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OBJECTIVES

At the end of the case presentation, the evaluators will be able to:

Knowledge

Define the case of my patient basing upon the Pathophysiology.

Identify the signs and symptoms that mark Killips 4 of acute MI.

Enumerate the present medications the client has.

Rationalize nursing interventions performed.

Correct any errors in the case study.

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Skills

Note down the important info. presented.

Listen attentively all throughout the case presentation

Raise questions that is relevant to the case

Answer the questions given after the case presentation

Attitude

Respect the discussion time of the case by listening only

Show interest in the presentation

Acknowledge Gods guidance before starting and after the case presentation

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DEMOGRAPHIC DATA

oName: Mr. Good Boy

oAge: 58

oSex: Male

oStatus: Married

oAddress: F.T. Geslani Drive Taculing Bacolod City, Negros Occidental 6100

oReligion: SDA

oType of community: Urban

oChief Complaints: Chest Pain

oMedical Diagnosis: Acute Myocardial Infarction (Killips IV),

Hypoxic Ischemic Encephalopathy Secondary to Cardiac Arrest.

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oOccupation: None

oParents: Father: Deceased, Liver Cirrhosis

oMother: Deceased, Unrecalled

oRank Among Siblings: 5

oNumber of Siblings: 8

oSouse: Live( DM2)

oNumber of Children: 3

FAMILYBACKGROUND

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Adapted to life according to limitations

Decreased productivity

Achieved adult civic and social responsibility.

Established and maintained an economic standard of living.

Assisted teenage children to become responsible and happy adults.

Developed adult leisure-time activities

Related oneself to ones spouse as a person.

Accepted and adjusted to the physiologic changes or middle age.

DEVELOPMENTAL DATA

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Mr. Good Boy is a past smoker and alcoholic drinker, has a

past diet of high cholesterol foods and caffeinated beverages, especially when

there are celebrations in his family and works overtime to provide daily family

needs as stated by SO.

Mr. Good Boy was known hypertensive since 2000 and was

experiencing angina, palpitations, dyspnea, seizures/ syncope long ago since he

experienced 4 attacks before and was hospitalized twice. The start of the

disease was unrecalled as stated by SO.

HEALTH HISTORY

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Present Illness: Prior to admission, SO states that client was not able to sleep

well for 8 days with sleeping hours of 3-4 after a family reunion. The next day

client got angry with his brother because of a problem and then got angry

with his wife for not preparing his daily coffee. Pt. felt an aching pain on his

chest and went with his wife to the hospital. Pt had an arrest at the hospital

but was revived.

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GORDONS FUNCTIONALMODELHealth Perception Health management Pattern

The client takes multivitamins not prescribed by the physician. SO aids pt

in general hygiene feeding, grooming and exercise.

Nutrition Metabolic Pattern The client has some discomfort in swallowing hard foods and eats only

soft diet foods such as lugaw fish vegetables and fruit. Client usually eats

orange fruits. The client eats three times a day but sometimes looses his

appetite for 2 days. He is given bread mixed in milk at these times.

Typical fluid intake is to 2 glasses of water/day. Number of teeth 2

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Elimination Pattern

The client urinates 3 to 4 a day as counted every penile diaper change. No

difficulty or pain in urination. Bowel frequency is 2 to 3 times per day.

Character is semi formed. Uses provimin every day to soften stool passage.

Activity Exercise Pattern

The client is able to perform limited forms of ADLs. Needs assistance in

bathing, changing of clothes, moving from bed to wheel chair and eating.

Able to move upper extremities effectively. Pinky finger on the left hand

has calcified. Lower extremities are both weak and spastic when moved or

touched. (+) Babinskis Reflex. Passive range of motion is done every 30

min. both in upper and lower extremities.

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Sleep Rest Pattern

The client usually sleeps for at least 8 to 10 hours. Sleeps every 10am to

11am in the morning, 1pm to 3 pm at noon and 8pm in the evening after

the worship and wakes up at 6am in the morning. The client frequently

sleeps during day time and the SO/family member only wakes him up to

eat his meal. Sleeping problems start when bowel movement and

irritability start at night.

Sexuality Reproductive

SO states he is unresponsive in his sexual pattern since the disease.

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Cognitive Perceptual Pattern

Dysarthria is marked. Signs of memory loss is evident, unable to recall most of

past events. Seldom recalls family members and close family ties. Has low level of

concentration and may get confused. Decision making and learning abilities stillenact. Regression of intelligence level to a grade schooler.

Self-Perception/Self-Concept

SO states before the illness, he would get angry and annoyed of people who

would hurt his family. He would get depressed when he could not hug his

daughter because she does not come near him when he smokes. So states he washappy to let his children finish school and feels fulfilled and satisfied of what his

life and childrens life had become. Client could not articulate answers to

questions clearly.

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Role Relationship Pattern

The client is a father of 3 children with a composition of a nuclear family. Residing at

their home in Taculing. Their only family problem is in the financial area. SO states that

he was able to grow his family without relationship problems. The family states that the

illness was tragic but thankful that he was given a chance to live. Coping Stress Tolerance

SO states that when he was still well he goes out to drink alcohol with his friends or

family members whenever he was stressed. He also smokes and eats any food when in

stress. When in anger he lets his emotions out before calming down.

Values and Beliefs

The client was a converted SDA. SO states that he has fulfilled his important plans for his

family and prays to God for every trials that comes his way. He usually attend to church

services every Saturday but due to his condition he was not able to go to church.

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HCT: 0.36% deficient dietary intake, anemia

HGB: 127 g/L deficient dietary intake, anemia

WBC: 3.40 10^9/L dietary deficiency

Lymph: 0.14% sepsis

EO: 0.04% allergic reaction

Polys: 0.75 % infection

Uric Acid: 10.4 mg/dl gout

ALT: 90 u/L myocardial infarction

MEDICAL TREATMENTAND

MANAGEMENT

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PT Time Result: Pt Time - 9.8 sec indicates short time of blood to clot

Serum Electrolytes, Cholesterol, Triglycerides, Creatinin - Normal

CT Scan Brain Plain - Impression: hypoxic ischemic encephalopathy.

Chest X-Ray - Impression: Atherosclerotic aorta

ECG ; Ventricular Fibrilation.

ABG: PCO2- 25.7 mmol/L alkalosis; PO2-233 mmol/L alkalosis; HCO3-17.6 mmol/L acidic.

Urinalysis ; Normal

Surgery ; Tracheostomy

Troponin 1 ; (+) myocardial damage

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Generic/Trade Names Action Side Effects Contraindications

Omega-3-acid ethyl esters

(Lovaza)Decreases the amount of TG produced

by the liver and increases the removal of

TG by the liver

Upset stomach, burping, and

strange tastes in may occur.

-hypersensitive to fish.

Metropolol (Neoblock) Exerts mainlybeta1 adrenergic blocking

activity SNS influence, alsoblocksbeta-2receptors at high doses

Fatigue, dizziness, bradycardia,

edema, hypotension, nausea,

diarrhea, dyspnea, rash,

vomiting, dry eyes

Sinus bradycardia, 2nd or 3rd

degree heart block, Cardiogenic

shock , heart failure

Trimetazidine (Vastarel) Anti-ischemic (anti - anginal) metabolicagent, which

improves myocardial glucose utilization

through inhibition of fatty acid

metabolism, also known as fatty acid

oxidation inhibitor. (shifts energy

production from fatty acids to glucose

oxidation)

Nausea, vomiting Hypersensitivity to anycomponent of Vestar. Generally

not recommended during

breast feeding

MEDICATION

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PATHOPHYSIOLOGY

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NURSINGCAREPLANS