Mr. Corona D. Sease experienced chest pain or angina pectoris in medical term
when he was 55 years old on December 2012. He experienced chest pain again lastJanuary and August 2013 and was brought at a local hospital in Pampanga. He did not
buy his take home medications because of lack of financial resources. The day before
his admission, last September 17, 2013 at around 4:30 PM, he experienced sudden
difficulty of breathing and chest tightness when he was still in work. He was brought to a
local hospital here in Pampanga at around 6:30 PM by the worker, where he was
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working. His chief complaint was difficulty of breathing and chest tightness. He admitted
that before the day of admission, he ate high fat foods like chicharon and sisig and he
drank alcohol straight 4 days in that week.
The physician made the admitting and final diagnosis as Coronary Artery
Disease. Hence, he was admitted on September 17, 2013.
5. Physical Examination
(September 17, 2013Lifted from the chart)
Skin: (-) Dermatitis
Head-EENT: AS, PPC
Lymph Nodes: (-) Claps
Chest: Lungs - SF, Crackles in BLF
Cardiovascular: Angina Pectoris
o Abdomen: Flat, Soft
o Musculoskeletal: (+) grade # edema
o Admitting Impression: T/c ACS with CHF
(September 18, 2013First Day of Assessment)
General Appearance:
Mr. Corona D. Sease is lying on bed, with an IVF of 5% Dextrose in Water 500
cc, with an O2 Inhalation. He looks weak in appearance. He has pale skin and
conjunctiva.
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Vital Signs
Temperature: 36.5 degree Celsius
Pulse rate: 74 bpm
Respiratory rate: 31 cpm
Blood Pressure: 110/80 mmHg
o HairShort, black hair, no pediculosis and lesions noted, evenly distributed
o SkinPale complexion, good skin turgor, absence of edema and jaundice
o NailsLong and untrimmed
o HeadRound, smooth without lesions
o EyesPale palpebral conjunctiva, round eyes
o EarsNo presence of discharge
o MouthNo sores, reddish in color
o NoseNo nasal discharge
o LipsPale and slightly dry
o NeckNo lymph nodes were palpated
o HeartDiminished in heart rate, irregular heart rhythm
o LungsCrackles and rales were auscultated in BLF
o Abdomen - Skin is as the same color as with that of that body or lighter. Hair is
evenly distributed. Bluish discoloration of the umbilicus is not presence. Bowel
sounds are 15 per minute/quadrant. Pain is not felt during urination.
o Legs and feetNegative Homans sign, edema
(September 19, 2013Second Day of Assessment)
General Appearance:
Mr. Corona D. Sease is lying on bed, with an IVF of 5% Dextrose in Water 500
cc, with an O2 Inhalation. He looks weak in appearance. He has pale skin and
conjunctiva.
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Vital Signs
Temperature: 35.8 degree Celsius
Pulse rate: 77 bpm
Respiratory rate: 31 cpm
Blood Pressure: 110/80 mmHg
o HairShort, black hair, no pediculosis and lesions noted, evenly distributed
o SkinPale complexion, good skin turgor, absence of edema and jaundice
o NailsLong and untrimmed
o HeadRound, smooth without lesions
o EyesPale palpebral conjunctiva, round eyes
o EarsNo presence of discharge
o MouthNo sores, reddish in color, had excessive sputum
o NosePresence of nasal discharge
o LipsPale and slightly dry
o NeckNo lymph nodes were palpated
o Heart - Diminished in heart rate, irregular heart rhythm
o LungsCrackles and rales were auscultated in BLF
o Abdomen - Skin is as the same color as with that of that body or lighter. Hair is
evenly distributed. Bluish discoloration of the umbilicus is not presence. Bowel sounds
are 15 per minute/quadrant. Pain is not felt during urination.
o Legs and feetNegative Homanssign, edema
(September 20, 2013Third Day of Assessment)
General Appearance
Mr. Corona D. Sease is lying on bed, with an IVF of 5% Dextrose in Water 500
cc, with an O2 Inhalation. He looks weak in appearance. He has pale skin and
conjunctiva.
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Vital Signs
Temperature:36.8 degree Celsius
Pulse rate: 78 bpm
Respiratory rate: 26 cpm
Blood Pressure: 120/80 mmHg
o HairShort, black hair, no pediculosis and lesions noted, evenly distributed
o Skin Slightly pale complexion, good skin turgor, absence of edema and
jaundice
o NailsLong and untrimmed
o HeadSymmetrical, round, smooth without lesions
o EyesSlightly pale palpebral conjunctiva
o EarsNo presence of discharge
o MouthNo sores, reddish in color
o NosePresence of nasal discharge
o LipsPale and slightly dry
o NeckNo lymph nodes were palpated
o Heart - Diminished in heart rate, irregular heart rhythm
o LungsCrackles and rales were auscultated in BLF
o Abdomen - Skin is as the same color as with that of that body or lighter. Hair is
evenly distributed. Bluish discoloration of the umbilicus is not presence. Bowel sounds
are 15 per minute/quadrant. Pain is not felt during urination.
o Legs and feetNegative Homanssign, edema
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Diagnostic/Laboratory
Procedures
Date Ordered
Date
Resulted
Indications or
Purposes
Results Normal
Values/
Units used
in Hospital
Analysis and
Interpretation of results
(Client-centered)
> Complete Blood
Count
Hemoglobin DO: 09-17-
2013
DS: 09-18-
2013
Measures the
amount of Hgb,
protein found in
RBC in the blood
130 115155 g/L The result is normal, can be
seen by client having the
absence of dehydration
Hematocrit DO: 09-17-
2013
DS: 09-18-
2013
Measures the
proportion of the
blood that is made
up of RBC
0.44 0.380.48 Same of Hgb, hydration
status is normal
White Blood Cells DO: 09-17-
2013
DS: 09-18-
2013
Numerates the
number of WBC in
the blood, a
decrease and
increase in this
may suggest
presence of
7 510 x
10^9/L
The client did not acquire
any infections as a result to
normal WBC
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Lymphocytes DO: 09-17-
2013
DS: 09-18-
2013
This test measures
amount of
neutrophils type of
WBC in the blood
if disease or
toxicity issuspected
0.27 0.200.35 The amount of lymphocytes
in the blood is normal as
evidenced by clients
absence of infection; this is
related to WBC and
neutrophils sinceneutrophils and
lymphocytes are types of
WBC
illness
Neutrophils DO: 09-17-
2013
DS: 09-18-
2013
This test
measures the
amount of
neutrophils type of
WBC in the bloodif disease or
toxicity is
suspected
0.49 0.450.65 Client did not manifest
infection as evidenced by
normal neutophils
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Platelet DO: 09-17-
2013
DS: 06-18-
2013
To determine any
bleeding disorders
or bone marrow
diseases and for
unexplained
bruises
298 150400 x
10^9
The client did not have any
spontaneous bleeding, bone
marrow disorder or
leukemia which results to a
normal platelet count> Blood Chemistries
Fasting Blood Sugar DO: 09-17-
2013
DS: 09-18-
2013
This is to measure
the amount of
glucose present in
the body
6.02 4.19.00
mmol/L
Clients glucose level is
within normal range. No
signs of diabetes
Blood Urea Nitrogen DO: 09-17-
2013
DS: 09-18-
2013
Measures amount
of urea nitrogen is
the blood
4.1 1.7/8.3mmol/
L
Result is normal as
evidenced by clients normal
kidney function
Creatinine DO: 09-17-
2013
DS: 09-18-
2013
Measures the
amount of
creatinine present
is the blood and/or
urine
130.8 58-
120mmol/L
The client is dehydrated. His
urine is tea-colored. Pain is
felt when urinating but there
is no presence of blood.
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Sodium (Na) DO: 09-17-
2013
DS: 09-18-
2013
Measures the level
of Na is the blood
146.6 135145
mmol/L
Client is in good hydration
status
Potassium (K) DO: 09-17-
2013
DS: 09-18-
2013
Measures the
amount of K
present is the
blood
4.23 3.555
mmol/L
Clients K level is within
normal range
Urinalysis DO: 09-17-
2013
DS: 09-18-
2013
Urinalysis can
reveal diseases
that have gone
unnoticed because
they do not
produce striking
signs and
symptoms
Determination of
Color Normal
Patient has lightyellow color
urine.
Yellow Yellow to
amber in
color
Transparency
There is presence of
suspended particles in theurine such as normal urine
crystals and mucus because
of inflammation of the
gallbladder.
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urine composition
and possible
abnormal
components (e.g.
protein or glucose)
or infection
Turbid Clear
Specific Gravity
Normal
This means that the
patient has normal
hydration status AEB
patient didnt manifest
signs of dehydration
such as poor skin turgor,
etc.
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1.013 1.0101.025
Sugar
Normal
There is absence of sugar in the urine
which means that the patient is notindicative of diabetes.
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Negative Negative
Microscopic Findings
Pus
Cells
The patient has mild inflammation of the
gallbladder and mild infection.
0-1 /hpf 0-1/hpf
RBCThe patient has mild inflammation of the
gallbladder and mild infection.
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12 (Negative or
Rare)
Epithelial
Cells
Normal
This indicates that the patient is not
indicative of inflammation in the bladder
and present of epithelial cells represent
possible contamination of the specimen
with skin bacteria
Few Rare
BacteriaBacteria in urine are unusual, but few
bacteria can due to contamination
Few None
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Electrocardiogram
There is an Elevated ST Segment which means independent of changes in ventricular activation and that
may be the result of global or segmental pathologic processes that affect ventricular repolarization and has Occasional
Pulmonary Vascular Resistance.
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7. ANATOMY AND PHYSIOLOGY
The heart is located in the chest between the lungs behind the sternum and
above the diaphragm. It is surrounded by the pericardium. Its size is about that of a fist,
and its weight is about 250-300 g. Its center is located about 1.5 cm to the left of themidsagittal plane. Located above the heart are the great vessels: the superior and
inferior vena cava, the pulmonary artery and vein, as well as the aorta. The aortic arch
lies behind the heart. The esophagus and the spine lie further behind the heart.
(Williams and Warwick, 1989).
The walls of the heart are composed of cardiac muscle, called myocardium. It
also has striations similar to skeletal muscle. It consists of four compartments: the right
and left atria and ventricles. The heart is oriented so that the anterior aspect is the right
ventricle while the posterior aspect shows the left atrium. The atria form one unit and
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the ventricles another. This has special importance to the electric function of the heart,
which will be discussed later. The left ventricular free wall and the septum are much
thicker than the right ventricular wall. This is logical since the left ventricle pumps blood
to the systemic circulation, where the pressure is considerably higher than for the
pulmonary circulation, which arises from right ventricular outflow. The cardiac muscle
fibers are oriented spirally and are divided into four groups: Two groups of fibers wind
around the outside of both ventricles. Beneath these fibers a third group winds around
both ventricles. Beneath these fibers a fourth group winds only around the left ventricle.
The fact that cardiac muscle cells are oriented more tangentially than radially,
and that the resistivity of the muscle is lower in the direction of the fiber has importance
in electrocardiography and magneto cardiography. The heart has four valves. Between
the right atrium and ventricle lies the tricuspid valve, and between the left atrium and
ventricle is the mitral valve. The pulmonary valve lies between the right ventricle and the
pulmonary artery, while the aortic valve lies in the outflow tract of the left ventricle
(controlling flow to the aorta). The blood returns from the systemic circulation to the right
atrium and from there goes through the tricuspid valve to the right ventricle. It is ejected
from the right ventricle through the pulmonary valve to the lungs. Oxygenated blood
returns from the lungs to the left atrium and from there through the mitral valve to the
left ventricle. Finally blood is pumped through the aortic valve to the aorta and the
systemic circulation.
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In the heart muscle cell, or myocyte, electric activation takes place by means of
the same mechanism as in the nerve cell - that is, from the inflow of sodium ions across
the cell membrane. The amplitude of the action potential is also similar, being about 100
mV for both nerve and muscle. The duration of the cardiac muscle impulse is, however,
two orders of magnitude longer than that in either nerve cell or skeletal muscle. A
plateau phase follows cardiac depolarization, and thereafter repolarization takes place.
As in the nerve cell, repolarization is a consequence of the outflow of potassium
ions. (Netter, 1971).Associated with the electric activation of cardiac muscle cell is its
mechanical contraction, which occurs a little later. For the sake of comparison, Figure
6.5 illustrates the electric activity and mechanical contraction of frog sartorius muscle,
frog cardiac muscle, and smooth muscle from the rat uterus (Ruch and Patton, 1982).
An important distinction between cardiac muscle tissue and skeletal muscle is
that in cardiac muscle, activation can propagate from one cell to another in any
direction. As a result, the activation wavefronts are of rather complex shape. The only
exception is the boundary between the atria and ventricles, which the activation wave
normally cannot cross except along a special conduction system, since a non-
conducting barrier of fibrous tissue is present. Located in the right atrium at the superior
vena cava is the sinus node (sinoatrial or SA node) which consists of specialized
muscle cells. The sinoatrial node in humans is in the shape of a crescent and is about
15 mm long and 5 mm wide (see Figure 6.6). The SA nodal cells are self-excitatory,
pacemaker cells. They generate an action potential at the rate of about 70 per minute.
From the sinus node, activation propagates throughout the atria, but cannot propagate
directly across the boundary between atria and ventricles, as noted above. The
atrioventricular node (AV node) is located at the boundary between the atria and
ventricles; it has an intrinsic frequency of about 50 pulses/min. However, if the AV node
is triggered with a higher pulse frequency, it follows this higher frequency. In a normal
heart, the AV node provides the only conducting path from the atria to the ventricles.
Thus, under normal conditions, the latter can be excited only by pulses that
propagate through it. Propagation from the AV node to the ventricles is provided by a
specialized conduction system. Proximally, this system is composed of a common
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bundle, called the bundle of His (named after German physician Wilhelm His, Jr., 1863-
1934). More distally, it separates into two bundle branches propagating along each side
of the septum, constituting the right and left bundle branches. (The left bundle
subsequently divides into an anterior and posterior branch.) Even more distally the
bundles ramify into Purkinje fibers (named after Jan Evangelista Purkinje (Czech; 1787-
1869)) that diverge to the inner sides of the ventricular walls. Propagation along the
conduction system takes place at a relatively high speed once it is within the ventricular
region, but prior to this (through the AV node) the velocity is extremely slow. From the
inner side of the ventricular wall, the many activation sites cause the formation of a
wavefront which propagates through the ventricular mass toward the outer wall. This
process results from cell-to-cell activation. After each ventricular muscle region has
depolarized, repolarization occurs. Repolarization is not a propagating phenomenon,
and because the duration of the action impulse is much shorter at the epicardium (the
outer side of the cardiac muscle) than at the endocardium (the inner side of the cardiac
muscle), the termination of activity appears as if it were propagating from epicardium
toward the endocardium.
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8. THE PATIENT AND HIS ILLNESS
a. PATHOPHYSIOLOGY (BOOK-CENTERED)
Schematic Diagram
Non-modifiable Factors:
Age (older adults)
Gender (male and menopause
women)
Hereditary(Including Race)
Modifiable Factors:
Smoking
Physical Inactivity
Obesity
Diabetes
Stress
Homocysteine Levels
Inflammatory Response
Menopause
Thrombus formation
Activation latelet
M ocardial ischemia Anaerobic metabolism
Lactic Acid Production
Acidosis
Prolonged unrelieved
ischemia
Change in the condition of the plaque in the coronary artery
An ina
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Myocardial cell death
Altered re olarizationRelease of lysosomal
enz mes
Conduction system
disorder
Heart Contractility
SNS Stimulation LV Function
Elevated ST segment
Elevated Cardiac
Biomarkers
D srh thmias
Decreased COIncreased
Afterload
Increased
Oxygen Demand
Tach cardia Increased
Preload
Increased
CVP and
PCWP
VasoconstrictionTach nea
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b. Synthesis of the disease
b.1. Definition of the disease
Coronary artery disease develops when your coronary arteries the major
blood vessels that supply your heart with blood, oxygen and nutrients become
damaged or diseased. Cholesterol-containing deposits (plaque) on your arteries are
usually to blame for coronary artery disease. When plaques build up, they narrow your
coronary arteries, causing your heart to receive less blood.
Eventually, the decreased blood flow may cause chest pain (angina), shortness
of breath, or other coronary artery disease signs and symptoms. A complete blockage
can cause a heart attack. Because coronary artery disease often develops over
decades, it can go virtually unnoticed until you have a heart attack. But there's plenty
you can do to prevent and treat coronary artery disease. Start by committing to a
healthy lifestyle.
Coronary artery disease is a narrowing or blockage of the arteries and vessels
that provide oxygen and nutrients to the heart. It is caused by atherosclerosis, an
accumulation of fatty materials on the inner linings of arteries. The resulting blockage
restricts blood flow to the heart. When the blood flow is completely cut off, the result is a
heart attack.
Coronary artery disease, also called coronary heart disease or heart disease, is
the leading cause of death for both men and women in the United States. According to
the American Heart Association, deaths from coronary artery disease have declined
some since about 1990, but more than 40,000 people still died from the disease in
2000. About 13 million Americans have active symptoms of coronary artery disease.
Coronary artery disease occurs when the coronary arteries become partially
blocked or clogged. This blockage limits the flow of blood from the coronary arteries,
which are the major arteries supplying oxygen-rich blood to the heart. The coronary
arteries expand when the heart is working harder and needs more oxygen. Arteries
expand, for example, when a person is climbing stairs, exercising, or having sex. If the
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arteries are unable to expand, the heart is deprived of oxygen (myocardial ischemia).
When the blockage is limited, chest pain or pressure, called angina, may occur. When
the blockage cuts off the flow of blood, the result is heart attack (myocardial infarction or
heart muscle death).
Healthy coronary arteries are clean, smooth, and slick. The artery walls are
flexible and can expand to let more blood through when the heart needs to work harder.
The disease process in arteries is thought to begin with an injury to the linings and walls
of the arteries. This injury makes them susceptible to atherosclerosis and blood clots
(thrombosis).
b.2. Nonmodifiable
HEREDITARY (INCLUDING RACE)
Children whose parents had heart disease are at higher risk for coronary artery
disease. This increased risk is related to genetic predisposition to hypertension,
elevated lipid levels, diabetes and obesity, all of which increase the risk f coronary
artery disease.
For people 35 to 74 years of age, the age adjusted death rate from coronary artery
disease for African American women is 72% higher than that for white women and
Native Americans. The prevalence of coronary is lowest among Mexican American
AGE
Age influences both the risk and the severity of coronary artery disease.
Symptomatic coronary artery disease appears predominantly in people older than 40
years of age and 4 of 5 people who die of coronary artery disease are age 65 years or
older. Angina and Myocardial Infarction, however, can occur in a persons 30s and even
in ones 20s. at older ages, women who have heart attacks are twice as likely as to die
from the heart attack.
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GENDER
Coronary artery disease is the number one killer of both men and women. In 1999
mortality from coronary artery disease was almost equal for men and women. Although
men are at higher risk for heart attacks at younger ages, the risk for women increasessignificantly at menopause, so that coronary artery disease rates in women after
menopause are two to three times that of women the same age before menopause.
Women who take oral contraceptives and who smoke or have high blood pressure are
at greater risk for coronary artery disease. Women with an early menopause are also at
higher risk than are women with a normal or late menopause.Two lifestyle changes
during the past 2 decades may be responsible for the increased incidence of coronary
artery disease among women. More women (many with full responsibility for the
household and children) have entered the work force, and more women have begun to
smoke tobacco at an earlier age.
Modifiable
SMOKING
Both active smoking and passive smoking have been strongly implicated as a risk
factor in the development of coronary artery disease. Currently 23% of men and 18% of
women are smokers. The prevalence of smoking is higher in people with 11 years of
education or less. Smoking triples the risk of heart attack in women and doubles the risk
of heart attack in men. It also doubles the risk of dying from a heart attack and may
quadruple the risk of sudden death. Nonsmokers who are exposed to second hand
tobacco smoke at home or work may also have a higher death rate from coronary artery
disease. The risk of coronary artery disease is decreased by 50% 1 year after smokers
quit. The risk is further reduced to that of nonsmokers within 5 to 10 years after smoking
cessation.Tar, nicotine, and carbon monoxide contribute to the damage. Tar contains
hydrocarbons and other carcinogenic substances. Nicotine increases the release of
epinephrine and norepinephrine, which results in peripheral vasoconstriction, elevated
blood pressure and heart rate, greater oxygen consumption, and increased likelihood of
dysrhythmias. In addition, nicotine activates platelets and stimulates smooth muscle cell
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proliferation in the arterial walls. Carbon monoxide reduces the amount of blood
available to the intima of the vessel wall and increases the permeability of the
endothelium.
PHYSICAL INACTIVITY
In the United States about 25% of adults report no leisure time physical activity,
even though regular aerobic exercise is important in preventing heart and blood vessel
disease. There is an inverse relationship between exercise and the risk of coronary
artery disease. Those who exercise reduce their risk of coronary artery disease
because they have (1) higher HDL levels; (2) lower LDL cholesterol, triglyceride and
blood glucose levels; (3) greater insulin sensitivity; (4) lower blood pressure; and (5)
lower body mass index. The AHA recommends 30 to 60 minutes of physical activity on
most days of the week.
OBESITY
Obesity places an extra burden on the heart, requiring the muscle to work harder to
pump enough blood to support added tissue mass. In addition obesity increases the risk
for coronary artery disease because it is often associated with elevated serum
cholesterol and triglyceride levels, high blood pressure, and diabetes. The prevalence of
obesity has increased to 30% in the years 1999 to 2002 compared to 22% from 1988 to
1994. Since 1993 the prevalence of those who are obese increased to 61%. Distribution
of body fat is also important. A waist measurement is a way to estimate fat. For men a
highrisk waistline measurement is more than 40 inches and for women a high risk
waist measurement is more than 35 inches. Body mass index is another measure to
estimate body fat. A BMI from 18.5 to 24.9 is considered healthy. Extreme obesity, or a
BMI greater than 40, is estimated to occur in 4.9% of the population. People can lower
their heart disease risk by losing as little as 10 to 20 pounds. An altering pattern of
weight gain and weight loss, however, is associated with an increased risk for coronary
artery disease.
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DIABETES
Since 1990 the prevalence of people diagnosed with diabetes increased by 61%. In
addition, the prevalence of diabetes has increased by 8% since 2000 to 2001.
Contributing to these statistics is the increased frequency of obesity and sedentarylifestyles. A fasting blood glucose level of more than 126 mg/dl or a routine blood
glucose level of 180 mg/dl and glucosuria signals the presence of diabetes and
represents an increased risk for coronary artery disease. Clients with diabetes have a
two to four fold higher prevalence, incidence, and mortality from all forms of
coronary artery disease.
STRESS
A persons response to stress may contribute to the development of coronary artery
disease. Some researchers have reported a relationship between coronary artery
disease risk and stress levels, health behaviors, and socioeconomic status. Stress
response appears to increase coronary artery disease risk through its effect on major
risk factors. For example, some people respond to stress by overeating or by starting or
increasing smoking. Stress is also associated with elevated blood pressure. Although
stress is unavoidable in modern life, an excessive response to stress can be a health
hazard. Significant stressors include major changes in residence, occupation, or
socioeconomic status.
HOMOCYSTEINE LEVELS
Researchers have reported that elevated levels of plasma Homocysteine (an amino
acid produced by the body) are associated with an increased risk of coronary artery
disease. Scientists do not know whether homocysteine directly or indirectly increases
coronary artery disease risk, however, because homocysteine levels are related to renalfunction, smoking, fibrinogen, and C reactive protein (CRP). Elevated homocysteine
levels can be reduced by treatment with folic acid, vitamin B6, and vitamin B12. Experts
currently recommend that homocysteine levels be measured in people with a history of
premature coronary artery disease, stroke, or both in the absence of other risk factors.
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after stopping the stressful activity. In some people, especially women, this pain
may be fleeting or sharp and noticed in the abdomen, back or arm.
Shortness of breath. If your heart can't pump enough blood to meet your body's
needs, you may develop shortness of breath or extreme fatigue with exertion.
Heart attack. If a coronary artery becomes completely blocked, you may have a
heart attack. The classic signs and symptoms of a heart attack include crushing
pressure in your chest and pain in your shoulder or arm, sometimes with
shortness of breath and sweating. Women are somewhat more likely than men
are to experience less typical signs and symptoms of a heart attack, including
nausea and back or jaw pain. Sometimes a heart attack occurs without any
apparent signs or symptoms.
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PATHOPHYSIOLOGY (CLIENTCENTERED)
Schematic Diagram
Non-modifiable Factors:
Age (older adults)
Gender (male)
Hereditary
Modifiable Factors:
Physical Inactivity
Stress
High fat diet
Alcohol drinking
Thrombus formation
Activation latelet
M ocardial ischemia Anaerobic metabolism
Lactic Acid Production
Acidosis
Prolonged unrelieved ischemia
Change in the condition of the plaque in the coronary artery
An ina
M ocardial cell death
Altered repolarization Release of lysosomal enzymesConduction
system disorder
Heart Contractilit
SNS Stimulation LV Function
Elevated ST
segment D srh thmias
September 18, 2013
he patient has
ccasional PVC.
On
Septem
18, 2
the pa
verbalizdifficulty
breathin
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NONMODIFIABLE FACTORS (CLIENTCENTERED)
HEREDITARY
Children whose parents had heart disease are at higher risk for coronary artery
disease. This increased risk is related to genetic predisposition to hypertension,
elevated lipid levels, diabetes and obesity, all of which increase the risk f coronary
artery disease.
AGE
Age influences both the risk and the severity of coronary artery disease.
Symptomatic coronary artery disease appears predominantly in people older than 40
years of age and 4 of 5 people who die of coronary artery disease are age 65 years or
older.
GENDER
Coronary artery disease is the number one killer of both men and women. In 1999
mortality from coronary artery disease was almost equal for men and women. Men are
at higher risk for heart attacks at younger ages.
Decreased
CO
Increased
Oxygen Demand
Tachypnea
September 18, 201
The patie
manifested palenes
of skin, conjunctiva
body weakness an
dry mucou
membrane. Rale
and crackles wer
also heard durin
auscultation.
September 18, 2013
The patient manifested
increased respiratory rate
of 31cpm
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MODIFIABLE FACTORS
PHYSICAL INACTIVITY
In the United States about 25% of adults report no leisure time physical activity,
even though regular aerobic exercise is important in preventing heart and blood vessel
disease. There is an inverse relationship between exercise and the risk of coronary
artery disease. Those who exercise reduce their risk of coronary artery disease
because they have (1) higher HDL levels; (2) lower LDL cholesterol, triglyceride and
blood glucose levels; (3) greater insulin sensitivity; (4) lower blood pressure; and (5)
lower body mass index. The AHA recommends 30 to 60 minutes of physical activity on
most days of the week.
STRESS
A persons response to stress may contribute to the development of coronary artery
disease. Some researchers have reported a relationship between coronary artery
disease risk and stress levels, health behaviors, and socioeconomic status. Stress
response appears to increase coronary artery disease risk through its effect on major
risk factors. For example, some people respond to stress by overeating or by starting or
increasing smoking. Stress is also associated with elevated blood pressure. Although
stress is unavoidable in modern life, an excessive response to stress can be a health
hazard. Significant stressors include major changes in residence, occupation, or
socioeconomic status.
HIGH FAT DIET
The vessels that bring blood to the heart are called the coronary arteries. They are
like narrow tubes. A fatty substance called plaque (say this: plak) can build up in these
arteries and make them narrow, so less blood gets to the heart. A diet high in saturated
fat greatly increases your risk of heart disease. Saturated fat increases your LDL
cholesterol. LDL cholesterol is bad cholesterol.
SIGNS AND SYMPTOMS
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Pain and discomfort are the main symptoms of angina. Angina often is described
as pressure, squeezing, burning, or tightness in the chest. The pain or discomfort
usually starts behind the breastbone. Pain from angina also can occur in the
arms, shoulders, neck, jaw, throat, or back. The pain may feel like indigestion.
(September 18, 2013)
Difficulty of breathing due to tightness of chest brought about interruption in the
artery.
Pallor manifested on September 18, 2013 due to poor perfusion, poor venous
return and decreased oxygen level in the blood.
Restlessness manifested on September 18, 2013 caused by loss of oxygen and
nutrients to the myocardial tissue because of inadequate coronary blood flow.
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PLANNING (NURSING CARE PLAN)
Problem#1: Ineffective airway clearance related to retained secretions due to decreased cardiac output
Assessment Diagnosis Scientific
Explanation
Objective Nursing
Intervention
Rationale Expected
Outcome
S=
O=The patient
may manifest:
-restlessness
-Increased RR
-dyspnea
-cyanosis
-excessive
sputum
-rales
-crackles
-fatigue
Ineffectiveairway
clearance
related to
retained
secretions
When mucussecretion and
mucus
clearance are
not in
balance,
excessive
airway mucus
can cause
serious
problems.
This condition
is called
impaired
airway
clearance.
Short term:
After 2-3
hours of
nursing
interventions
, the patient
will verbalize
understandin
g of disease
process.
Long term:
After two
days of
nursing
interventions
1. assesspatients
condition
2. monitor
and record vital
signs.
3. encourage
deep breathing
exercises
4. elevate headof bed and
change position
every 2 hours
5. encourage
hydration
6. balance
1. todetermine
possible
problems
2. for
baseline data
3. To maximize
effort
4. to decrease
pressure in thediaphragm and
enhance
ventilation
5. to loosen
secretion
6. to reduce
Short term:
The patient shall
have verbalized
understanding of
disease process.
Long term:
The patient shall
have maintained
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Excess, often
sticky mucus
may
accumulate in
the airways inconditions as
varied as
cystic fibrosis,
cerebral
palsy, and
chronic
obstructive
pulmonary
disease
bronchiectasi
s. Retained
secretions
are a
universal
problem in
people with
the patient
will maintain
airway
patency
rest periods with
activities
7. position head
appropriate for
condition
8. Instruct
patient the
importance of
ambulation
fatigue
7. to maintain
open airway
8. help maintain
adequate lung
expansion
airway patency
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carbon
dioxide.
Although
underlying
causes are
diverse,
consequence
s are the
same:
vulnerable
individuals
are caught up
in the vicious
cycle of
recurrent,
ever-worsening
episodes of
inflammation,
pulmonary
infection,
increased
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production of
excess
mucus, and
airway
obstruction,
lung damage,
and
respiratory
failure.
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Problem#2: Decreased Cardiac Output related to Increased Vascular Resistance
ASSESSMENT DIAGNOSIS SCIENTIFIC
EXPLANATION
OBJECTIVE NURSING
INTERVENTIONS
RATIONALE EXPECTED
OUTCOME
S-
O-The patientmay manifest:
-Restlessness
-Increased BP
-Cold clammy
skin
-Decreased
peripheral
pulses
-Dyspnea
Decreased
cardiac
output r/t
increased
vascular
resistance
CAD causes
narrowing of
blood vessels.
This condition
leads to intense
pressure exerted
on the walls of the
blood vessels.
The bodys
compensatory
mechanism is to
increase theworkload of the
heart and thus the
patient has
decreased
cardiac output
Short term:
After 2-3 hoursof nursing
interventions,
the patient will
verbalize
understanding
of disease
process.
Long term:
After two days
of nursing
interventions
the patient will
participate in
activities to
decrease in the
1. Assess patients
condition
2. Monitor and
record vital
signs
3. Encourage
patient toverbalize
concerns
4. Encourage
patient to
change position
1. To
determine
possible
problems
2. To obtain
baseline
data
3. To make
client
express his
feelings
4. To improve
venous
return
Short term:
The patientshall have
verbalized
understanding
of disease
process.
Long term:
The patient
shall have
participated in
activities to
decrease in
the hearts
workload
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Problem#3: Ineffective Tissue Perfusion related to decreased cardiac output
ASSESSMENT NURSING
DIAGNOSIS
SCIENTIFIC
EXPLANATION
PLANNING INTERVENTIONS EXPECTED
OUTCOME
S-
O- The patient
manifested the
following:
-Shortness of
breath
-Fatigue
- The patient
may manifest:
-Pallor
Ineffective tissue
perfusion related to
decreased cardiac
output secondary
to Coronary Artery
Disease
During a chest
pain, vessels of
the heart, such as
the coronary
arteries, can
become occluded
with intravascular
plaques. The
heart does not
absorb blood
through the
myocardial wall.Instead, blood is
pumped through
the heart's own
vasculature
during the
relaxation
Short term:
After 3 hours of
nursing
interventions, the
patient will be
able to
demonstrate
behaviors on
how to have
effective airways.
Long term:
After 1- 2 days of
nursing
interventions, the
1. Established
therapeutic
relationship.
2. Assessed pt.s
condition.
3. Monitored and
recorded vital
signs.
4. Performed
morning care
5. Noted color
andtemperature of
the skin.
6. Monitored
peripheral
pulse.
7. Provided a
Short term:
The pt. shall have
demonstrated
behaviors on how
to have effective
airways.
Long term:
The patient shall
be free from
shortness of
breath.
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-Cool
temperature
-Decrease
pulse
-Decrease
urine output
(diastole) period
between heart
beats. An
occlusion of a
blood vessel is
known by the
clinical
designation
"thrombus." If a
cardiac plaque
breaks off from
one vessel and
becomes lodged
in another vessel,
the tissue-fed
oxygen-rich bloodis inadequately
perfused.
patient will be
able to
demonstrate
adequate tissue
perfusion as
evidenced by
palpable
peripheral
pulses, warm
and dry skin,
adequate urinary
output, and the
absence of
respiratory
distress.
warmth
environment.
8. Encouraged
active rom.
9. Monitored
urine output.
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Problem#4: Acute Pain
ASSESSMENT NURSING
DIAGNOSIS
SCIENTIFIC
EXPLANATION
PLANNING INTERVENTIONS EXPECTED
OUTCOME
S-
O- The patientmanifested:
-Pain scale of 8/10
-Increase
respiratory rate
-Chest pain
-The patient may
manifest:
Acute Pain Coronary artery
disease (CAD) is
caused by a
narrowing of the
arteries that
supply the heart
muscle with
blood. When the
arteries narrow,
blood flow is
reduced. The
reduced bloodflow causes the
heart muscle to
receive less
oxygen than it
needs to function
properly. When
Short Term:
After 3 hours of
Nursing
Interventions,
the patient,
pain scale will
decrease from
8 to 6.
Long term:
After 2 days of
Nursing
Interventions,
the patient will
demonstrate
behavior of
1. Established
therapeutic
relationship
2. Assessed
pt.s
condition.
3. Monitored
and recorded
vital signs
4. Assessed
pains location
andintensity/seve
rity arising
with.
5. Provided
diversional
activities like
Short term:
The patient shallhave identified
and used
techniques to
enhance activity
intolerance.
Long term:
The patient shall
have participated
willingly in
necessary
activities.
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-Restlessness
-Irritability
- (+) guarded
behavior
-(+) facial grimaces
-Crying
-v/s change
-Diaphoresis
-Sleep disturbance
ischemia occurs
patients typically
develop angina or
chest pain
originating from
the heart. It has
been described as
chest pain or
discomfort that
has a squeezing
or pressure-like
quality, usually felt
behind the
breastbone
(sternum), but
sometimes felt inthe shoulders,
arms, neck, jaws,
or back.
being relieved
from pain and
will be free
from the
complications
of the
condition.
having
conversation
w/ the
patient.
6. Stressed to
patient the
importance of
providing
adequate rest
period to the
patient.
7. Administered
meds as
ordered.
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Problem#5: Fatigue related to Poor Physical Condition
ASSESSMENT DIAGNOSIS SCIENTIFIC
EXPLANATION
OBJECTIVE NURSING
INTERVENTIONS
RATIONALE EXPECTED
OUTCOME
S-The patient
may verbalize
overwhelming
lack of energy
O-The patient
may manifest:
-Lethargy or
drowsiness
-Disinterest in
surroundings
-Decreased
performance
Fatigue
related to poor
physical
condition
Fatigue is an
overwhelming
sense of
exhaustion
resulting to
decreased
capacity to
perform activities
at the usual level.
This is due to the
patients poor
physical conditionbrought about by
the disease
condition.
Short term:
After 2 hoursof nursing
interventions
, the patient
will be able
to verbalize
understandin
g of
condition
and
causative
factors.
Long term:
After 3 days
of nursing
interventions
, the patient
1. Monitor and
record vital
signs
2. Determine
ability to
participate in
activities
3. Establish
realistic activity
goals with client
1. To obtain
baseline
data
2. To
enhance
commitme
nt to
promoting
optimal
outcomes
3. To
maximize
participatio
n
Short term:
The patientshall have
verbalized
understanding
of condition
and causative
factors.
Long term:
The patient
shall have
performed
ADLs and
participate in
desired
activities/level
of activity.
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-Listlessness
-Compromised
concentration
-Introspection
will be able
to perform
ADLs and
participate in
desired
activities/lev
el of activity.
4. Plan care to
allow
individually
adequate rest
periods,
schedule
activities for
periods when
client has the
most energy
5. Provide
environment
conducive to
health
4. To
encourage
patients
cooperatio
n
5. To
maintain/in
crease
strengthand
muscle
tone and to
enhance
sense of
well-being.
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6. Give medication
as ordered
6. To lessen
fatigue
Problem#6: Activity intolerance related to imbalance oxygen supply and demand
Assessment Diagnosis Scientific
Explanation
Objective Nursing
Intervention
Rationale Expected
Outcome
S=
O=The patient
may manifest:
-restlessness
-Increased RR
-cold clammy
skin
-decreased
peripheral
Activity
intolerance
related to
imbalance
oxygen
supply and
demand
Coronary artery
disease results
from the
interruption of
blood supply to
a part of the
heart, causing
heart cells to
die. Typical
symptoms
Short term:
After 2-3
hours of
nursing
interventions,
the patient will
verbalize
understanding
of disease
1. assess
patients
condition
2. monitor and
record vital
signs
3. encourage
patient to
verbalize
1. to determine
possible
problems
2. for baseline
data
3. to make client
express his
feelings
4. to improve
Short term:
The patient shall
have verbalized
understanding of
disease process.
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pulses
-pallor
-cyanosis
-fatigue
include sudden
chest pain
(typically
radiating to the
left arm or left
side of the
neck),
shortness of
breath, nausea,
vomiting,
palpitations,
sweating, and
anxiety.
Women may
experience
fewer typicalsymptoms than
men, most
commonly
shortness of
breath,
weakness, a
process.
Long term:
After two days
of nursing
interventions
the patient will
be able to
maintain her
breathing
pattern as
evidenced by:
vital signs
within the
normal range
concerns
4. encourage
patient to
change
position
every two
hours
5. encourage
patient to do
relaxation
techniques
6. Encourage
patient to
engage in
diversional
activities
such as
chatting with
family and
friends.
7. reinforced
venous return
5. to reduce
stress
6. to divert
attention and
help patient
lessen
experienced
pain and
anxiety
7. to prevent
further
complications
of the disease
8. to prevent
overexertion
9. to reduce
fatigue
10. to conserve
energy
Long term:
The patient shall
have maintained
her breathing
pattern as
evidenced by: vital
signs within the
normal range
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feeling of
indigestion, and
fatigue resulting
in
musculoskeletal
impairment
and/or pain,
cognitive
impairment and
anxiety,
metabolic
abnormalities.
low salt and
low fat diet
8. adjust
activities
9. balance rest
periods with
activities
10. increase
activity levels
gradually
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C. IMPLEMENTATION
1. MEDICAL MANAGEMENT
a. IVFs, NGT feeding, Nebulization, TPN, Oxygen therapy, etc
Medical
Management/Treatment
Date Ordered
Date PerformedDate Changed
General Description Indication
OrPurposes
Clients Response to
Treatment
D5W 500ccx KVO Date ordered:
09/17/2013
Date performed:
09/17/2013
D5W is initially infused,
it is an isotonic
solution, but when the
dextrose is
metabolized, the
solution actually
becomes hypotonic,a
solution where
osmotic pressure
causes fluid to shift
into cells.
Lactated Ringers and
5% Dextrose, is
indicated to Mr.
Corona D. Sease as
a source of water and
calories or as an
alkalinizing agent.
Mr. Corona D. Sease
was able to maintain
good hydration status
as evidenced by good
skin turgor and moist
oral mucous
membrane.
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Nursing Responsibilities
Prior
Verify the Doctors order
Prepare all the equipment needed
Do not administer unless solution is clear and container is undamaged.
Properly label the IV fluid.
Explain the purpose of the procedure and what to expect
During
Provide patient's safety
Locate for a good vein
Apply antiseptic to the puncture site
Check if it is the correct type of IV fluid
After
Secure the IV tubing
Discard unused portion
Regulate the IV fluid as prescribed
Document the procedure
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Medical
Management/
Treatment
Date Ordered
Date Performed
Date Changed
General Description Indication
Or
Purposes
Clients Response to
Treatment
O2 Inhalationregulated at 2-3 LPM
Date ordered:09/17/2013
Date performed:
09/17/2013
Inhalation of oxygenaimed at restoring
toward normal any
physiologic alterations
of gas exchange in the
cardiopulmonary
system, as by the use
of a respirator, nasal
catheter, tent,
chamber, or mask.
O2 Inhalation, isindicated to Mr.
Corona D. Sease as
a source of
supplementary
oxygen.
Mr. Corona D. Seasewas able to maintain
normal respiratory
breathing pattern.
Nursing Responsibilities
Prior
Verify the Doctors order
Prepare all the equipment needed
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During
Provide patient's safety
Place properly on patients nose
Regulate at 2-3LPM as ordered
After
Document and record
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b. Drugs
1. Aspirin
Name of
Drug; Genericname; Brand
name
Date
Ordered/Date Taken
Date
Changed
Route, Dosageand Frequency
General Action,
Mechanism ofAction
Indication or
Purposes
Clients
Response tothe Medication
with Actual
Side Effect
Generic name:
Aspirin
(acetylsalicylic
acid)
Brand Name:
Asaphent
Date ordered:
08/17/2013
Date taken:
08/17/2013
PO, 80 mg 1 tab , OD General action:
NSAID;
Anti-platelet
aggregation
Mechanism of
action:
Inhibits
prostaglandin
synthesis,
resulting in anti-
inflammatory
Indicated for
Mr. Corona
D. Sease for
treatment of
mild to
moderate
pain;
reduction of
risk of death
or unstable
angina
pectoris, or
Mr. Corona D.
Sease
responded well
in the drug as
evidenced by
normal platelet
count.
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Nursing responsibilities
Prior
Verify the doctor's order
Give necessary information to the patient
Obtain a history of previous use and reactions to medication.
During
Administer medication as ordered
Verify/check the medication again
activity, and
platelet
aggregation
inhibition;
reduces fever by
acting on the
brain's heat-
regulating center
to promote
vasodilation and
sweating.
recurrent
transient
ischemia
attacks
(TIAs).
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After
Monitor fungal/bacterial super infection
Monitor sodium level
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2. Clopidogrel
Name of drug;
Generic Name;
Brand Name
Date ordered/
Date Taken/
Date Changed
Route, Dosage
and Frequency
General Action,
Mechanism of
Action
Indication or
Purposes
Clients
Response to
the medication
with Actual
Side Effect
Generic name:
Clopidogrel
Brand name:
Plavix
Date ordered:
09/17/2013
Date taken:
09/17/2013
PO, 75mg/tab, 1 tab
OD
General action:
Inhibits platelet
aggregation by
blocking AD
Preceptors on
platelets ,preventing
clumping of platelets
Mechanism of
action:
It was found to inhibit
prostaglandin
synthesis and to
complete for binding
It was indicated
for Mr. Corona D.
Sease for
prevention of
thrombosis along
with Aspirin and
to prevent
vascular
ischemic events.
Mr. Corona D
Sease
responded we
in the drug a
evidenced b
normal platele
count.
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Nursing Responsibilities
Prior
Check the doctors order three times and verify the patient
Check the label of the drug, its name and its expiration date.
Explain the importance of compliance in medication regimen