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I. INTRODUCTION
A. Overview of the Case
Myocardial ischemia occurs when blood flow to your heart muscle is
decreased by a partial or complete blockage of your heart's arteries (coronary
arteries). The decrease in blood flow reduces your heart's oxygen supply. Myocardial
ischemia, also called cardiac ischemia, can damage your heart muscle, reducing its
ability to pump efficiently. A sudden, severe blockage of a coronary artery may lead
to a heart attack. Myocardial ischemia may also cause serious abnormal heart
rhythms.
More than 6 million Americans live with myocardial ischemia, or angina. The
term refers to chest pain or discomfort that occurs when the heart muscle is not
getting enough oxygen-rich blood for a short period of time. The inadequate blood
flow is caused by narrowed coronary arteries, which are the vessels that supply
blood to the heart. A bout of myocardial ischemia is not a heart attack, but it means
that you're more likely to have a heart attack than someone who doesn't have
myocardial ischemia.
As mentioned, myocardial ischemia is caused by a temporary lack of oxygen-
rich blood to the heart muscle. This decrease in blood flow can happen for a number
of reasons and will vary based on the type. In most cases, the cause of myocardial
ischemia is coronary artery disease (CAD), or what most people refer to as just heart
disease. Sometimes, other types of heart disease (such as aortic stenosis) or
uncontrolled high blood pressure (hypertension) can cause it.
Myocardial infarction is a common presentation of ischemic heart
disease/coronary artery disease. The World Health Organization estimated in 2004,
that 12.2% of worldwide deaths were from ischemic heart disease; with it being the
leading cause of death in high or middle income countries and second only to lower
respiratory infections in lower income countries. Rates of death from ischemic heart
disease have slowed or declined in most high income countries, although
cardiovascular disease still accounted for 1 in 3 of all deaths in the USA in 2008. In
contrast, ischemic heart disease is becoming a more common cause of death in the
developing world.
| CAD – HCVD 1
B. Objectives of the Study
As a fourth year (N107) nursing students of Liceo de Cagayan University,
within three 32) days of nursing intervention on a client with Myocardial Infarction at
Sabal Hospital Inc., the group will be able to conduct a thorough and comprehensive
study of the assigned patient according to the data that was gathered through a
series of interviews. The condition of the aforementioned will augment and free of
possible complications from the disorder.
The completion of this case study enables the proponent to do the following:
1. To organize my patient’s data for the establishment of good background
information
2. To show the family history as well as the history of past and present illness for
the knowledge of what could be the predisposing factors that might contribute
to the patient’s illness
3. To review Patient’s Chart and carry out Medical Orders; thus, relate these
interventions to the alleviation of the Patient’s health condition
4. To present the different results of the patient’s diagnostic exams together with
the comparison of normal values for the understanding of what changes
during the disease
5. To discuss the Anatomy, Physiology and Pathophysiology of the Patient’s
health condition
6. To present the data from the nursing assessment performed on the patient
using the cephalocaudal approach for the good overview of her over-all health
7. To identify Patient’s Clinical Manifestations as basis for a specific,
measurable, attainable, realistic and time-bounded Actual and Ideal Nursing
Care Plans.
8. To impart appropriate health teachings specifically for the patient to promote
wellness and appropriate discharge plan
9. To have an over-all conclusion and recommendation about the care study
| CAD – HCVD 2
C. Scope and Limitation of the Study
The case presentation merely covers data that have been gathered through
interview per assessment tool and chart referral on the day of the assessment phase
in loading assigned patients and in the succeeding days of the rotation, in the care
formulated and intervened to its progress as the week’s rotation ended. Thus, it is
limited to the days in the rotation the student nurse interacted with the client in the
hope to gather the necessary data to support the presentation which is not enough to
acquire a bulk of specific details.
| CAD – HCVD 3
II. HEALTH HISTORY (NURSING ASSESSMENT)
A. Patient’s Profile
Client’s Name : Patient A
Age : 62 years old
Address : Sto. Nino, Brgy. 31 Cogon, Cagayan de Oro City
Civil Status : Married
Sex : Male
Nationality : Filipino
Religion : Aglipay
Birthday : May 8, 1950
Height : 167.64 cm.
Weight : 55 Kgs.
Informant : Patient
Date of Admission : June 25, 2012
Time of Admission : 4:30PM
Admitting Diagnosis : T/C Myocardial Infarction with CAD – HCVD
Attending Physician : Dr. Jorge Bedayo, M.D.
| CAD – HCVD 4
B. Personal History/Family History
Patient A is not allergic to any food and drug. He occasionally smokes and
doesn’t drink alcohol. Patient A has a history of being hypertensive and was
previously diagnosed of having a Cardiovascular Disease.
C. History of Present Illness
Few hours prior to admission, noted chest tightness and shortness of breath.
D. Chief Complains
Patient A, a 62 year old male, was admitted last June 25, 2012 at exactly
4:30PM due to his complaint which is tightening of the chest and shortness of breath.
| CAD – HCVD 5
III. DEVELOPMENTAL DATA
The rate of person’s growth and development is highly individual: however the
sequence of growth and development is predictable. Stages of growth usually
correspond and theories of achieving these developmental tasks are used as
framework that the nurse can use to evaluate a person’s general accomplishments.
Aging begins at birth and continues unto birth. Our client belongs to the adult
age (57 years old and above) in which men and women reach the peak of their
influence upon society, and at the same time the society makes its maximum
demands upon them for social and civic responsibility. It is the period of life to which
they have looked forward during their adolescence and early adulthood. And the time
passes so quickly during this full and active middle age the beginning of later
maturity with surprise and a sense of having finished the journey while they were still
preparing to commence it.
Erikson’s theory
Erikson’s theory of psychosocial development is one of the best-known theories
of personality in psychology. Similar to Freud, Erikson believed that personality
develops in a series of stages. Unlike Freud’s theory of psychosexual stages,
Erikson’s theory describes the impact of social experience across the whole lifespan.
One of the main elements of Erikson’s psychosocial stage theory is the development
of ego identity.
Ego identity is the conscious sense of self that we develop through social
interaction. According to Erikson, our ego identity is constantly changing due to new
experience and information we acquire in our daily interactions with others.
In addition to ego identity, Erikson also believed that a sense of competence also
motivates behaviors and actions. Each stage in Erikson’s theory is concerned with
becoming competent in an area of life. If the stage is handled well, the person will
feel a sense of mastery. If the stage is managed poorly, the person will emerge with
a sense of inadequacy. In each stage, Erikson believed people experience a conflict
that serves as a turning point in development. In Erikson’s view, these conflicts are
centered on either developing a psychological quality or failing to develop that
quality. During these times, the potential for personal growth is high, but so is the
potential for failure.
| CAD – HCVD 6
Our patient belongs to generativity vs. stagnation which generativity derives from
the word generation, parents and children specifically the unconditional giving that
characterizes positive parental love and care for their offspring. In this stage
creativity, productivity and concern for others happens, this is an indicator of a
positive resolution. Indicators of negative resolution are self-indulgence, self
concern, lack of interests and commitments. But in the case of our patient, her
attention is focused in her work and in caring of her children. Giving unconditional
support for her children and also her work is an important thing to do. Stagnation is
an extension of intimacy which turns inward in the form of self-interest and self-
absorption.
HAVIGHURT'S DEVELOPMENTAL TASK THEORY
In this stage, a task which arises at or above a certain period in the life of an
individual, successful achievement of which leads to his happiness and to success
with later tasks, while failure leads to unhappiness to an individual, disapproval by
society, and difficulty with later tasks.
Our patient belongs to the later maturity age period (57 and over). She is
adjusting to the decrease of physical and strength, establishing an explicit affiliation
with one's age group. She was able to meet social and civil obligations and
established satisfactory physical living arrangements.
Kohlberg’s Stages of Moral Development
The age of my client falls under the post-conventional stage of moral
development. The person’s lives autonomously and defines moral values and
principles that are distinct from personal identification with group values. He lives
according to principles that are universally agreed on and that the person considers
appropriate for life. In this case, my client believes and applies higher moral
principles such as equality, justice, or due process. The social rules are not her basis
for decisions and behaviour; it is based on internalized rules, on conscience rather
than social laws, and on self-chosen ethical and abstract principles that are
universal, comprehensive, and consistent.
| CAD – HCVD 7
IV. MEDICAL MANAGEMENT
A. Doctor’s Order
Date/Time Ordered Order RationaleJune 25, 2012(4:30pm) Please admit to room of
choice under the service of Dr. Bedayo
TPR q4
DAT
Venoclysis of PLR 1L @20gtts/min
Labs:CBC
U/A
Hgt
ECG 12 lead
-For further observation of the pts’ condition
-To monitor vital signs so that any discrepancies will be referred as follows
-Proper nutrition and support body’s nutritional needs.
-An Isotonic solution used to supply water and electrolytes (e.g., calcium, potassium, sodium, chloride), either with or without calories (dextrose), to the body.
- It used to determine the quantity of each type of blood cell in a given sample of blood
- to detect and measure various compounds that pass through the urine
- used to determine if the blood sugar level has been High for a long time.
- to measure the rate and regularity of heartbeats, as well as the size and position of the chambers, the presence of any damage to the heart, and the effects of drugs or devices used to regulate the heart
-To evaluate kidney function in a wide range of
| CAD – HCVD 8
(5:30pm)
BUN
FBS
Meds:Gaviscon 10cc @ 9:3:9
Lilac 10cc @ HS
Simvastatin 20mg OD
I and O qshift
O2 inhalation @3LPM
v/s q4
For electrolytes
For daily ECG 6am
Continue Metoprolol 100mg 1tab OD
circumstances, to help diagnose kidney disease
- to diagnose if pt has diabetes mellitus
-Antacid, treatment for heartburn
-gastrointestinal hepatobiliary drugs, treatment for hepatic encephalopathy
-HMG CoA reductase inhibitortreatment for coronary heart disease, diabetes, peripheral vascular disease, or history of stroke or other cerebrovascular disease, simvastatin is prescribed for reducing the risk of mortality by reducing death from coronary heart disease, reducing nonfatal myocardial infarction (heart attack) and stroke,
- To know if patient has excess fluid or is having dehydration.
-for supplemental purposes
- To monitor vital signs so that any discrepancies will be referred as follows
- to know any abnormalities of pts’ electrolytes
- to monitor pts’ heart condition
- Beta blockers, used in treatment of cardiovascular
| CAD – HCVD 9
(8:20pm)
June 26, 2012
Give clopidogrel 75mg 4tabs now
Give Aspilet (ASA) 4tabs now
Continue Omeprazole 40mg IVTT OD
Start Vessel Due 1amp IVT now then q12
Imdur 60mg ½ tab BID
NPO until tomorrow
Monitor BP q2
May have soft diet
For HbA1c in am
Omeprazole 40mg IVTT q12
For repeat CBC tomorrow
Simvastatin 20g OD
disease especially hypertension.
-Anticoagulants, used for preventing strokes, heart attacks, unstable angina
-Anticoagulant, treatment for transient ischemic attacks and stroke
- Proton pump inhibitor, treatment of frequent heartburn
- Antithrombotic, treatment for vascular pathologies with thrombotic risk.
- Antianginal agent, to prevent angina attacks
- for FBS test
-for close monitoring of pts’ blood pressure
- Proper nutrition and support body’s nutritional needs.
-to know pts’ average amount of sugar in the blood for 3mos.- Proton pump inhibitor, treatment of frequent heartburn
- to know if there is any changes of pts’ blood count
-HMG CoA reductase inhibitortreatment for coronary heart disease, diabetes, peripheral vascular disease, or history of stroke or other cerebrovascular disease, simvastatin is prescribed for reducing the risk of mortality
| CAD – HCVD 10
June 27, 2012(5:40am)
Vestar 35mg 1tab BID
Lilac 10cc HS
Take note of stool color,clarity
Refer for blood typing
Refer 2”U” packed RBC x-match and transfuse
Isordil 5mg SL PRNIf not subside, give tramadol ½ amp IVTTInstruct pt. to rest.
by reducing death from coronary heart disease, reducing nonfatal myocardial infarction (heart attack) and stroke,
-Antiangina, treatment for angina attacks
- gastrointestinal hepatobiliary drugs, treatment for hepatic encephalopathy
-to know any abnormalities to pts; stool and to refer it immediately to the physician
-for blood transfusion purposes
-to replace blood loss
-Antianginal drug, treatment for angina attacks
| CAD – HCVD 11
B. Laboratory Results
COMPLETE BLOOD COUNT
PARAMETER RESULT NORMAL VALUES UNIT
Hemoglobin 60 140-150 g/dl
RBC 2.69 4.2-5.6 x 10 12/L
Hematocrit 0.24 .40-.54 %
MCV 90 80-100 L
MCH 30 27-33 pg
MCHT 33 32-36 g/dl
Platelet 271 150-400 x 10 9/L
WBC 6.32 3.8-10.6 x 10 9/L
DIFFERENTIAL COUNT
Neutrophils 0.60 .48-.73 %
Lymphocytes 0.28 .20-45 %
Monocytes 0.10 .00-.10 %
Eusinophils 0.02 .00-.05 %
Basophils 0.0 .00-.020 %
INDICATION:
Result shows that there is a decrease of hemoglobin, RBC and hematocrit.
Decrease of hemoglobin and RBC means that the patient has anemia and the body may not be getting the oxygen it needs. A low level of hematocrit represents anemia low levels of hematocrit could be dangerous if it leads to the reduction of oxygen supply to various parts of the body.
Date: 6-25-12 5:22pm
| CAD – HCVD 12
COMPLETE BLOOD COUNT
PARAMETER RESULT NORMAL VALUES UNIT
Hemoglobin 90 140-150 g/dl
RBC 2.95 4.2-5.6 x 10 12/L
Hematocrit 0.27 .40-.54 %
MCV 92 80-100 L
MCH 30 27-33 pg
MCHT 33 32-36 g/dl
Platelet 320 150-400 x 10 9/L
WBC 5.65 3.8-10.6 x 10 9/L
DIFFERENTIAL COUNT
Neutrophils 0.54 .48-.73 %
Lymphocytes 0.3 .20-45 %
Monocytes 0.12 .00-.10 %
Eusinophils 0.04 .00-.05 %
Basophils 0.0 .00-.020 %
INDICATION
Result shows that there is a decrease of hemoglobin, RBC and hematocrit. There is an increase level of monocytes.
Decrease of hemoglobin and RBC means that the patient has anemia and the body may not be getting the oxygen it needs. A low level of hematocrit represents anemia low levels of hematocrit could be dangerous if it leads to the reduction of oxygen supply to various parts of the body.
Levels of monocytes in the blood tend to rise when someone has an infection, because more of these cells are needed to fight it. Monocytes can also increase in response to stress and other factors. A high monocyte count may be referred to as monocytosis, and it is typically addressed by determining why the count is so high, and addressing the problem. For example, if monocytes are elevated
| CAD – HCVD 13
because of an inflammation caused by a viral infection, the patient would be given medication to kill the virus and bring down the inflammation.
DATE: 6-25-12
HGT
RESULT: 114mg/dl
INDICATION: NORMAL
URINALYSIS:
COLOR: yellow
Sp.gravity: 1.020
Sugar: negative
Transparency: hazy
pH: 6.0
Albumin: negative
Puss cells: 0-1
Epithelial cells: few
Mucus threads : negative
Bacteria: few
INDICATION: NORMAL
TROP T-
RESULT: POSITIVE
INDICATION:
Because troponin is specific to the heart, even slight elevations may indicate some degree of damage to the heart. When a person has significantly elevated troponin levels and, in particular, a rise and/or fall in the results from a series of tests done over several hours, then it is likely that the person has had a heart attack or some other form of damage to the heart.
| CAD – HCVD 14
Date: 6-26-12
BLOOD TYPE
Results: “O” Rh (+)
INDICATION:
Type "O", however, does not have any antigens in the blood.Because of this, people with type O blood are called universal donors. It means you can give blood to any of the other blood types, however the person with type O blood can only recieve blood from other type O's.The positive means that your blood has the RhD antigen. People with negative blood can only recieve negative blood, but people that are 'RhD positive' can recieve both postive and negative blood
| CAD – HCVD 15
V. ANATOMY AND PHYSIOLOGY WITH PATHOPHYSIOLOGY
A. Anatomy And Physiology of Heart
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.
The 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.
Cardiac Chambers
Right AtriumThe superior vena cava and inferior vena cava drain systemic venous blood
into the posterior wall of the right atrium. The internal wall of the right atrium is composed of a smooth posterior portion (into which the vena cavae and coronary sinus drain) and a ridgelike, muscular anterior portion. The coronary sinus drains coronary venous blood into the anteroinferior portion of the right atrium. The thebesian valve is located at the orifice of the coronary sinus. The limbus of the fossa ovalis is located on the medial wall of the right atrium and circumscribes the septum primum of the fossa ovalis anteriorly, posteriorly, and superiorly.
| CAD – HCVD 16
The right auricle is separated from the right atrium by a shallow posterior vertical indentation on the right atrium (ie, the sulcus terminalis) and, internally, by a vertical crest (ie, the crista terminalis). The crista terminalis separates the right atrium into trabeculated and nontrabeculated portions.
Congenital anomalies of right atrial components can be associated with clinically significant cardiac malformations. For example, in patients with tricuspid atresia, the eustachian and thebesian valves may be so enlarged that they physically separate the right atrium into 2 distinct sections. Other variations include juxtaposition of both atrial appendages and malpositioning of both appendages.
Left Atrium
The 4 pulmonary veins drain into the left atrium. The flap valve of the fossa ovalis is located on the septal surface of the left atrium. The appendage of the left atrium is consistently narrow and long; recognition of this appendage is the most reliable way to differentiate the left atrium from the right atrium. The left atrial appendage is the only trabeculated structure in the left atrium because, unlike the right atrium, the left atrium has no crista terminalis.
Right Ventricle
The right ventricle receives blood from the right atrium across the tricuspid valve, which is located in the large anterolateral (ie, sinus) portion of the right ventricle. The right ventricle discharges blood into the pulmonary artery across the pulmonic (semilunar) valve located in the outflow tract (infundibulum). The inflow tract (sinus) and outflow tract (infundibulum) of the right ventricle are widely separated. Internally, the sinus area and infundibulum contain coarse trabeculations.
The septal portion of the right ventricle has 3 components: (1) the inflow tract, which supports the tricuspid valve; (2) the trabecular wall, which typifies the internal appearance of the right ventricle; and (3) the outflow tract, which itself is subdivided into 3 components, namely, the conal septum, septal band division, and trabecular septum. Of these 3 subdivisions, the conal septum is clinically significant because it can be malpositioned in patients with congenital disorders (eg, double outlet right ventricle).
Lateral to the conal septum, the parietal extension of the infundibular septum and the infundibular fold comprise the crista supraventricularis. Ventricular septal defects (VSDs) commonly occur in the area between the sinus and the outlet tract of the right ventricle. However, because the surface of the right ventricle is trabecular, small defects of the muscular portion of the ventricular septum may be difficult to see.
The tricuspid valve is supported by a large anterior papillary muscle, which arises from the anterior free wall and the moderator band, and by several small posterior papillary muscles, which attach posteriorly to the septal band.
Left Ventricle
The left ventricle receives blood from the left atrium via the mitral (ie, bicuspid) valve and ejects blood across the aortic valve in the aorta. The left ventricle can be divided into 2 primary portions, namely, the large sinus portion containing the mitral
| CAD – HCVD 17
valve and the small outflow tract that supports the aortic (semilunar) valve. Inflow and outflow portions are closely juxtaposed, unlike in the right ventricle, in which the tricuspid and pulmonic valves are widely separated.
The free wall and apical half of the septum contain fine internal trabeculations. The septal surface is divided into a trabeculated portion (sinus) and a smooth portion (outflow). The sinus area just beneath the mitral valve is termed the inlet septum; the remainder of the sinus area is termed the trabecular septum. The outflow tract is located anterior to the anterior mitral leaflet and is part of the atrioventricular (AV) septum. Both the right half of the anterior mitral valve leaflet and the right aortic cusp attach to the septum. (In the right ventricle, only the septal tricuspid leaflet attaches to the septum.)
The left half of the anterior mitral leaflet is in direct, fibrous contact with the aortic valve at the aortic-mitral annulus. The conal septum of the right ventricle is positioned opposite the aortic valve. The mitral valve is supported by 2 large papillary muscles (ie, anterolateral, posteromedial) attached to the free wall. The anterior papillary muscle is attached to the anterior portion of the left ventricular wall, and the posterior papillary muscle arises more posteriorly from the ventricle's inferior wall.
Great Vessels and Septi
Aorta
The aorta begins at the base of the heart and typically branches to form the coronary arteries just distal to the aortic valve. In patients with cardiac malformations, the aorta almost always can be identified by tracing it back from the brachiocephalic arteries, which only very rarely originate from the pulmonary artery.
Pulmonary Artery
The main pulmonary artery branches into the pulmonary arterial system. In patients with aberrant cardiac anatomy with a patent ductus arteriosus, accurate identification of the pulmonary artery can be difficult using angiography, because the pulmonary artery becomes opaque during aortic injection. To differentiate the pulmonary artery from the aortic valve, remember that the pulmonary artery almost never gives off brachiocephalic branches.
Ventricular Septum
The ventricular septum is divided into a muscular section (inferior) and a membranous section (superior). The muscular portion makes up the left and right ventricular walls. The membranous septum, also termed the pars membranacea, is a fibrous structure partially separating the left ventricular outflow tract from the right atrium and ventricle.
Atrioventricular Septum
The atrioventricular (AV) septum, located behind the right atrium and left ventricle, is divided into 2 portions: a superior portion (membranous) and an inferior portion (muscular). Inside the left ventricle, the muscular component makes up part
| CAD – HCVD 18
of the outlet septum. The AV node lies in the atrial septum, juxtaposed to the membranous and muscular portions of the AV septum
Electrical Conduction System
The heart is composed primarily of muscle tissue. A network of nerve fibers coordinates the contraction and relaxation of the cardiac muscle tissue to obtain an efficient, wave-like pumping action of the heart.
1. Sinoatrial node (SA node)
2. Atrioventricular node (AV node)
3. Common AV Bundle4. Right & Left Bundle
Branches
The Sinoatrial Node (often called the SA node or sinus node) serves as the natural pacemaker for the heart. Nestled in the upper area of the right atrium, it sends the electrical impulse that triggers each heartbeat. The impulse spreads through the atria, prompting the cardiac muscle tissue to contract in a coordinated wave-like manner.
The impulse that originates from the sinoatrial node strikes the Atrioventricular node (or AV node) which is situated in the lower portion of the right atrium. The atrioventricular node in turn sends an impulse through the nerve network to the ventricles, initiating the same wave-like contraction of the ventricles.
The electrical network serving the ventricles leaves the atrioventricular node through the Right and Left Bundle Branches. These nerve fibers send impulses that cause the cardiac muscle tissue to contract.
Cardiac Valves
Cardiac valves are categorized into 2 groups, based on function and morphology. Mitral and tricuspid valves make up the AV group; aortic and pulmonary valves make up the semilunar group. On cross section, the aortic valve is located in a central location, halfway between the mitral and tricuspid valves. The pulmonary valve is positioned anterior, superior, and slightly to the left of the aortic valve. The
| CAD – HCVD 19
tricuspid and mitral anuli merge and fuse with each other and with the membranous septum to form the fibrous skeleton of the heart.
Mitral Valve
The AV valve of the left ventricle is bicuspid. The AV valve has a large anterior leaflet (septal or aortic) and a smaller posterior leaflet (mural or ventricular). The anterior leaflet is triangular with a smooth texture. The posterior leaflet has a scalloped appearance. The chordae tendineae to the mitral valve originate from the 2 large papillary muscles of the left ventricle and insert primarily on the leaflet's free edge.
Tricuspid Valve
The AV valve of the right ventricle has anterior, posterior, and septal leaflets. The orifice is larger than the mitral orifice and is triangular. The tricuspid valve leaflets and chordae are more fragile than those of the mitral valve. The anterior leaflet, largest of the 3 leaflets, often has notches. The posterior leaflet, smallest of the 3 leaflets, is usually scalloped. The septal leaflet usually attaches to the membranous and muscular portions of the ventricular septum.
A major factor to consider during surgery is the proximity of the conduction system to the septal leaflet. The membranous septum lies beneath the septal leaflet, where the His bundle penetrates the right trigone beneath the interventricular membranous septum. Moreover, the portion of the septal leaflet between the membranous septum and the commissure may form a flap valve over some ventricular septal defects (VSDs).
Aortic Valve
The aortic valve has 3 leaflets composed of fragile cusps and the sinuses of Valsalva. Thus, the valve apparatus is composed of 3 cuplike structures that are in continuity with the membranous septum and the mitral anterior leaflet. The free end of each cusp has a stronger consistency than the cusp. The midpoint of each free edge contains the fibrous nodulus arantii, which bisects the thin crescent-shaped lunula on either side.
The aortic sinuses of Valsalva are 3 dilations of the aortic root that arise from the 3 closing cusps of the aortic valve. The right and left sinuses give rise to the right and left coronary arteries; the noncoronary sinus has no coronary artery. The sinus of Valsalva walls are much thinner than the aortic wall, which is a factor of surgical significance; therefore, aortotomies are typically performed away from this region.
The aortic annulus is situated anteriorly to the mitral valve annulus and the anterior leaflet of the mitral valve. The cranial portion of the left atrium is interposed between the aortic and mitral valves. Anteriorly, the aortic annulus is related to the ventricular septum and right ventricular outflow tract. The His bundle courses beneath the right and noncoronary aortic valve cusps of the membranous ventricular septum. Thus, incision of the aortic annulus or septal myocardium anterior to the right coronary sinus should not interfere with the conduction system.
Pulmonary Valve
| CAD – HCVD 20
As with the aortic valve, the pulmonary valve has 3 cusps, with a midpoint nodule at the free end and lunulae on either side; a sinus is located behind each cusp. Compared with the aortic valve, the pulmonary valve has thinner cusps, no associated coronary arteries, and no continuity with the corresponding (anterior) tricuspid valve leaflet. The term used for each cusp reflects its relationship to the aortic valve, namely, right, left, and nonseptal
Coronary Arteries
The 2 main coronary arteries are the right and left. However, from a surgical standpoint, 4 main arteries are named: the left main, the left anterior descending, and the left circumflex (LCX) arteries (which are all branches of the left coronary artery) and the right coronary artery (RCA). The RCA and LCXs form a circle around the AV sulci. The left anterior descending and posterior descending arteries form a loop at right angles to this circle; these arteries feed the ventricular septum. The LCX gives off several parallel, obtuse, marginal arteries that supply the posterior left ventricle. The diagonal branches of the left anterior descending artery supply the anterior portion of the left ventricle.
The term dominance is used to refer to the origin of the posterior descending artery (PDA). When the PDA is formed from the terminal branch of the RCA (>85% of patients), it is termed a right-dominant heart. A left-dominant heart receives its PDA blood supply from a left coronary branch, usually the LCX. This is often referred to as a left posterolateral (LPL) branch.
Left Main Coronary Artery
The left main coronary artery (LCA) originates from the ostium of the left sinus of Valsalva. The LCA, which courses between the left atrial appendage and the pulmonary artery, typically is 1-2 cm in length. When it reaches the left AV groove, the LCA bifurcates into the left anterior descending (LAD) and the LCX branches. The LCA supplies most of the left atrium, left ventricle, interventricular septum, and AV bundles. The LCA arises from the left aortic sinus and courses between the left auricle and the pulmonary trunk to reach the coronary groove.
Left Anterior Descending Artery
After originating from the left main artery, the LAD artery runs along the anterior interventricular sulcus and supplies the apical portion of both ventricles. The LAD artery is mostly epicardial but can be intramuscular in places. An important identifying characteristic of the LAD artery during angiography is the identification of 4-6 perpendicular septal branches. These branches, approximately 7.5 cm in length, supply the interventricular septum.
The first branch of the LAD artery is termed the ramus intermedius. In fewer than 1% of patients, the LCA is absent, and the LAD and LCX arteries originate from the aorta via 2 separate ostia. As the LAD artery passes along the anterior interventricular groove toward the apex, it turns sharply to anastomose with the posterior interventricular branch of the RCA. As the LAD artery courses anteriorly
| CAD – HCVD 21
along the ventricular septum, it sends off diagonal branches to the lateral wall of the left ventricle. Congenital LAD artery variations may include its duplication as 2 parallel arteries (4% incidence) and length variations (premature or delayed distal termination).
Left Circumflex Artery
The LCA gives off the LCX artery at a right angle near the base of the left atrial appendage. The LCX artery courses in the coronary groove around the left border of the heart to the posterior surface of the heart to anastomose to the end of the RCA. In the AV groove, the LCX artery lies close to the annulus of the mitral valve. The atrial circumflex artery, the first branch off the LCX artery, supplies the left atrium. The LCX artery gives off an obtuse marginal (OM) branch at the left border of the heart near the base of the left atrial appendage to supply the posterolateral surface of the left ventricle. The color contrast between the yellow-orange OM and the adjacent red-brown myocardium may be the most reliable way to identify this artery intraoperatively. In patients with a left-dominant heart, the LCX artery supplies the PDA. Many variations in the origin and length of the LCX artery are noted. In fewer than 40% of patients, the sinus node artery may originate from the LCX artery.
Right Coronary Artery
The RCA is a single large artery that courses along the right AV groove. The RCA supplies the right atrium, right ventricle, interventricular septum, and the SA and AV nodes. The RCA arises from the right aortic sinus and courses in the coronary (AV) groove between the right auricle and the right ventricle. In 60% of patients, the first branch of the RCA is the sinus node artery. As the RCA passes toward the inferior border of the heart, it gives off a right marginal branch that supplies the apex of the heart. After this branching, the RCA turns left to enter the posterior interventricular groove to give off the PDA, which supplies both ventricles.
The AV node artery arises from the "U-turn" of the RCA at the crux (ie, the junction of the AV septum with the AV groove). At this point, the PDA feeds the septal, right ventricular, and left ventricular branches. The PDA courses over the ventricular septum on the diaphragmatic surface of the heart. Unlike the septal branches off the LAD artery, the septal branches from the RCA typically are short (< 1.5 cm). Terminal branches of the RCA supply the posteromedial papillary muscle of the left ventricle. (The LAD artery supplies the anterolateral papillary muscle of the right ventricle.) Near the apex, the PDA anastomoses with the anterior interventricular branch of the LCA.
Common variations involving RCA anatomy include the following:
An RCA originating from the right sinus of Valsalva The sinus node artery originating from the RCA The acute marginal (AM) artery crossing the inferior aspect of the right ventricle to
supply the diaphragmatic interventricular septum
Coronary Veins
The coronary sinus is a short (approximately 2 cm) and wide venous channel that runs from left to right in the posterior portion of the coronary groove. The
| CAD – HCVD 22
opening of the coronary sinus is located between the right AV orifice and the inferior vena cava orifice. The coronary sinus drains all venous blood from the heart except the blood carried from the anterior cardiac veins. The coronary sinus receives outflow from the great cardiac vein on the left and from the middle and small cardiac veins on the right.
The great cardiac vein is the main tributary of the coronary sinus and drains areas of the heart supplied by the LCA. It begins at the apex of the heart, ascends in the anterior interventricular groove with the LAD artery, and enters the left end of the coronary sinus.
The middle and small cardiac veins drain most of the heart supplied by the RCA. The middle cardiac vein begins at the apex, ascends in the posterior interventricular groove with the posterior interventricular artery, and empties into the right side of the coronary sinus. The small cardiac vein runs in the coronary groove along with the marginal branch of the RCA; this vein usually empties into the coronary sinus but may empty directly into the right atrium.
Coronary veins of the right ventricle drain directly into the right atrium; thebesian veins drain into the right ventricle. The left ventricle venous return drains into the coronary sinus located next to the septal portion of the tricuspid valve annulus
Cardiac Cycle
The cardiac cycle is the sequence of events that occurs in one complete beat of
the heart. The pumping phase of the cycle, also known as systole, occurs when
heart muscle contracts. The filling phase, which is known asdiastole, occurs when
heart muscle relaxes. At the beginning of the cardiac cycle, both atria and ventricles
are in diastole. During this time, all the chambers of the heart are relaxed and
receive blood.
The atrioventricular valves are open. Atrial systole follows this phase. During
atrial systole, the left and right atria contract at the same time and push blood into
the left and right ventricles, respectively. The next phase is ventricular systole.
During ventricular systole, the left and right ventricles contract at the same time and
pump blood into the aorta and pulmonary trunk, respectively. In ventricular systole,
the atria are relaxed and receive blood. The atrioventricular valves close immediately
after ventricular systole begins to stop blood going back into the atria. However, the
semilunar valves are open during this phase to allow the blood to flow into the aorta
and pulmonary trunk. Following this phase, the ventricles relax that is ventricular
diastole occurs. The semilunar valves close to stop the blood from flowing back into
the ventricles from the aorta and pulmonary trunk. The atria and ventricles once
again are in diastole together and the cycle begins again.
| CAD – HCVD 23
SystoleThe contraction of the cardiac muscle tissue in the ventricles is called systole. When the ventricles contract, they force the blood from their chambers into the arteries leaving the heart. The left ventricle empties into the aorta and the right ventricle into the pulmonary artery. The increased pressure due to the contraction of the ventricles is called systolic pressure.
DiastoleThe relaxation of the cardiac muscle tissue in the ventricles is called diastole. When the ventricles relax, they make room to accept the blood from the atria. The decreased pressure due to the relaxation of the ventricles is called diastolic pressure.
Components of the Heartbeat
The adult heart beats around 70 to 80 times a minute at rest. When you listen to your heart with a stethoscope you can hear your heart beat. The sound is usually described as "lubb-dupp". The "lubb" also known as the first heart sound, is caused by the closure of the atrioventricular valves. The "dupp" sound is due to the closure of the semilunar valves when the ventricles relax (at the beginning of ventricular diastole). Abnormal heart sounds are known as murmurs. Murmurs may indicate a problem with the heart valves, but many types of murmur are no cause for concern.
| CAD – HCVD 24
B. Pathophysiology Myocardial Ischemia – a condition in which the heart muscle cells receive less oxygen than needed.
| CAD – HCVD 25
PREDISPOSING FACTORS: Family history of heart disease Age Sex: Male Hypertension Anatomic structure of the Coronary
Artery
PRECIPITATING FACTORS: Diet Smoking History Obesity Less Exercise
Accumulation of fatty streaks of lipids in the intima of the arterial wall
Injury to the vascular epithelium
Inflammation
Vasoconstriction of arterioles
Hypertension
Attraction of inflammatory cells including macrophages
Macrophages release biochemical substances
that further damage endothelium
Macrophages infiltrate the injured vascular endothelium and ingest lipids which turn
into foam cells
Attracts platelets
Initiation of clotting
Smooth muscles proliferate and form a fibrous cap over a core filled lipid and inflammatory infiltrate (atheromas)
Atherosclerosis
CADImpediment of blood flow
Oxygen deprivation of the cardiac muscle cells
Myocardial Ischemia
↑ Blood Pressure
HCVD
VI. NURSING REVIEW CHART
Name: Patient A Date: June 27, 2012
Temp.:35.8 C Heart Rate: 74bpm Respiration Rate: 22cpm
Height: 70cm Weight: 65kgs
INSTRUCTIONS: Place an [X] in the area of abnormality. Comment at the space provided. Indicate the
location of the problem in the figure using [X]
EENT:
[ ] impaired vision [ ] blind [ ] pain *Dyspnea
[ ] reddened [ ] drainage [ ] gums
[ ] Hard of hearing [ ] deaf [ ] burning * Chest pain
[ ] edema [ ] lesion [ ] teeth
Assess eyes, ears, nose throat for abnormalities.
[x] no problem *Body weakness
[ ] asymmetric [ ] tachypnea [ ] apnea
[ ] rales [ ] cough[ ] barrel chest [ ] bradypnea Dry skin
[ ] shallow [ ] rhonchi
[ ] sputum [ ] diminished [x] dyspnea
[ ] orthopnea [ ] labored [ ] wheezing
[x] pain [ ] cyanotic
Assess resp. rate, rhythm, pulse blood breath
sounds,
Comfort [ ] no problemCARDIOVASCULAR:
[ ] arrhythmia [ ] tachycardia [ ] numbness
[ ] diminished pulses [ ] edema [ ] fatigue
[ ] irregular [ ] bradycardia [ ] murmur
[ ] tingling [ ] absent pulses [ ] pain
Assess heart sound, rate, rhythm, pulse,
blood pressure, circulation, fluid retention,
comfort [x] no problem
GASTROINTESTINAL TRACT:
[ ] obese [ ] distention [ ] mass
| CAD – HCVD 26
[ ] dysphagia [ ] rigidity [ ] pain
Assess abdomen, bowel habits, swallowing bowel sounds,
Comfort [x] no problem
GENITO-URINARY AND GYNE:
[ ] pain [ ] urine color [ ] vaginal bleeding
[ ] hematuria [ ] discharge [ ] nocturia
Assess urine frequency, control, color, odor,
Comfort, gyne bleeding, discharge [x] no problem
NEURO: Fatigue
[ ] paralysis [ ] stuporous [ ] unsteady
[ ] seizures [ ] lethargic [ ] comatose
[ ] vertigo [ ] tremors [ ] confused
[ ] vision [ ] grip
Assess motor, function, sensation, LOC
Strength, grip, gait, coordination, speech
[x] No problem
MUSCULOSKELETAL AND SKIN:
[ ] appliance [ ] stiffness [ ] itching
[ ] petechiae [ ] hot [ ] drainage
[ ] prosthesis [ ] swelling [ ] lesion
[x ] poor turgor [ ] cool [ ] deformity
[ ] wound [ ] rash [ ] skin color
[ ] flushed [ ] atrophy [ ] pain
[ ] ecchymosis [ ] diaphoretic [ ] moist
Assess mobility, motion, gait, alignment, joint function, skin color, texture, turgor, integrity
[x] no problem
| CAD – HCVD 27
SUBJECTIVE OBJECTIVE
Communication:
[ ] hearing loss Comments:
[ ] visual changes “ wala man koy problema
ana” as verbalized by the
patient
[ ] denied
[ ] glasses [ ] languages
[ ] contact lens [ ] hearing aide
R L
Pupil size: 2-3mm [ ] speech difficulties
Reaction: pupil equally round and reactive to light and accomodation
Oxygenation:
[x] dyspnea Comments :
[ ] smoking history “ ga lisod kog ginhawa
Inig musakit akon dughan”
N/A as verbalized by the patient.
[ ] cough
[ ] denied
Resp. [ x] regular [ ] irregular
Describe: the patient’s respiration is regular.
R: symmetrical to the left lung.
L: symmetrical to the right lung.
Circulation:
[x] chest pain Comments:
[ ] leg pain “mag sakit ra akong dughan og kalit”
As verbalized by the patient.
[ ]numbness of
extremities
[ ]denied
Heart Rhythm [ x ] regular [] irregular
Ankle Edema: None
Pulse Car. Rad. DP. FEM*
R + + + not obtain
L + + + not obtain
Comments
Right and left pulse are palpable
Nutrition:
Diet : Soft Diet
[ ] N [ ] V Comments:
“ Sukad lagi nag sugod og sakit
akong dughan og na hospital ko,
mga humok nlang man pwede
nako kaonon.”
as verbalized by the patient.
Character .
[ ] dentures [ x ] none
Full Partial W/ Patient
Upper [] [ ] []
Lower [] [ ] []
| CAD – HCVD 28
[x] recent change in
weight, appetite
[ ] swallowing
difficulty
[ ] denied
Elimination:
Usual bowel pattern [ ] urinary frequency
Once a day 3 times a day
[ ] constipation [ ] urgency
remedy [ ] dysuria
none [ ] hematuria
Date of Last BM [ ] incontinence
[ ] polyuria
[ ] Diarrhea [ ] foley in place
character [x] denied
Comments: the client has active bowel sound
Bowel sounds: active
Abdominal distention
Present [ ] yes [x ] no
Urine:(consistency, odor)
yellow amber, slight aromatic
MGT. of Health & Illness:
[ ] alcohol [x] smoking : [ ] denied (amount, frequency)
Not obtain
[ ] SBE: N/A Last Pap Smear: N/A LMP: N/A
Briefly describe the patient’s ability to follow treatments (diet, meds, etc.) for chronic health problems (if present).
Patient has Myocardial Ischemia and he was following on his doctor’s instruction as well as to the nurses. He is also following on medication regimen and Instructed to avoid ambulation.
SUBJECTIVE OBJECTIVE
Skin Integrity:
[ ] dry Comments:
. “ wala ma’y problema sa akong pamanit,
wala pud nangatol“ as verbalized by
the patient.
[ ] itching
[ ] other .
[ x] dry [ ] cold [ ] pale
[ ] flushed [ ] warm
[ ] moist [ ] cyanotic
*rashes, ulcers, decubitus (describe size, location, drainage)
No rashes and ulcers noted, but patient has poor skin
| CAD – HCVD 29
[x ] denied turgor and has dry skin.
Activity/Safety:
[ ] convulsion Comments:
“maka lihok-lihok man ko pero
Instruction sa doctor diri ra daw ko sa
katre og dili mag lakaw-lakaw”, as
verbalized by the patients daughter.
[ ] dizziness
[ ] limited motion of joints .
Limitation in ability to
[ ] ambulate [ ]bathe self
[ ]other [ ] denied
[ ] LOC and orientation the patient is oriented to the place, date and time.
Gait: [ ] walker [ ] cane [ ] other
[ x ] steady [ ] unsteady
[ ] sensory and motor losses in face or extremities:
No sensory and motor losses in face or extremities.
[ ] ROM limitations: the patient has normal range of motion but instructed to avoid ambulation
Comfort/Sleep/Awake:
[ x] pain Comment:
(Location, frequency) “mayo man ako pagkatulog
pero usahay makamata rakog
kalit kay nag sakit napud akong
dughan og murag ga pi-ot
” as verbalized by the patient
[ ] nocturia
[ ] sleep difficulties
[ ] denied
[ ] facial grimaces
[ ] guarding
[ ]No other signs of pain
none .
[ ] side rail release from signed (60 + years)
No side rail release was observed
Coping:
Occupation: Retired
Member of household: 5
Most supportive person: Wife
Observed non-verbal behavior: the patient was conscious and coherent
Person(Phone number): 09056911195
| CAD – HCVD 30
VII. NURSING MANAGEMENT
A. Ideal Nursing Management
NURSING DIAGNOSIS:
Acute Pain r/t myocardial ischemia resulting from coronary artery occlusion with
loss/restriction of blood flow to an area of the myocardium and necrosis of the
myocardium
| CAD – HCVD 31
Interventions:
Assess characteristics of chest pain, including location, duration, quality, intensity, presence of radiation, precipitating and alleviating factors, and as associated symptoms, have client rate pain on a scale of 1-10 and document findings in nurse’s notes.
Obtain history of previous cardiac pain and familial history of cardiac problems
Assess respirations, BP and heart rate with each episodes of chest pain.
Aaintain bed rest during pain, with position of comfort, maintain relaxing environment to promote calmness
Rationale:
Pain is indication of MI. assisting the client in quantifying pain may differentiate pre-existing and current pain patterns as well as identify complications.
This provides information that may help to differentiate current pain from previous problems and complications.
Respirations may be increased as a result of pain and associate anxiety.
To reduce oxygen consumption and demand, to reduce competing stimuli and reduces anxiety.
NURSING DIAGNOSIS:
Activity Intolerance r/t cardiac dysfunction, changes in oxygen supply and
consumption as evidenced by shortness of breath.
| CAD – HCVD 32
Interventions:
Monitor heart rate, rhythm,
respirations and blood pressure
for abnormalities. Notify
physician of significant changes
in VS.
Identify causative factors
leading to intolerance of activity.
Encourage patient to assist with
planning activities, with rest
periods as necessary.
Instruct patient in energy
conservation techniques.
Assist with active or passive ROM
exercises at least QID.
Rationale:
Changes in VS assist with
monitoring physiologic
responses to increase in activity.
Alleviation of factors that are
known to create intolerance can
assist with development of an
activity level program.
To help give the patient a
feeling of self-worth and well-
being.
To decrease energy
expenditure and fatigue
To maintain joint mobility and
muscle tone
NURSING DIAGNOSIS:
| CAD – HCVD 33
Deficient Knowledge r/t new diagnosis and lack of understanding of medical
condition
Interventions:
Monitor patient’s readiness to learn and determine best methods to use for teaching.
Provide time for individual interaction with patient.
Instruct patient on procedures that may be performed. Instruct patient on medications, dose, effects, side effects, contraindications, and signs/symptoms to report to physician.
Instruct in dietary needs and restrictions, such as limiting sodium or increasing potassium.
Provide printed materials when possible for patient/family to reviews.
Rationale:
To promote optimal learning environment when patient show willingness to learn
To establish trust.
To provide information to manage medication regimen and to ensure compliance.
Client may need to increase dietary potassium if placed on diuretics; sodium should be limited because of the potential for fluid retention.
To provide reference for the patient and family to refer
B. Actual Nursing Management
| CAD – HCVD 34
SOAPIE
S “ inig mu tindog ko mura man kog gaka lipong og luya kaayu akong pamati” as verbalized by the patient
O Increased heart rate Increased blood pressure Dyspnea with exertion Fatigue and weakness
A Activity Intolerance r/t cardiac dysfunction, changes in oxygen supply and consumption as evidenced by shortness of breath.
P Long term: At the end of 2 days of nursing interventions, the client will be able to increase and achieve desired activity level, progressively, with no intolerance symptoms noted, such as respiratory compromise.
Short term: At the end of 8 hours of nursing interventions, the client will be able to tolerate activity without excessive dyspnea and will be able to utilize breathing techniques and energy conservation techniques effectively.
I 1. Monitor heart rate, rhythm, respirations and blood pressure for abnormalities. Notify physician of significant changes in VS (changes in VS assist with monitoring physiologic responses to increase in Activity)2. Instruct patient in isometric and breathing exercises (To improve breathing and to increase activity level.)3. Instruct patient in energy conservation techniques (to decrease energy expenditure and fatigue)4.Patient is instructed to avoid sudden ambulation (to prevent increase demand of oxygen)5. encourage patient to assist with planning activities, with rest periods as necessary (to help give the patient a feeling of self-worth and well-being)DEPENDENT:Assisst patient with ambulation, as ordered, with progressive increases as patient’s tolerance permits
E At the end of 2days of nursing intervention, the client increased and achieved desired activity level, progressively, with no intolerance symptoms noted, such as respiratory compromise. Goal was met.
SOAPIE
| CAD – HCVD 35
S “ Gasakit napud akong dughan”, as verbalized by the patient.
O Restlessness Facial grimace Fatigue Fast, shallow breathing dyspnea
A Acute Pain r/t myocardial ischemia resulting from coronary artery occlusion with loss/restriction of blood flow to an area of the myocardium and necrosis of the myocardium
P Long Term: The client will have an improved feeling of control as evidenced by verbalizing a sense of control over present situation and future out comes within 2 days of nursing interventions.Short Term: Within 1 hour of nursing interventions, the client will have improved comfort in chest, as evidenced by: States a decrease in the rating of the chest pain.
I 1. Vital signs monitored every 2 hours (to obtain data for comparison)2. Patient instructed to avoid ambulation (t o help decrease oxygen demand) 3. Taught and encouraged to use diaphragmatic and pursed lip breathing. (These help patient prolong expiration time and decreases air trapping. And patient Could breathe more efficiently and effectively.)4. Provide adequate rest and with head of the bed elevated (Decrease pressure on the diaphragm and decrease oxygen demand)5. Assess respirations, BP and heart rate with each episodes of chest pain. (Respirations may be increased as a result of pain and associate anxiety.)DEPENDENT:6. -obtain a 12-leadECG on admission, then each time chest pain recurs for evidence of further infarction as prescribed-Administer analgesics as ordered, such as morphine sulfate, meferidine of Dilaudid N.- Administer beta-blockers as ordered
E The client had an improved feeling of control as evidenced by verbalizing a sense of control over present situation and future out comes within 2 days of nursing intervention. Goal was met.
SOAPIE | CAD – HCVD 36
S “luya man kaayu akong pamati ” as verbalized by the patient.
O Weak in appearance
fatigue
A Fatigue related to inadequate supply of oxygen into the myocardium
P Long term: At the end of 8 hours the patient will be able to verbalize comfort as evidence by liveliness and cooperation
Short term: At the end of 1 hour of nursing intervention the patient will be able relieve from weakness and fatigue
I Independent:1. Monitor v/s every 2hours (to prevent fatigue and complications)2. Intructed to prevent ambulation ( to prevent more oxygen demand)3. Provide adequate rest ( by doing so it promotes rest and healing)4. Limit visitors ( to prevent stress which may trigger ischemia)5. Instruct patient in energy conservation techniques (to decrease energy expenditure and fatigue)
Dependent: Administer Hyosine to prevent myocardial ischemia thus promoting
fatigue and weakness
E At the end of the desired time, goals were met. Patient was able to
verbalized comfort and were relieve from fatigue
| CAD – HCVD 37
VIII. DRUG STUDY
Name of Drug
Generic/ Brand
Date Ordered
Classification Dose/ Frequenc
y
Mechanism of Action
Specific Indication
Contraindication Side Effects Nursing Precaution
Metoprolol(Lopressor)
June 26,2012
Beta1-selective adrenergic blocker, Antihypertensive
100mg tab, OD,PO
Competitively blocks beta-adrenergic receptors in the heart and juxtaglomerular apparatus, decreasing the influence of the sympathetic nervous system on these tissues and the excitability of the heart, decreasing cardiac output and the release of renin, and lowering BP; acts in the CNS to reduce sympathetic outflow and vasoconstrictor tone.
Hypertension, alone or with other drugs, especially diureticsTreatment of stable, symptomatic CHF of ischemic, hypertensive,
Contraindicated
with sinus
bradycardia (HR <>
0.24 sec),
cardiogenic shock,
CHF, systolic BP
<>
Pharyngitis,
erythematous rash,
fever, sore throat,
laryngospasm
Dizziness, vertigo,
tinnitus, fatigue,
emotional depression,
paresthesias, sleep
disturbances,
hallucinations,
disorientation,
memory loss, slurred
speech
CHF, cardiac
arrhythmias,
peripheral vascular
insufficiency,
claudication, CVA,
pulmonary edema,
hypotension
Do not discontinue drug
abruptly after long-term therapy (hypersensitivity
to catecholamines may have
developed, causing
exacerbation of angina, MI, and
ventricular arrhythmias). Taper drug
gradually over 2 wk with
monitoring.Ensure that
patient swallows the ER tablets
whole; do not cut, crush, or chewGive oral drug
with food to facilitate
absorption.
| CAD – HCVD 38
DRUG STUDY
Name of Drug
Generic/ Brand
Date Ordered
Classification Dose/ Frequency
Mechanism of Action
Specific Indication
Contraindication Side Effects Nursing Precaution
Omeprazole(Prilosec)
June 25,2012
proton pump inhibitors
Anti secretory drug
40mg, IVTT, OD
Omeprazole suppresses gastric acid secretion by
specific inhibition of the enzyme system hydrogen/potassiu
m adenosine triphosphatase (H+/K+ ATPase) present on the
secretory surface of the gastric parietal
cell.
Duodenal and gastric ulcer
Long-term use for gastroesophagea
l reflux disease, duodenal ulcers;
lactation
Diarrhoea, nausea, fatigue,
constipation, vomiting,
flatulence, acid regurgitation,
taste perversion, arthralgia, myalgia,
urticaria, dry mouth,
dizziness, headache,
paraesthesia, abdominal pain,
skin rashes, weakness, back
pain, upper respiratory
infection, cough.
Give before food,
preferably breakfast;
capsules must be swallowed whole (do not
open, chew, or crush).
Tell your doctor if your
condition persists or worsens
| CAD – HCVD 39
DRUG STUDY
Name of Drug
Generic/ Brand
Date Ordered
Classification Dose/ Frequenc
y
Mechanism of Action
Specific Indication
Contraindication
Side Effects Nursing Precautio
n
Simvastatin(Zocor)
June 25,2012
Antihyperlipidemic, HMG-CoA
reductase inhibitor
20 mg,OD,PO
Simvastatin is a prodrug
metabolised in the liver to form
the active β-hydroxyacid
derivative. This inhibits the
conversion of HMG-CoA to
mevalonic acid by blocking HMG-CoA
reductase, an early and rate-limiting step in
cholesterol biosynthesis. It reduces total
cholesterol, LDL-cholesterol and triglycerides and increases HDL-
cholesterol levels.
Adjunct to diet in the treatment of elevated total
cholestrol and LDL cholesterol with
primary hypercholesterolemia (types IIa and
IIb) in those unresponsive to
dietary restriction of saturated fat and cholesterol
and other nonpharmacologic
measures
Acute liver disease or
unexplained persistent
elevations of serum
transaminases. Pregnancy, lactation.
Porphyria.
Headache, nausea, flatulence, heartburn,
abdominal pain, diarrhea/constipation
, dysgeusia; myopathy features like myalgia and
muscle weakness; serum
transaminases and CPK elevations;
hypersensitivity; lens opacities; blurring of
vision; dizziness; sexual dysfunction;
insomnia;
Ensure that patient has
tried a cholesterol-
lowering diet regimen for 3–6 mo
before beginning therapy.
Give in the evening; highest rates of
cholesterol synthesis
are between midnight
and 5 AM.
| CAD – HCVD 40
DRUG STUDY
Name of Drug
Generic/ Brand
Date Ordered
Classification Dose/ Frequency
Mechanism of Action
Specific Indication
Contraindication Side Effects Nursing Precaution
Aspilet(
acetylsalicylic acid or ASA)
June 25,2012
platelet aggregation
inhibitorsAntiplatelet
4 tabs, PO, now
associated with inhibition of COX-1 activity, which
plays for the major enzyme
metabolism of arachidonic acid
which is precursors of
prostaglandins which play a major
role in the pathogenesis of
inflammation, pain and fever. Reduce
thrombocyte aggregation,
platelet adhesion and thrombus
formation through suppression of
thromboxane A2 synthesis in
thrombocyte. Reducing the risk
of myocardial infarction in
unstable stenocardia.
Suspected acute MI;
Prophylactic treatment of
thromboembolic disorders, MI,
transient ischemic attacks
& stroke
Asthma, rhinitis & nasal polyps.
History of active peptic ulcer
disease. Hypersensitivity.
Fever, hypothermia,
thirst. Dysrythmias, hypotension, tachycardia.
Agitation, cerebral edema, coma,
confusion, dizziness, headache, subdural or intracranial
hemorrhage, lethargy, seizures.
Dehydration, hyperkalemia,
metabolic acidosis, resp
alkalosis, dyspepsia, GI
bleeding, ulceration & perforation,
nausea, vomiting, transient hepatic
enzyme elevations, hepatitis,
Should be taken with food. (Take
immediately after meals w/ a
full glass of water unless
patient is fluid-restricted.
Swallow whole, do not chew/
crush/ bite the tab.)
| CAD – HCVD 41
DRUG STUDY
Name of Drug
Generic/ Brand
Date Ordere
d
Classification
Dose/ Frequenc
y
Mechanism of
Action
Specific Indication
Contraindication Side Effects Nursing Precautio
n
Clopidogrel(Plavix)
June 25,2012
anti-platelet drug
75 mg,4 tabs, now, PO
a drug that inhibits the
ability of platelets to
clump together as
part of a blood clot. Clopidogrel
prevents blood clots by
irreversibly binding to the
P2Y12 receptor on platelets,
preventing adenosine
diphosphate (ADP) from activating platelets. I
is used to prevent heart attacks and strokes in persons
with heart disease (recent hea
rt attack), recent stroke, or blood circulation
disease
contraindicated in patients with hypersensitivity
(e.g., anaphylaxis) to clopidogrel or any component
of the productcontraindicated in patients with
active pathological bleeding such as peptic
ulcer or intracranial hemorrhage.
Diarrhea, rash, or itching occurs in
approximately 1 in 20 persons taking
clopidogrel. Abdominal pain also occurs in
about 1 in 20 persons, but it is less frequent
than with aspirin. Headache, chest pain, muscle aches, anddizziness may also occur. Clopidogrel may
also cause severe bleeding, allergic
reactions, pancreatitis, and liver failure.
Clopidogrel bisulfate usually is
taken once daily. It can
be taken with or without
food. Clopidogrel is activated by enzymes in the liver to
its active form.
| CAD – HCVD 42
DRUG STUDY
Name of Drug
Generic/ Brand
Date Ordered
Classification Dose/ Frequency
Mechanism of Action
Specific Indication
Contraindication Side Effects
Nursing Precaution
Gaviscon( Aluminum/Magnesium Trisilicate)
June 25, 2012
Antacid 10 cc @ 9-3-9, P0
It works by neutralizing acid in the stomach.
Treating acid indigestion,
heartburn, and sour stomach.
Hypersensitivity to Renal
dysfunction. Sodium
restricted diet.
Constipation; diarrhea Severe allergic
reactions (rash; hives;
itching; difficulty
breathing; tightness in the chest; swelling of the mouth,
face, lips, or tongue); loss of appetite;
muscle weakness;
nausea; slow reflexes; vomiting.
Do NOT take more than the recommended
dose or take the maximum dose for longer than
2 weeks without checking with your doctor
If your symptoms do not get better
within 2 weeks or if they get
worse, or if you experience black, tarry
stools or vomit that looks like
coffee grounds, check with your
doctor
| CAD – HCVD 43
DRUG STUDY
Name of Drug
Generic/ Brand
Date Ordered
Classification Dose/ Frequency
Mechanism of Action
Specific Indication
Contraindication
Side Effects
Nursing Precaution
Lilac(Lactulose)
JUNE 25,2012
gastrointestinalagent;
hyperosmotic laxative
10 cc @ HS, PO
Reduces blood ammonia; appears to involve metabolism of
lactose to organic acids by resident
intestinal bacteria.
For Constipation Low galactose diet and intestinal obstruction.
GI
:Flatulence,bor
borygmi,belchi
ng,abdominal c
ramps,pain,an
d distention
(initial
dose);diarrhea
(excessive
dose);
nausea, vomiti
ng, colon
accumulation
of hydrogen
gas;
hypernatremia.
Do not self-medicate with
another laxative due to slow
onset of drug action.
Notify physician if diarrhea (i.e.,
more than 2 or 3 soft stools/d) persists more than 24–48 h. Diarrhea is a
sign of overdosage.
Dose adjustment may be
indicated.
| CAD – HCVD 44
DRUG STUDY
Name of Drug
Generic/ Brand
Date Order
ed
Classification
Dose/ Frequen
cy
Mechanism of Action
Specific Indication
Contraindication Side Effects
Nursing Precaution
Vessel Due F
(Sulodexide
)
June 25,201
2
Anticoagulants
Antithrombotic
Antiplatelet
1 amp. IVTT, NOW, then q
12 hours
Inhibits coagulation by attacking several
sites of the coagulationsystem.
Its effect is dependent on the
presence of antithrombin III,
an alpha 2-globulin whose
activity is augmented by heparin. The
heparin- antithrombi
nc o m p l e x i n a c t iv a t e s f a c t o r s I Xa , X a , X I a a n d X I I a , a n d p r e v en t s t h r o m b i n for
mation. Furthermore, the complex
reverses the effect of
already formedthrombin. In high
concentrations, heparin also inhibits thrombocyte
aggregation.
Peripheral vascular
insufficiency with thrombotic risk,
myocardial infarction,
cerebral transient ischemic attack or strokes and
diabetic retinopathy.
Hypersensitivity to sulodexide, heparin & heparin- l ike products.Diathesis & hemorrhagic
diseases
Gastrointestinal
disorders e.g.,
nausea, vomiting,
epigastralgia. Amp:
Pain, burn &
hematoma at the site
of injection.
Periodically monitor
hemocoagulative
parameters.
| CAD – HCVD 45
IX. REFERRALS and FOLLOW-UP (Discharge plan)
Referral and Follow-up RationaleMedication Instruct the patient and the family to follow the
home medications as prescribed by the physician
Explain each purpose of the medication
Instruct the client not to take over-the-counter drugs without doctor’s knowledge
Explain the side effects or adverse reaction on each medication. Report immediately as soon as there is an occurrence or such
Inculcate to the mind of the patient to comply all the medications prescribed at the ordered dosage, route and at the ordered time
Let the patient complete the whole course of drug therapy
Treatment regimen is important to have fast recovery
Knowledge about the medication will make the client become aware of what he is taking and for the family to participate in patient’s treatment
Non-prescribed drug may have antagonistic or synergistic effect in any drug therapy
Explaining the side effects will make the patient and the family identify what harmful effects to expect
Taking the drugs at the ordered dose, route and time limits the chance of toxicity and ensure it’s effectiveness
This can help the patient alleviate the problem and be able to experience the full therapeutic effect of the medication
Exercise Encourage early ambulation
Promote exercise to the patient especially ROM
Instruct client to avoid strenuous activities for at least a week or month until fully recovered
Advise patient to have adequate rest and sleep
Practice deep breathing exercise
Walking is a good exercise and could promote circulation, hence, proper healing
This will promote good physical health
Activities that required great muscle strength should be avoided to prevent injury and muscle strain
To gain back the lost strength and able to return to it’s normal state thus allow ample time for healing
This will help alleviate any pain or discomfort that patient will encounter
Treatment Explain the need of treatment after discharge and must take it seriously to prevent such complication to the patient
Explain to the family the condition of the patient
To make the client and family aware that the treatment does not only end up in hospital but needs to be continued at home to make the client responsible towards medication
To have better understanding of the patient’s condition and
| CAD – HCVD 46
and give them factual information about the illness
to be able to know what intervention should they give and could not alter the effect of the therapy
Hygiene Encourage having proper hygiene like taking a bath, meticulous hand washing, and brushing of teeth every after meal
Encourage patient to continue hygienic measures practiced at present such as changing of clothes everyday and changing of underwear as often as necessary, keeping the nails neatly trimmed, maintaining own supplies/items for personal necessities
Provide a calm and accepting
Hygiene provides comfort and cleanliness to the patient. It also increases the patient’s sense of well-being, which is very much needed in the therapy process
Keeping all practiced measures is necessary in consistent maintenance of proper hygiene
Calm, clean and non-threatening may lessen the occurrence of possible infection and would be a good place for healing
Out Patient Inform the patient that follow-up check-up is important to have a continuous monitoring and care even after attainment of the course medical therapy
Advice the patient and the family to carry out follow-up diagnostic examinations
Instruct the family to report any unusual signs and symptoms experienced by the patient
Through constant visit as out patient, the physician would still monitor the progress of the therapeutic intervention availed by the patient
This is to evaluate the therapeutic response of the patient to the treatment
This will help detect early signs and symptoms of the recurrence of disease
Diet Encourage the client to eat variety of nutritious foods like fruits and vegetables once instructed by the physician
Instruct client to take vitamins as ordered Advise client not to skip meals and have a
regular eating pattern/schedule Tell the patient not to take foods contraindicated
by the client
To maintain and promote healthy body
To boost the body’s immune system Regular interval of meals is the basic principle of a good
dietary plan To prevent the occurrence of complication
| CAD – HCVD 47
As referrals, patient should contact physician for immediate management of the
condition if any unusualities occurs. Patient was instructed to have follow-up check up
with her physician in the exact day at the exact time of schedule, usually one week after
discharge, even if he already feels better. Follow-up is needed to check the patient as
well as possible side effects of certain treatments and drugs. Advised to increase intake
of nutritious foods like fruits and vegetables for proper nutrition and optimum health and
avoid foods and drinks which could trigger the recurrence and severity of the disease
like salty foods. Discourage alcohol and cigarette smoking and instructed to drink
enough amount of fluid. Advice for compliance of medications prescribed to her by the
doctor after being discharged.
X. EVALUATION AND IMPLICATIONS
The entire three days exposure at Station 3 of Sabal Hospital assigned to a client with
Myocardial Infarction with CAD – HCVD has thought us a lot of things. That is,
understanding the entire pathogenesis of the disorder its affectation and what approach
are to be implemented. Thus, consequently an improvement of client’s condition is
achieved with the help and assistance of the team of caregivers implementing effective
plan of care including active participation of the client and significant other. Therapeutic
relationship and communication between the caregivers and the client with the
significant others contributed to the achievement of the set goal. With the nursing skills
and interpersonal relationship with the people we worked with has improved accordingly
in the experience of the exposure. This study will serve as a reference material in
rendering competent care to our client especially those with similar situation. Through
this, we will be able to develop our knowledge as well as our skills and attitudes in
applying the care needed to improve the health status of our patient .Moreover this
study teaches us students to provide clients care more efficiently and competently to
achieve an effective and quality nursing care.
Survival from a heart attack has improved dramatically over the last two decades.
However, some people experience sudden death and never make it to the hospital. For
most people that do reach the hospital soon after the onset of symptoms, the prognosis
is very good. Many people leave the hospital feeling well with limited heart damage .
| CAD – HCVD 48
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http://d3jonline.tripod.com/neurosurgery/07-MyoCardialInfarction/Anatomy_Arterial.htm
http://emedicine.medscape.com/article/323120-overview#aw2aab6b3
http://emedicine.medscape.com/article/323120-overview#aw2aab6c17
http://www.medicalnewstoday.com/articles/184601.php
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collaborative care. (5th Edition). St. Louis, Missouri: Elsevier Saunders.
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| CAD – HCVD 49
