coronary artery disease (metabilism)

8/13/2019 Coronary Artery Disease (Metabilism)

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Coronary heart disease (CHD) is the most common cause of death worldwide.

Mortality from CHD increases with advancing age, and age-adjusted CHD rates are

higher in men compared to women. There is a large regional variation in coronary

mortality both within and between countries. Coronary risk factors include

socioeconomic factors, classic risk factors such as hypertension or diabetes, lifestyle

factors, and family history. A variety of factors such as emotional stress or acute

physical exertion can trigger coronary events. Also, an increased risk has been

observed in the morning hours and during winter months. Preventive efforts include

lifestyle measures and appropriate medication. CHD is caused by a narrowing of the

coronary arteries, leading to an imbalance between the functional requirements of the

heart and the capacity of the coronary arteries to supply blood and oxygen. As a

consequence, the heart muscle is damaged, which will eventually become clinically

apparent with cardiac symptoms. Clinical manifestations of CHD include stable or

unstable angina pectoris, myocardial infarction, cardiac arrhythmias, congestive heart

failure, and/or sudden cardiac death. The main cardiac symptoms are thoracic pain and

dyspnea. In the long term, CHD is associated with disability, impaired health-related

quality of life, and premature death. In addition, disease-related costs as induced by

medical resource utilization and loss of productivity are considerable.

As what we have researched, the worlds statistics, from various sources aboutthe causes of Coronary heart disease, it is the leading cause of cardiovascular mortality

worldwide, with >4.5 million deaths occurring in the developing world. Despite a recent

decline in developed countries, both CAD mortality and the prevalence of CAD risk

factors continue to rise rapidly in developing countries and thats from the World Health

Organization.

For the Philippines statistics of Coronary artery disease, there were 4,185, 258

prevalent cases and 86, 241, 692 incidents. The word 'prevalence' of Coronary heartdisease usually means the estimated population of people who are managing Coronary

heart disease at any given time (i.e. people with Coronary heart disease).

During the past three years, eight of the ten leading causes of morbidity in Davao

Region were communicable but highly preventable diseases. The non-communicable


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leading causes of morbidity were hypertensive diseases and genitourinary system

diseases. In 2002- 2004, cerebrovascular diseases topped the leading causes of

mortality, indicating the need to examine closely the lifestyle of the at-risk population in

the region. In 2002, heart diseases including coronary artery disease ranked second to

cerebrovascular diseases.

We choose Mr. R.G.C. as our client since his current illness is appropriate to our

concept which is metabolism. Mr. R.G.C has 4 diagnosis which are Acutegastroenteritis,

Diabetes Mellitus, CAD and Left ventricular hypertrophy, but we just focused on

Diabetes Mellitus which leads to other complications such as CAD, stroke and left

ventricular hypertrophy.

Nursing implications are as follows. For the nursing education, this can increase

our knowledge in all aspects of nursing care most especially in knowing the signs and

symptoms, assessing our patients comprehensively in order to detect various deviations

in his body and most importantly, knowing the disease process and interventions that

we must apply to obtain quality and optimum health to our patients. Since nursing is

viewed holistically, we must also have a good background about the disease in order for

us to know what is right and what is wrong for our patient.


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General Objective:

That within our 3 weeks rotation at the St. DominicsWard of San Pedro Hospital, we,

the BSN 3F, of group 1, will be able to formulate a nursing case study that aims to

present a comprehensive information of our patients condition in relation with the

concept and theories we have in this Metabolism rotation that would utilize nursing

principles and interventions to help us enhance our skills in this rotation.

Specifically, we will be able to:

1. Choose a client for our nursing case study

2. Establish rapport with our client and his significant others

3.Gather all the necessary information of our client through the patients chart

and the actual observation which will be the source of our data

4. Present an introduction that will give an overview and a brief summary on the

topic that will be embarking upon in this case study;

5. Develop specific, measurable, attainable, realistic and time-bounded

objectives to identify and relay the main purpose of our case study;

6. Present the clients personal data

7. Discuss the clients past health history, present health history and the

genogram that would serve as an aid in the identification of problems of our

client;

8. Explain the clients developmental task based on the theory of Robert

Havighurst and Erik Erikson;

9. Present the normal anatomy and physiology of a human body as our baseline

data for any variation in the clients anatomy and physiology

10 .Perform a thorough cephalocaudal assessment of the client;

11. Present a comprehensive physical assessment to reveal further irregularity;

12. Provide a definition of the diagnosis for further understanding of our clients

current health status;


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13. Discuss the pathophysiology of Diabetes Mellitus leading complications like

CAD, stroke and left ventricular hypertrophy;

14. Present the diagnostic examinations that our client went through with all the

necessary information such as the results, interpretation and the nursing

Responsibilities;

15. Gather all the names of our clients prescribed medications to know their

information such as their generic name, brand name, classification, the ordered

and the suggested dose of the doctor, their action, indication by the drug,

contraindications, drug interactions, side effects and their nursing interventions

towards our client;

16. Discuss the medical and surgical managements done to our patient

accordingly

17. Present the nursing management of our client to develop nursing care plans;

18 Implement health teachings to our client appropriate with his health care

needs

19. Formulate our prognosis on his current health condition based on the

following information that we have gathered; and

20. Enumerate the references used for the achievement of this case study.


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Name: Patient X

Age: 64 Years Old

Birthday: July 07, 1947

Birthplace: Australia

Nationality: Australian

Religion: Catholic

Sex: Male

Civil Status: Divorced

Occupation: Former Military in Vietnam

Address: Lanang, Davao City

Live-in Partner: Partner Y

CLINICAL STATUS

Chief Complaint: Epigastric Pain & Vomiting

Date of Admission: August 8, 2011

Admission Time: 8:00 pm

Manner of Admission: Per Wheelchair

Ward: St. Dominic

Room and Bed no: 409-2

Attending Physician: Dr. Marilyn O. Arguelles, MD

Dr. R. Cabahug, MD

Dr. L. Gallardo, MD

Impression: AGE with chronic Aspirin Intake

R/OAcute Pancreatitis


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Diabetic Gastropathy

CAP MR

DM type 2

Discharged Date: August 11, 2011

Discharged Time: 8:23 pm

Final Diagnosis: Age with Some Dehydration

Others: Coronary Artery Disease,

Left Ventricular Hypertrophy,

PAC frequent FCI

Post CVA,

MRE 2 DM


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FAMILY HEALTH HISTORY

During the interview, we asked Patient X about their familys health status and

the hereditary diseases that run in their family and he was able to recall some and

provide the data we needed.

The hereditary diseases present in Patient Xs on his materna l side were

Hypertension, Diabetis Mellitus and Cardiac disease. His grandmother died at age of 74

due to embolism that leads to stroke. He does not remember the reason of his

grandfathers death. However, he said that his grandfather had Diabetis Mellitus . Her

mother had hypertension and died at the age of 34 due to stroke. He had no aunt and

uncle on his maternal side.

On his paternal side, when we asked our patient he said that he does not

anymore remember the names of his grandparents and the hereditary that are present

on them. His dad died because of lung cancer at the age of 75. He does not know the

reason of death of his only uncle and if there is any hereditary diseases present on him.

He had 5 siblings, their eldest JDC 66 years old, next is our patient 64 years old

followed by CCC 62 years old, an obese person, then MGC 58 years old, she is

mentally retarded, next BRC 56 years old and their youngest LRC 54 years old who had

Polio when he was a baby.

Lastly, Patient X was diagnosed of having Coronary Artery Disease, Left

Ventricular Hypertrophy, PAC frequent FCI, Post CVA, MRE 2 DM.


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MATERNAL SIDE PATERNAL SIDE

GD ED

79

AD

74

? ?

CVC

75

JC

64JDC

66

CCC

62

LRC

54

MGC

58

BRC

56

LEGEND:

?

HPN

CARDIAC DSE.

DM

DECEASED

POLIO

LUNG CANCER

MENTAL ILLNESS

FEMALE

MALE

STROKE

UNKNOWN


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PAST HEALTH HISTORY

We asked our patient some questions that was related to his health and he said

that he experienced childhood illnesses such as Mumps, Chicken pox or Measles.

Furthermore, he had no allergies in food.

In the year 1964 our client was 17 years old and he had his first tattoo on his

anterior lateral left arm, measuring 16x8cm with visible color of green and black. Our

client claimed that there were no complications after the procedure. When our client

was 52 years old (1999) he was forced to end his military work in Vietnam due to his

post traumatic distress disorder and he became a pensioner afterwards. He was back to

his home land after the end of his work in Vietnam. He was put on rehabilitation in

Australia for a few weeks and the patient was given instruction on how to manage his

disorder since our client stated that the doctors told him that there is no cure to the

disorder, however there are drugs that should be maintained.

In the year 2003, our patient stated that he started to feel chest pain which

prompted his first admission in a hospital in Australia. Upon asking if he still remember

the month or date the patient said that it was a long time ago so the only thing he could

remember was the year. There in his admission he was diagnosed as having a Diabetis

Mellitus type 2 and Coronary Artery Disease. He was supposed to be operated for a

heart bypass but because his glucose level was still high due to his Diabetis Mellitus the

doctors told him that they should wait till the glucose level is stabilized or within normal

range before he will have the surgery. After he was stabilized the heart bypass was

done to him by getting a vein in his anterior left arm and was connected to his heart by

doing a Median Sternotomy for the surgical approach for CABG surgery. No

complications happened after the surgery as stated by the patient. The heart bypass

was a successful operation. He was given maintenance drugs of Nexium(1 tablet aday), Simvastat in(1 tablet a day), Aspirin(100mg/1 tablet a day) and Melformin GA(40

mg/2 times a day) for his diabetes.


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In the year 2006 he went to the Philippines because of his Filipina girlfriend. The

couples relationship did not went well and because of a lot of problems that caused him

stress he ended his relationship and went back to his home land in Australia. He stated

that he cannot handle the stress and because he has a disorder he decided to go back

to his place. It was also on the same year that he went to the Philippines and went back

to Australia.

In 2009 he had another Filipina girlfriend on which he decided to go back to the

Philippines and settle there. Hes relationship went well and he is staying now with her

as a live-in partner. He said that his partner is the one assisting him in his maintenance

medications.

In the year 2010 he had his first admission in Davao city in a hospital due to

abdominal pain. He also stated that he had episodes of allergy during his stay in the

hospital. He stayed for the hospital for a few weeek and was discharged.

Due to his traumatic experience he became very irritable until now however he

sometimes can manage it by avoiding the stimulant or the problem. During his military

work he usually has an intake of 3 bottles of beer a day. He is a smoker, who usually

consumes 2-3 packs a day for approximately more than 40 years now. He stated that

he was not as diligent in taking his medication when he was still in Australia, it was just

here in the Philippines during 2009 that he was able to take them religiously. His highest

blood pressure was 140/100 and his lowest was 110/80 as recorded in the chart.

HISTORY OF PRESENT ILLNESS

A week prior to admission our client complained of on and off epigastric pain

described as sharp pain, minimal modulation, above condition tolerable, sought consult

SPH-out patient department and was given Nexium, Durpature and was relieved to

above condition.

August 8, 2011, early morning he complained of gradual onset of epigastric pain,

described as sharp pain relatively to peripheral area at the left and lower quadrant. He


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was only able to eat toast bread and a chocolate drink for his breakfast since he wasnt

feeling well. He wasnt able to consume any food during lunch time but had taken water

for his drinks. Late evening around 7:30 he started vomiting. The watcher claimed that

his first episode of vomiting was with food however on the 2nd up to the 5th time his

vomitus was mostly water in small quantity of around 5-10ml of fluids, until such time no

vomitus was noted but still exhibit vomiting response. He also complained that during

those times he was suffering from abdominal pain, body malaise and headache. The

watcher claimed that due to his vomiting, abdominal pain, dry lips and pale appearance

which prompted them for admission at SanPedroHospital around 9:00 in the evening on

that day.

In the assessment he was negative for LBM, melena, hematochezia and fever

and was positive on having a dry cough. During the admission a physical assessment

was done which revealed awake, afebrile, not in respiratory distress, enecteric eyes,

symmetrical chest expansion, scar in midline anterior arm, soft, tender on epigastric

area and negative on cold clammy skin. The watcher also reported that during the

assessment the nurse wasnt able to get any blood pressure and was only able to

record 80 bpm palpable on his radial pulse and after wards he was already stabilized

which revealed a blood pressure of 100/60. He was then given an impression and

tentative diagnosis of: AGE with chronic Aspirin intake, R/O Acute Pancreatitis,

Diabetic Gastropathy, CAP MR, Diabetis Mellitus type 2.

Our client was then transported to his room per wheelchair at St Dominics ward

room 409-2. Admission orders were carried out by nurse on duty.


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DEVELOPMENTAL TASK

a. Psychosocial Theory

Psychosocial development is how a person's mind, emotions, and maturity level

develop throughout the course of their lifetime. Different people will develop

psychosocially at different speeds depending on biological processes and

environmental interactions. Erik Eriksons believes that people continue to develop

throughout life. His Psychosocial theory describes eight stages of development. At each

stage, there is a conflict between two opposing forces. The decision of each conflict or

accomplishment of the developmental task of that stage allows the individual to go on to

the next phase of development.

Patient X, 64 years old belongs to the 7th psychosocial stage in Eriksons

theory, which is the Middle Adulthood. In this stage, the primary developmental task is

one of contributing to society and helping to guide future generations. Adults need to

create or nurture things that will outlast them, often by having children or creating a

positive change that benefits other people. Success leads to generativity or feelings of

usefulness and accomplishment, while failure results in stagnation which makes shallow

involvement in the world.

STAGE CENTRAL TASK ACTUAL JUSTIFICATION

Middle

Adulthood

(35-65 yrs

old.)

Generativity vs.

Stagnation

Task: Fulfilling life

goals that involve

family, career, and

society

MET Our patient has been divorced

with his previous wife.

However, at present he is living

happily together with hispartner. Although he has been

forced to end his military duty,

he was able to serve his

country during the times of war.


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DEVELOPMENTAL TASK THEORY

Robert Havighurst defines a developmental task as one that arises at a certain

period in our lives, the successful achievement of which leads to happiness andsuccess with later tasks; while leads to unhappiness, social disapproval, and difficulty

with later tasks. Havighurst uses lightly different age groupings, but the basic divisions

are quite similar to those used in this book. He identifies three sources of developmental

tasks.

He believes that learning is basic to life and that people continue to learn

throughout life. He describes growth and development as occurring during six stages,

each associated with six to ten tasks to be learned. Our patient, Patient x belongs to:

STAGE DEVELOPMENTAL TASK ACTUAL JUSTIFICATION

Middle

Age

Achieving adult civic

and social

resposibilityMET

Patient X worked as a

military and served his

country during the war.

Establishing and

maintaining an

economic standard of

living

MET

Our patient has became a

pensioner since the day he

was forced to end his duty.

All his needs were provided

by the government of

Australia.

Assisting teenage

children to become

responsible and

happy adults

UNMET

Our patient does not have

any children to assist to.


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Developing adult

leisure time activitiesMET

Patient X said that he spent

most of his time watching

TV and going to the mall

and different places.

Relating oneself to

ones spouse as a

personMET

Patient X said that her

partner gives everything he

wanted, she makes sure

that they talk in every

problem they encounter.

Accepting and

adjusting to the

physiologic changes

in the middle age and

aging process

MET

Patient X said that he

accepts all the changes that

is happening to his body.

With rehards to this, he said

that he needs to wear his

eyeglasses because he is

already old and he cant

clearly see without his

eyeglasses.


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General Survey:

Upon assessment the patient was placed on a moderate high back rest. He is

awake, conscious and responsive to any stimuli. He is well groomed and was wearing a

hospital gown, body and breath odor were not noted. He is ectomorph, with good

posture. He is 65 years old, from Australia.

Mouth

Uniform pink in color, soft, moist, smooth in texture symmetry of contour and he

was ability to purse his lips. 13 teeth were extracted- 7 upper teeth, 6 lower teeth. The

color of the filling of his teeth is black.

Anterior chest

Scar was noted upon inspection, with a width of 2cm and a length of 21cm on the

transverse scar and 3cm on the horizontal scar. The scar was due to his bypass

operation.

Extremities

Upon inspection scar was noted at the left forearm with a length of 23cm due to

his bypass.

At his left leg a fresh scratch was noted.


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Coronary Artery Disease (CAD) is defined as a progressive atherosclerotic

disorder of the coronary arteries in which a coronary luminal obstruction caused by

plaque buildup of cholesterol, lipids and cellular debris infiltrating the intimal lining of the

arterial wall, causing a reduced blood flow to the myocardium that resultsin narrowing or

complete occlusion of the vessel lumen. It includes abnormal conditions such as

arteriosclerosis and arteritis of the coronary arteries, all of which result in reduced flow

of oxygen and nutrients to the Myocardium.

The dominant effect of Coronary Artery Disease is the loss of oxygen and

nutrients to myocardial tissue because of diminished coronary blood flow. This disease

is near epidemic in the western world. It occurs more commonly in men than women, in

whites and in middle-aged and elderly people.

Yuan, s.(2006). Handbook of Diseases. Third edition. Lippincott williams and

wilkins.pp.231-236.

Coronary Artery Disease (CAD) is the most prevalent type of cardiovascular

disease. It is an abnormal accumulation of lipid, or fatty, substances and fibrous tissuein

the vessel wall. These blockage create blockages or narrow the vessel in a way

thatreduces blood flow to the myocardium.studies indicate that atheroscleros involves a

repetitious imflammatory response to artery wall injury and an alteration in the

biophysical and biochemical properties of the arterial walls.

Smeltzer, S., Bare, B. Brunner and Suddarths Textbook of Medical-Surgical Nursing.

Vol. 1. 10th

edition. Lippincott-Raven Publisher. Lippincott Williams and Wilkins.

Coronary artery disease(CAD; alsoatheroscleroticheart disease)is the end

result of the accumulation ofatheromatous plaques within the walls of thecoronary

arteries that supply themyocardium (the muscle of theheart)with oxygen and nutrients.It is sometimes also calledcoronary heart disease(CHD), although CAD is the most

common cause of CHD, it is not the only one.

http://en.wikipedia.org/wiki/Coronary_artery_disease
http://en.wikipedia.org/wiki/Atherosclerosishttp://en.wikipedia.org/wiki/Atherosclerosishttp://en.wikipedia.org/wiki/Heart_diseasehttp://en.wikipedia.org/wiki/Heart_diseasehttp://en.wikipedia.org/wiki/Atheromahttp://en.wikipedia.org/wiki/Coronary_circulationhttp://en.wikipedia.org/wiki/Coronary_circulationhttp://en.wikipedia.org/wiki/Myocardiumhttp://en.wikipedia.org/wiki/Hearthttp://en.wikipedia.org/wiki/Coronary_heart_diseasehttp://en.wikipedia.org/wiki/Coronary_heart_diseasehttp://en.wikipedia.org/wiki/Coronary_heart_diseasehttp://en.wikipedia.org/wiki/Coronary_heart_diseasehttp://en.wikipedia.org/wiki/Hearthttp://en.wikipedia.org/wiki/Myocardiumhttp://en.wikipedia.org/wiki/Coronary_circulationhttp://en.wikipedia.org/wiki/Coronary_circulationhttp://en.wikipedia.org/wiki/Atheromahttp://en.wikipedia.org/wiki/Heart_diseasehttp://en.wikipedia.org/wiki/Atherosclerosis


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Coronary artery disease (CAD)is the most common type of heart disease. It is

the leading cause of death in the United States in both men and women.CAD happens

when the arteries that supply blood to heart muscle become hardened and narrowed.

This is due to the buildup ofcholesterol 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 a blood

clot suddenly cuts off the hearts' blood supply, causing permanent heart damage.Over

time, CAD can also weaken the heart muscle and contribute toheartfailure 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.

http://www.nlm.nih.gov/medlineplus/coronaryarterydisease.html

Coronary artery disease isatherosclerosis of the coronary arteries, producing

blockages in the vessels which nourish the heart itself. Atherosclerosis occurs when the

arteries become clogged and narrowed, restricting blood flow. Without adequate blood

flow from the coronary arteries, the heart becomes starved of oxygen and vital nutrients

it needs to work properly.

http://www.webmd.com/heart-disease/guide/heart-disease-coronary-artery-disease
http://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/heartfailure.htmlhttp://www.nlm.nih.gov/medlineplus/arrhythmia.htmlhttp://www.webmd.com/heart-disease/what-is-atherosclerosishttp://www.webmd.com/heart-disease/what-is-atherosclerosishttp://www.nlm.nih.gov/medlineplus/arrhythmia.htmlhttp://www.nlm.nih.gov/medlineplus/heartfailure.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.html


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The cardiovascular system provides the transport system hardware that keeps

blood continuously circulating to fulfill this critical homeostatic need. Stripped of its

romantic cloak, the heart is no more than the transport system pump; the hollow blood

vessels are the delivery routes. Using blood as the transport medium, the heart

continually propels oxygen, nutrients, wastes, and many other substances into the

interconnecting blood vessels that service body cells.

The blood vessels that carry blood to and from the lungs form thepulmonary circuit

(pulmonos = lung), which serves gas exchange. The blood vessels that carry the

functional blood supply to and from all body tissues constitute thesystemic circuit.

The right side of the heart is the pulmonary circuit pump. Blood returning from the body

is relatively oxygen-poor and carbon dioxiderich. It enters the right atrium and passes

into the right ventricle, which pumps it to the lungs via the pulmonary trunk. In the lungs,

the blood unloads carbon dioxide and picks up oxygen. The freshly oxygenated blood is

carried by the pulmonary veins back to the left side of the heart. Notice how unique this

circulation is. Typically, we think of veins as vessels that carry blood that is relatively

oxygen-poor to the heart and arteries as transporters of oxygen-rich blood from the


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heart to the rest of the body. Exactly the opposite condition exists in the pulmonary

circuit.

The left side of the heart is the systemic circuit pump. Freshly oxygenated blood

leaving the lungs is returned to the left atrium and passes into the left ventricle, which

pumps it into the aorta. From there the blood is transported via smaller systemic arteries

to the body tissues, where gases and nutrients are exchanged across the capillary

walls. Then the blood, once again loaded with carbon dioxide and depleted of oxygen,

returns through the systemic veins to the right side of the heart, where it enters the right

atrium through the superior and inferior venae cavae. This cycle repeats itself

continuously.

Although equal volumes of blood are pumped to the pulmonary and systemic circuits at

any moment, the two ventricles have very unequal workloads. The pulmonary circuit,

served by the right ventricle, is a short, low-pressure circulation, whereas the systemic

circuit, associated with the left ventricle, takes a long pathway through the entire body

and encounters about five times as much friction, or resistance to blood flow. This

functional difference is revealed in the anatomy of the two ventricles. The walls of the

left ventricle are three times as thick as those of the right ventricle, and its cavity is

nearly circular. The right ventricular cavity is flattened into a crescent shape that

partially encloses the left ventricle, much the way a hand might loosely grasp a

clenched fist. Consequently, the left ventricle can generate much more pressure than

the right and is a far more powerful pump.

The three major types of blood vessels are arteries, capillaries, and veins. As the heart

contracts, it forces blood into the large arteries leaving the ventricles. The blood then

moves into successively smaller arteries, finally reaching their smallest branches, the

arterioles, which feed into the capillary beds of body organs and tissues. Blood drains

from the capillaries into venules , the smallest veins, and then on into larger and largerveins that merge to form the large veins that ultimately empty into the heart. Altogether,

the blood vessels in the adult human stretch for about 100,000 km (60,000 miles)

through the internal body landscape!

Because arteries carry blood away from the heart, they are said to branch,

diverge, or fork as they form smaller and smaller divisions. Veins, by contrast, carry


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blood toward the heart and so are said to join, merge, and converge into the

successively larger vessels approaching the heart. In the systemic circulation, arteries

always carry oxygenated blood and veins always carry oxygen-poor blood. The

opposite is true in the pulmonary circulation, where the arteries, still defined as the

vessels leading away from the heart, carry oxygen-poor blood to the lungs, and the

veins carry oxygen-rich blood from the lungs to the heart. The special umbilical vessels

of a fetus also differ in the roles of veins and arteries.

Of all the blood vessels, only the capillaries have intimate contact with tissue cells and

directly serve cellular needs. Exchanges between the blood and tissue cells occur

primarily through the gossamer-thin capillary walls

Structure of Blood Vessel Walls

The walls of all blood vessels, except the very smallest, have three distinct layers, or

tunics (coverings), that surround a central blood-containing space, the vessel lumen.

The innermost tunic is the tunica intima . This tunic contains the endothelium, the simple

squamous epithelium that lines the lumen of all vessels. The endothelium is a

continuation of the endocardial lining of the heart, and its flat cells fit closely together,


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forming a slick surface that minimizes friction as blood moves through the lumen. In

vessels larger than 1 mm in diameter, a subendothelial layer, consisting of a basement

membrane and loose connective tissue, supports the endothelium.

The middle tunic, the tunica media, is mostly circularly arranged smooth muscle cells

and sheets of elastin. The activity of the smooth muscle is regulated by sympathetic

vasomotor nerve fibers of the autonomic nervous system and a whole battery of

chemicals. Depending on the bodys needs at any given moment, either

vasoconstriction (reduction in lumen diameter as the smooth muscle contracts) or

vasodilation (increase in lumen diameter as the smooth muscle relaxes) can be

effected. Because small changes in vessel diameter greatly influence blood flow and

blood pressure, the activities of the tunica media are critical in regulating circulatory

dynamics. Generally, the tunica media is the bulkiest layer in arteries, which bear the

chief responsibility for maintaining blood pressure and continuous blood circulation.

The outermost layer of a blood vessel wall, the tunica externa is composed largely of

loosely woven collagen fibers that protect and reinforce the vessel, and anchor it to

surrounding structures. The tunica externa is infiltrated with nerve fibers, lymphatic

vessels, and, in larger veins, a network of elastin fibers. In larger vessels, the tunica

externa contains a system of tiny blood vessels, the vasa vasorum (vasah va-sorum)

literally, vessels of the vessels that nourish the more external tissues of the blood

directlyfrom blood in the lumen.

Hearts Anatomy(Size, Location, and Orientation)


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The modest size and weight of the heart belie its incredible strength and

endurance. About the size of a fist, the hollow, cone-shaped heart has a mass of

between 250 and 350 gramsless than a pound. Snugly enclosed within the

mediastinum, the medial cavity of the thorax, the heart extends obliquely for 12 to 14

cm (about 5 inches) from the second rib to the fifth intercostal space . As it rests on the

superior surface of the diaphragm, the heart lies anterior to the vertebral column and

posterior to the sternum. The lungs flank the heart laterally and partially obscure it.

Approximately two-thirds of its mass lies to the left of the midsternal line; the balance

projects to the right. Its broad, flat base, or posterior surface, is about 9 cm (3.5 in) wide

and directed toward the right shoulder. Its apex points inferiorly toward the left hip. If

you press your fingers between the fifth and sixth ribs just below the left nipple, you can

easily feel your heart beating where the apex contacts the chest wall. Hence, this site is

referred to as the point of maximal intensity (PMI).

The heart is enclosed in a double-walled sac called thepericardium.The loosely fitting

superficial part of this sac is the fibrous pericardium. This tough, dense connective

tissue layer (1) protects the heart, (2) anchors it to surrounding structures, and (3)

prevents overfilling of the heart with blood.

Deep to the fibrous pericardium is the serous pericardium, a thin, slippery, two-layer

serous membrane. Its parietal layer lines the internal surface of the fibrous pericardium.

At the superior margin of the heart, the parietal layer attaches to the large arteries

exiting the heart, and then turns inferiorly and continues over the external heart surface

as the visceral layer, also called the epicardium (upon the heart), which is an integral

part of the heart wall.

Between the parietal and visceral layers is the slitlike pericardial cavity, which

contains a film of serous fluid. The serous membranes, lubricated by the fluid, glide

smoothly past one another during heart activity, allowing the mobile heart to work in a

relatively friction-free environment.


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Chambers and Associated Great Vessels

The heart has four chambers two superior atria and two inferior ventricles.

The internal partition that divides the heart longitudinally is called the interatrial septum

where it separates the atria, and the interventricular septum where it separates the

ventricles. The right ventricle forms most of the anterior surface of the heart. The left

ventricle dominates the inferoposterior aspect of the heart and forms the heart apex.

Two grooves visible on the heart surface indicate the boundaries of its four chambers

and carry the blood vessels supplying the myocardium. The coronary sulcus, or

atrioventricular groove, encircles the junction of the atria and ventricles like a crown

(corona = crown). The anterior interventricular sulcus, cradling the anterior

interventricular artery, marks the anterior position of the septum separating the right and

left ventricles. It continues as the posterior interventricular sulcus, which provides a

similar landmark on the hearts posteroinferior surface.

Atria: The Receiving Chambers

Except for small, wrinkled, protruding

appendages called auricles, which increase

the atrial volume somewhat, the right and left

atria are remarkably free of distinguishing

surface features. Internally, the right atrium

has two basic parts: a smooth-walled posterior

part and an anterior portion in which the walls

are ridged by bundles of muscle tissue.

Because these bundles look like the teeth of a comb, these muscle bundles are called

pectinate muscles (pectin = comb). The posterior and anterior regions of the right atrium

are separated by a C-shaped ridge called the crista terminalis (terminal crest). In

contrast, the left atrium is mostly smooth and undistinguished internally. The interatrial


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septum bears a shallow depression, the fossa ovalis, that marks the spot where an

opening, the foramen ovale, existed in the fetal heart .

Functionally, the atria are receiving chambers for blood returning to the heart from the

circulation (atrium = entryway). Because they need contract only minimally to push

blood downstairs into the ventricles, the atria are relatively small, thin-walled

chambers. As a rule, they contribute little to the propulsive pumping activity of the heart.

Blood enters the right atrium via three veins (1) The superior vena cava returns

blood from body regions superior to the diaphragm; (2) the inferior vena cavareturns

blood from body areas below the diaphragm; and (3) the coronary sinus collects blood

draining from the myocardium. Four pulmonary veins enter the left atrium, which

makes up most of the hearts base. These veins, which transport blood from the lungs

back to the heart, are best seen in a posterior view (Figure 18.4d).

Ventricles: The Discharging Chambers

Together the ventricles make up most of the volume of the heart. As already mentioned,

the right ventricle forms most of the hearts anterior surface and the left ventricle

dominates its posteroinferior surface. Marking the internal walls of the ventricular

chambers are irregular ridges of muscle called trabeculae carneae . Still other muscle

bundles, the conelike papillary muscles, which play a role in valve function, project into

the ventricular cavity.

The ventricles are the discharging chambers or actual pumps of the heart (the

difference in function between atria and ventricles is reflected in the much more

massive ventricular walls. When the ventricles contract, blood is propelled out of the

heart into the circulation. The right ventricle pumps blood into the pulmonary trunk,

which routes the blood to the lungs where gas exchange occurs. The left ventricle ejects

blood into theaorta,the largest artery in the body.


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Coronary Circulation

Although the heart is more or less continuously filled with blood, this blood provides little

nourishment to heart tissue. (The myocardium is too thick to make diffusion a practical

means of nutrient delivery.) The coronary circulation, the functional blood supply of

the heart, is the shortest circulation in the body. The arterial supply of the coronary

circulation is provided by the right and left coronary arteries, both arising from the base

of the aorta and encircling the heart in the coronary sulcus (Figure 18.7a). The left

coronary artery runs toward the left side of the heart and then divides into its major

branches: the anterior interventricular

artery (also known clinically as the left

anterior descending artery), which

follows the anterior interventricular

sulcus and supplies blood to the

interventricular septum and anterior

walls of both ventricles; and the

circumflex artery, which supplies the

left atrium and the posterior walls of the

left ventricle


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The right coronary artery courses to the right side of the heart, where it alsodivides into two branches: the marginal artery, which serves the myocardium of the

lateral right side of the heart, and the posterior interventricular artery, which runs to the

heart apex and supplies the posterior ventricular walls. Near the apex of the heart, this

artery merges (anastomoses) with the anterior interventricular artery. Together the

branches of the right coronary artery supply the right atrium and nearly all the right

ventricle.

The arterial supply of the heart varies considerably. For example, in 15% of people,

the left coronary artery gives rise to both the anterior and posterior interventricular

arteries; in about 4% of people, a single coronary artery supplies the whole heart.

Additionally, there may be both right and left marginal arteries. There are many

anastomoses among the coronary arterial branches. These fusing networks provide

additional (collateral) routes for blood delivery to the heart muscle, but are not robust

enough to supply adequate nutrition when a coronary artery is suddenly occluded.

Complete blockage leads to tissue death and heart attack.

The coronary arteries provide an intermittent, pulsating blood flow to the myocardium.

These vessels and their main branches lie in the epicardium and send branches inward

to nourish the myocardium. They deliver blood when the heart is relaxed, but are fairly

ineffective when the ventricles are contracting because they are compressed by the

contracting myocardium. Although the heart represents only about 1/200 of the bodys


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weight, it requires about 1/20 of the bodys blood supply. As might be expected, the left

ventricle receives the most plentiful blood supply.

After passing through the capillary beds of the myocardium, the venous blood is

collected by the cardiac veins, whose paths roughly follow those of the coronary

arteries. These veins join together to form an enlarged vessel called the coronary sinus,

which empties the blood into the right atrium. The coronary sinus is obvious on the

posterior aspect of the heart (Figure 18.7b). The sinus has three large tributaries: the

great cardiac vein in the anterior interventricular sulcus; the middle cardiac vein in the

posterior interventricular sulcus; and the small cardiac vein, running along the hearts

right inferior margin. Additionally, several anterior cardiac veins empty directly into the

right atrium anteriorly.

Heart Valves

Blood flows through the heart in one direction: from atria to ventricles and out the great

arteries leaving the superior aspect of the heart. This one-way traffic is enforced by four

valves (Figures 18.4e and 18.8) that open and close in response to differences in blood

pressure on their two sides.


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Atrioventricular Valves

The two atrioventricular (AV) valves, one located at each atrial-ventricular junction,

prevent backflow into the atria when the ventricles are contracting. The right AV valve,

the tricuspid valve, has three flexible cusps (flaps of endocardium reinforced by

connective tissue cores). The left AV valve, with two flaps, is called the mitral valve

because of its resemblance to the two-sided bishops miter or hat. It is sometimes called

the bicuspid valve. Attached to each AV valve flap are tiny white collagen cords called

chordae tendineae, heart strings which anchor the cusps to the papillary muscles

protruding from the ventricular walls.

When the heart is completely relaxed, the AV valve flaps hang limply into theventricular chambers below and blood flows into the atria and then through the open AV

valves into the ventricles. When the ventricles contract, compressing the blood in their

chambers, the intraventricular pressure rises, forcing the blood superiorly against the

valve flaps. As a result, the flap edges meet, closing the valve. The chordae tendineae

and the papillary muscles serve as guy-wires to anchor the valve flaps in their closed

position. If the cusps were not anchored in this manner, they would be blown upward

into the atria, in the same way an umbrella is blown inside out by a gusty wind. The

papillary muscles contract before the other ventricular musculature so that they take up

the slack on the chordae tendineae before the full force of ventricular contraction hurls

the blood against the AV valve flaps.

Semilunar Valves

The aortic and pulmonary (semilunar, SL) valves guard the bases of the large

arteries issuing from the ventricles (aorta and pulmonary trunk, respectively) and

prevent backflow into the associated ventricles. Each SL valve is fashioned from three

pocketlike cusps, each shaped roughly like a crescent moon (semilunar = half-moon).

Like the AV valves, the SL valves open and close in response to differences in


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pressure. In the SL case, when the ventricles are contracting and intraventricular

pressure rises above the pressure in the aorta and pulmonary trunk, the SL valves are

forced open and their cusps flatten against the arterial walls as the blood rushes past

them. When the ventricles relax, and the blood (no longer propelled forward by the

pressure of ventricular contraction) flows backward toward the heart, it fills the cusps

and closes the valves.


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PA

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M

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MEDICAL ORDER

DATE AND TIME DOCTORS ORDER RATIONALE

August 8, 2011

9:30pm

Admit patient under the service

of Dr. Aquillas

Admission to preferred specialist is

necessary in order to give specialattention to the needs of the client

in terms of health improvement

BP=80-100/60

HR=120

RR=21

Hgt= 327 mg/dl

VS q 4, BP monitoring q hourly

until stable

Vital signs are the baseline data

that a nurse collects during

assessment. Any abnormalities in

the results may indicate problems

in the patient

Labs:

-CBC

-serum uric acid

The complete blood count is the

calculation of the cellular (formed

elements) of blood. These

calculations are generally

determined by specially designed

machines that analyze the different

components of blood in less than a

minute.

The uric acid test is used to

measure serum uric acid levels,

the major end metabolite of purine.

Disorders of purine metabolism,

rapid destruction of nucleic acids,

and conditions marked by impaired

renal excretion characteristically

raise serum uric acid levels.


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-S. Creatinine

-HBA1C

-S.Amylase

-Hgt-now

-TROP I

Measuring serum creatinine is a

useful and inexpensive method of

evaluating renal dysfunction.

Creatinine is a non-protein waste

product of creatine phosphate

metabolism by skeletal muscle

tissue. Creatinine production is

continuous and is proportional to

muscle mass.

HbA1c is a test that measures the

amount of glycatedhemoglobin in

the blood.

A test can be done to measure the

level of this enzyme in the blood.

Amylase is anenzyme that helps

digest carbohydrates. It is

produced in the pancreas and the

glands that make saliva. When the

pancreas is diseased or inflamed,

amylase releases into the blood.

It is the immediate measurement of

blood for glucose using bloodsample from a fingerstick or

heelstick.

The troponin test measures the
http://www.nlm.nih.gov/medlineplus/ency/article/003677.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/002353.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/002353.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/003677.htm


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-FBS

-S. lipid profile

-SGPT (ALT)

levels of one of two proteins,

troponin T or troponin I, in a blood

sample. These proteins are

released when the heart muscle

has been damaged, such as during

a heart attack. The more damage

there is to the heart, the greater

the amount of troponin T and I

there will be in the blood.

A fasting blood sugar(FBS) level

is one of the tests used to

diagnose diabetes mellitus

(another being theoral glucose

tolerance test).

Lipid Profileis a group of tests that

are often ordered together to

determine risk of coronary heart

disease. The tests that make up a

lipid profile are tests that have

been shown to be good indicators

of whether someone is likely to

have a heart attack or stroke

caused by blockage of blood

vessels ("hardening of the

arteries").

An alanine aminotransferase (ALT)

test measures the amount of this

enzyme in the blood.ALT is found
http://www.healthypinoy.com/health/articles/diabetes/ogtt.htmlhttp://www.healthypinoy.com/health/articles/diabetes/ogtt.htmlhttp://www.webmd.com/hw-popup/enzymehttp://www.webmd.com/heart/anatomy-picture-of-bloodhttp://www.webmd.com/heart/anatomy-picture-of-bloodhttp://www.webmd.com/hw-popup/enzymehttp://www.healthypinoy.com/health/articles/diabetes/ogtt.htmlhttp://www.healthypinoy.com/health/articles/diabetes/ogtt.html


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-Xray abdominal upright and

spine(plain)

mainly in the liver, but also in

smaller amounts in the kidneys,

heart,muscles, andpancreas

An abdominalX-ray is a picture of

structures andorgans in the belly

(abdomen). This includes the

stomach,liver,spleen,large and

smallintestines,and the

diaphragm, which is the muscle

that separates the chest and belly

areas. Often two X-rays will be

taken from different positions. If the

test is being done to look for

certain problems of thekidneys or

bladder,it is often called a KUB

(forkidneys, ureters, and bladder).

Spinal X-rays are pictures of the

spine. They may be taken to find

injuries or diseases that affect the

discs or joints in your spine. These

problems may include spinal

fractures,infections, dislocations,

tumors, bone spurs, or disc

disease.

Spinal X-rays are also done to

check the curve of your spine

(scoliosis)or for spinal defects.
http://www.webmd.com/digestive-disorders/picture-of-the-liverhttp://www.webmd.com/hw-popup/heart-anatomyhttp://www.webmd.com/hw-popup/pancreashttp://www.webmd.com/hw-popup/x-rayhttp://www.webmd.com/hw-popup/abdominal-organshttp://www.webmd.com/digestive-disorders/picture-of-the-abdomenhttp://www.webmd.com/digestive-disorders/picture-of-the-stomachhttp://www.webmd.com/digestive-disorders/picture-of-the-liverhttp://www.webmd.com/digestive-disorders/picture-of-the-spleenhttp://www.webmd.com/digestive-disorders/picture-of-the-intestineshttp://www.webmd.com/urinary-incontinence-oab/picture-of-the-kidneyshttp://www.webmd.com/urinary-incontinence-oab/picture-of-the-bladderhttp://www.webmd.com/hw-popup/female-urinary-systemhttp://www.webmd.com/hw-popup/spinal-discshttp://www.webmd.com/a-to-z-guides/understanding-fractures-basic-informationhttp://www.webmd.com/hw-popup/scoliosis-7533http://www.webmd.com/hw-popup/scoliosis-7533http://www.webmd.com/a-to-z-guides/understanding-fractures-basic-informationhttp://www.webmd.com/hw-popup/spinal-discshttp://www.webmd.com/hw-popup/female-urinary-systemhttp://www.webmd.com/urinary-incontinence-oab/picture-of-the-bladderhttp://www.webmd.com/urinary-incontinence-oab/picture-of-the-kidneyshttp://www.webmd.com/digestive-disorders/picture-of-the-intestineshttp://www.webmd.com/digestive-disorders/picture-of-the-spleenhttp://www.webmd.com/digestive-disorders/picture-of-the-liverhttp://www.webmd.com/digestive-disorders/picture-of-the-stomachhttp://www.webmd.com/digestive-disorders/picture-of-the-abdomenhttp://www.webmd.com/hw-popup/abdominal-organshttp://www.webmd.com/hw-popup/x-rayhttp://www.webmd.com/hw-popup/pancreashttp://www.webmd.com/hw-popup/heart-anatomyhttp://www.webmd.com/digestive-disorders/picture-of-the-liver


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-USD of whole abdomen

include prostate in AM

-chest xray PA view

Abdominal ultrasound imaging is

performed to evaluate thekidneys,

liver,gallbladder,pancreas,

spleen,abdominal aorta and other

blood vessels of the abdomen.

Ultrasound may be used to provide

guidance for biopsies.

Chest x rays are ordered for a

wide variety of diagnostic

purposes. In fact, this is probably

the most frequently performed type

of x ray. In some cases, chest x

rays are ordered for a single check

of an organ's condition, and at

other times, serial x rays are

ordered to compare to previous

studies.

The chest x-ray film is important in

a complete evaluation of the

pulmonary and cardiac sysytem.

-for UGI series after xray ofabdomen is viewed.

An upper gastrointestinal (UGI)series looks at the upper and

middle sections of the

gastrointestinal tract . The test

usesbarium contrast material,
http://www.radiologyinfo.org/en/glossary/glossary1.cfm?gid=152http://www.radiologyinfo.org/en/glossary/glossary1.cfm?gid=27http://www.radiologyinfo.org/en/glossary/glossary1.cfm?gid=123http://www.radiologyinfo.org/en/glossary/glossary1.cfm?gid=189http://www.radiologyinfo.org/en/glossary/glossary1.cfm?gid=237http://www.radiologyinfo.org/en/glossary/glossary1.cfm?gid=654http://www.webmd.com/hw-popup/digestive-tracthttp://www.webmd.com/hw-popup/contrast-materialhttp://www.webmd.com/hw-popup/contrast-materialhttp://www.webmd.com/hw-popup/digestive-tracthttp://www.radiologyinfo.org/en/glossary/glossary1.cfm?gid=654http://www.radiologyinfo.org/en/glossary/glossary1.cfm?gid=237http://www.radiologyinfo.org/en/glossary/glossary1.cfm?gid=189http://www.radiologyinfo.org/en/glossary/glossary1.cfm?gid=123http://www.radiologyinfo.org/en/glossary/glossary1.cfm?gid=27http://www.radiologyinfo.org/en/glossary/glossary1.cfm?gid=152


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-start venoclysis with PNSS 1L

fast drip 300cc now then

120cc/hr

Meds:

1.) Pantoprazole 40mg now

then OD

2.) Humulin R 6 units SQ

now

3.) Metformin 1000 mg/

1tab OD @HS

fluoroscopy,andX-ray.It is to

detect ulcers, tumors,

inflammation, or anatomic

malposition.

Pantoprazole is a gastric acid-

pump inhibitor that suppresses

gastric secretion; blocks the final

step of acid production

Humulin R helps in lowering the

blood glucose level of the patientsince his blood sugar leer is aboe

normal

It is a drug for diabetic patients, it

also lowers the blood glucose level

in the body

-HGT q 6 and relay results

-refer for persistent of

epigastric pain, vomiting and

This is to monitor the blood

glucose level of the patient

To further assess the needs of the

patient
http://www.webmd.com/hw-popup/fluoroscopyhttp://www.webmd.com/hw-popup/x-rayhttp://www.webmd.com/hw-popup/x-rayhttp://www.webmd.com/hw-popup/fluoroscopy


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any unusualities

-O2 inhalation @2L/min nasal

cannula

Rendering an O2 inhalation helps

the patient during his respiration

August 9,2011

2:05pm

CXR normal

(+)slight pallor

(+)irritability-

refined physical

examination

(+) direct

tenderness in all

quadrants

Dry lips and

tongue

HGT 326mg/dl

-11units RI SQ now then start

-insulin slide scale as ff;

HGT (400mgdl-refer

If the patient has a high level of

glucose in the blood, he would be

given an regular insulin. Sliding

scale serves as a guide on giving

appropriate insulin base on the

level of glucose in the blood.

-hold Metformin

-UA (micc)

-urine ketones

Urinalysis is used as a screeningand/or diagnostic tool because it

can help detect substances or

cellular material in the urine

associated with different metabolic

andkidney disorders. It is ordered

widely and routinely to detect any

abnormalities that require follow

up.

ketones urine test measures the

presence or absence of ketones in

the urine.
http://50-57-79-249.static.cloud-ips.com/understanding/conditions/kidneyhttp://50-57-79-249.static.cloud-ips.com/understanding/conditions/kidney


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-HBG(routine)

-include serum lipase in next

blood extraction

-hold FBS please HBA1c

instead

-start MgSO4 drop 250cc

-D5W + 2g MgSO4 to run in 24

hours

-NPO except meds

-increase IVF for 180cc/hr x 40

then for reassessment

-120 q shift refer for UA


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(+) smoke (2-

3paks/day)

bacterium that may reside in the

gastrointestinal tract. It is known to

be a major cause of peptic ulcers

and is a potential contributor to the

development of stomach cancer.

9:00 am -for UGI series with follow

through

-if S. creatinine is normal and

UGIS is normal, plan to do CT

Scan of whole abdomen

To determine other problems of the

patient in order to assess him

thoroughly

9:55am -endocrine rounds

-follow up HBA1c and serum

creatinine

-proceed humulin R every 6

hours

To assess the other problems in

endocrine system of the patient

which needed an immediate

medical management

To determine the status of the

patient

It will help lowering the glucoselevel in the blood as soon as

possible

9:00am For 2D echo echocardiogram (echo)is a

graphic outline of the heart's

movement. During an echo test,

ultrasound (high-frequency sound

waves) from a hand-held wand

placed on your chest provides

pictures of the heart's valves and

chambers and helps the

sonographer evaluate the pumping

action of the heart.


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-aspirin 100mg/ tab, OD p.c

11:10am -refer all CBG result

-refer HBA1c and S.creatine

once in

To further assess the needs of the

patient.

Mg 0.41 decrease -give MgSO4 500mg IVTT q 6 x

4 doses

-repeat S.magnesium after 4th

dose of MgSO4

To increase the Magnesium level

of the patient

To determine if there is increase in

magnesium level of the patient

after administering the MgSO4

drugs

1:30pm

Ongoing UGIS

(+) abdominal

pain

BP= 120/70

-hold MgSO4 IV bolus already

on MgSO4 drip

-relay lab results once in

-maintain IVF @140cc/hr

-continue meds

To prevent dehydration

2:00pm

Decrease abdomi

nal pain

-soft diet

-CT Scan forum

A normal diet limited to soft, easily

digestible foods.

A computed tomography (CT) scan

is an imaging method that uses x-

rays to create cross-sectional

pictures of the body. Used to

detect tumors, cysts and

abscesses, dilated bile ducts,

pancreatic inflammation and some

gallstones. Also, identifies changes

in intestinal wall.


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August 11,2011

7:15 am

BP=120/70

HR=94

RR=20

(-) chest pain

(-) dyspnea

(+) epigastric pain

Comfortable out

in awhile

ECE

Possible discharge today: RX

management

Home meds

-amene 25mg 1 tab OD

Advised:

Lifestyle modification

Strictly no smoking

No strenuous activity

Promoting good lifestyle to the

patient will help for fast recovery

August 11, 2011

2:40pm

May go home

Home meds:

1.) Concore 2.0g/ tab 1tab

OD

2.) Zocar 40mg/tab 1 tab

OD

3.) Minidia l 10g/ 1tab 1

tab

4.) Pantoloc 40g 1tab OD

-Follow up after 2 weeks

-for barium enema as OPD

It is important to continue taking

the medicine even if the patient is

already discharged from the

hospital. The treatment should

continue even if after the

admission.


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DIAGNOSTICS

DATE COMPONENT RATIONALE RESULT INTERPRETATION/

SIGNIFICANCE

A

u

g

u

s

t

9,

2

0

1

1

Urine

Examination

desired :

Ketones

Normal result:

absence of

ketones

But if present;

Small: < 20mg/dL

Moderate: 30- 40 mg/dL

Large: > 80mg/dL

A ketones urine

test measures the

presence or

absence of

ketones in the

urine.

15mg/dl Small presence of ketones

Ketonuria is a complication of

diabetes mellitus which is one of

the disease of the our patient

2

s

4

A

s


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DATE COMPONENT RATIONALE RESULT INTERPRETATION/ SIGNIFICANCE NURSINGRESPONSIBILITIES

AUGUST

9,

2011

UrineExaminationdesired:H.Pylori

This test is used

to diagnose

infection due to

Helicobacter

pylori.

positive A positive test for H. pylori indicates

that the gastrointestinal pain may be

caused by due to apeptic ulcer this

bacterium.

The patient has a acute gastrointestinal

and the causative agent is the H.Pylori

Before:

1.) Explain the

procedure

During:

2.) Collect a fresh urine

specimen in a urine

container

3.) Instruct the patient to

collect a mid stream clean

catch urine specimen.

4.) instruct to wash his

hands after the urinesample collection

After:

5.) Transport the urine

specimen to the laboratory

promptly.
http://labtestsonline.org/understanding/conditions/peptic-ulcerhttp://labtestsonline.org/glossary/bacteriumhttp://labtestsonline.org/glossary/bacteriumhttp://labtestsonline.org/glossary/bacteriumhttp://labtestsonline.org/understanding/conditions/peptic-ulcer


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DATE COMPONENT RATIONALE RESULT INTERPRETATION/SIGNIFICANCE NURSINGRESPONSIBILITIES

AUGUST

9,

2011

Fluid serumTest: lipaseNormalvalues: 23-300U/L

The blood test for

lipase is ordered,

often along with

anamylase test,

to help diagnose

and monitor

acutepancreatitis,

chronic

pancreatitis, and

other disorders

that involve the

pancreas.

283 U/L Normal 1.) Explain the

procedure to the

patient

2.) Inform patient that

the test requires

blood sample taken

with the use of the

syringe

3.) Inform the patient

that the specimen

collection takes

approximately 5-10

minutes

4.) Ensure that the

blood is not taken

from the hand or

arm that has

intravenous line.

Hemodilution with

intravenous fluids

causes a false
http://labtestsonline.org/understanding/analytes/amylasehttp://labtestsonline.org/glossary/acutehttp://labtestsonline.org/glossary/chronichttp://labtestsonline.org/glossary/chronichttp://labtestsonline.org/glossary/acutehttp://labtestsonline.org/glossary/acutehttp://labtestsonline.org/understanding/analytes/amylase


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A

UGUST8,

2011

Specimen:

blood

Examination:TROP I

Normal value:


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are released

when the heart

muscle has

been damaged,

such as during a

heart attack.

The more

damage there is

to the heart, the

greater the

amount of

troponin T and I

there will be in

the blood.


that the specimen

collection takes

approximately 5-10

minutes

4.) Ensure that the

blood is not taken

from the hand or

arm that has

intravenous line.

Hemodilution with

intravenous fluids

causes a false

decrease in the

values of some test

5.) Instruct the patientto continue

compression of the

puncture site for 2 to

5 minutes or until

bleeding stops


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AUGUST

8,

2011

Creatinine

Normalvalues: 53.0-115.o umol/L

Amylase

Normalvalues: 25-115U/L

The creatinine

blood test is

used along with

aBUN (blood

urea nitrogen)

test to assess

kidney function

Amylase is an

enzymethat

helps digest

carbohydrates.

It is produced in

the pancreas

and the glands

that make

saliva. When

the pancreas is

diseased or

95.6 umol/L

81 U/L

Normal

Normal

PRETEST:

1.) Identify the patient

2.) Explain the purpose

for the laboratory

and diagnostic test

to the patient


the test requires

blood sample taken

with the use of the

syringe


that the specimen

collection takes

approximately 5-10

minutes

5.) Check vital signs of

the patient

http://labtestsonline.org/understanding/analytes/bunhttp://labtestsonline.org/understanding/analytes/bunhttp://labtestsonline.org/understanding/analytes/bunhttp://www.nlm.nih.gov/medlineplus/ency/article/002353.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/002353.htmhttp://labtestsonline.org/understanding/analytes/bunhttp://labtestsonline.org/understanding/analytes/bunhttp://labtestsonline.org/understanding/analytes/bun


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SodiumNormalvalues:136mmol/L

PotassiumNormal

inflamed,

amylase

releases into

the blood.

A test can be

done to

measure the

level of this

enzyme in the

blood.

The sodium

urine test

measures the

amount of salt

(sodium) in a

urine sample

This test

measures the

137.2mmol/L

4.21mmol/L

Normal

who will perform the

venipuncture and

when and note that

transient discomfort

may be felt from the

needle puncture

and pressure of the

tourniquet

7.) The patient maybe

seated or in the

supine position. The

patients arm isin

extension.

DURING THE TEST:

8.) Ensure that the

blood is not takenfrom the hand or

arm that has

intravenous line.

Hemodilution with

intravenous fluids

causes a false


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values: 3.5-5.5mmol/L

CalciumNormalvalues: 2.12-2.52mmol/L

amount of

potassium in

the blood.

A blood calcium

test is ordered

to screen for,

diagnose, and

monitor a range

of conditions

relating to the

bones, heart,

nerves, kidneys,

and teeth.

2.11mmol/L

normal

normal

decrease in the

values of some test

9.) Inspect the

antecubital fossae

of both arms to

select the best vein

for the venipuncture

10.) Ask the

patient to open and

close hand a few

times to help make

the veins more

visible

POSTTEST:

11.) Instruct thepatient to continue

compression of the

puncture site for 2

to 5 minutes or until

bleeding stops

12.) Assess the


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patients arm to

ensure that

subdermal bleeding

has ceased.

13.) If a

hematoma develops

at the site, apply

warm compress


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COMPONENT RATIONALE RESULTS INTERPRETATION/SIGNIFICANCE

NURSINGRESPONSIBILITY

MagnesiumNormal values:0.74-0.99 mmol/L

A magnesium

test is used to

measure the

level of

magnesium inthe blood

8/8/11

0.41mmol/L

8/10/11

0.8mmol/L

LowMagnesium can be excreted

in the body due to the

presence of gastrointestinal

disorders and also diarrhea.

Before the patient was

admitted he experienced

diarrhea and one of the

electrolytes that has been

excreted was magnesium.

normal

PRETEST:


2.) Explain the purpose

for the laboratory

and diagnostic testto the patient


the test requires

blood sample taken

with the use of the

syringe


that the specimen

collection takes

approximately 5-10

minutes

5.) Check vital signs of

the patient


who will perform the

venipuncture and


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when and note that

transient discomfort

may be felt from the

needle puncture and

pressure of the

tourniquet


seated or in the

supine position. The

patients arm is in

extension.

DURING THE TEST:

8.) Ensure that the

blood is not taken

from the hand or

arm that hasintravenous line.

Hemodilution with

intravenous fluids

causes a false

decrease in the

values of some test


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9.) Inspect the

antecubital fossae of

both arms to select

the best vein for the

venipuncture

10.) Ask the

patient to open and

close hand a few

times to help make

the veins more

visible

POSTTEST:

11.) Instruct the

patient to continue

compression of thepuncture site for 2 to

5 minutes or until

bleeding stops

12.) Assess the

patients arm to

ensure that


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subdermal bleeding

has ceased.

13.) If a

hematoma develops

at the site, apply

warm compress

DATE COMPONENT RATIONALE RESULT INTERPRETATION/SIGNIFICANCE

NURSINGRESPONSIBILITIES

AUGUST

2,

2011

CreatinineNormal values:53.0- 115.0umol/L

ALT (Alanineaminotransferase)

Normal values:30-65 U/L

The creatinine

blood test is

used along with

aBUN (blood

urea nitrogen)

test to assess

kidney function

An alanine

aminotransferase

(ALT) test

69.9umol/L

39

Normal

Normal

PRETEST:


2.) Explain the

purpose for the

laboratory and

diagnostic test to

the patient


the test requires

blood sample taken

with the use of the
http://labtestsonline.org/understanding/analytes/bunhttp://labtestsonline.org/understanding/analytes/bunhttp://labtestsonline.org/understanding/analytes/bunhttp://labtestsonline.org/understanding/analytes/bunhttp://labtestsonline.org/understanding/analytes/bunhttp://labtestsonline.org/understanding/analytes/bun


63/137

measures the

amount of this

enzyme in the

blood.ALT is

found mainly in

theliver,but also

in smaller

amounts in the

kidneys,heart,

muscles, and

pancreas.ALT

was formerly

called serum

glutamic pyruvic

transaminase

(SGPT).

syringe


that the specimen

collection takes

approximately 5-10

minutes


seated or in the

supine position.

The patients arm is

in extension.

DURING THE TEST:

6.) Ask the patient to

open and close

hand a few times to

help make theveins more visible

7.) Cleanse the skin

with 70% alcohol,

and allow it to air-

dry

POSTTEST:
http://www.webmd.com/hw-popup/enzymehttp://www.webmd.com/heart/anatomy-picture-of-bloodhttp://www.webmd.com/digestive-disorders/picture-of-the-liverhttp://www.webmd.com/hw-popup/kidneyshttp://www.webmd.com/hw-popup/heart-anatomyhttp://www.webmd.com/hw-popup/pancreashttp://www.webmd.com/hw-popup/pancreashttp://www.webmd.com/hw-popup/heart-anatomyhttp://www.webmd.com/hw-popup/kidneyshttp://www.webmd.com/digestive-disorders/picture-of-the-liverhttp://www.webmd.com/heart/anatomy-picture-of-bloodhttp://www.webmd.com/hw-popup/enzyme


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8.) Instruct the patient

to continue

compression of the

puncture site for 2

to 5 minutes or until

bleeding stops

9.) Assess the

patients arm to

ensure that

subdermal bleeding

has ceased.

10.) If a

hematoma

develops at the

site, apply warm

compress


65/137

DATE COMPONENT RATIONALE RESULT INTERPRETATION/SIGNIFICANCE NURSINGRESPONSIBILITY

AUGUST

8,

2011

Hemoglobin

Normal values:

Male:140-180g/L

Female: 120-160g/dL

Erythrocytes

(RBC)

male: 4.-5.0

To measure the

oxygen carrying

capacity of the

blood

To detect the

severity of

anemia

Transport

oxygen bound to

hemoglobin

molecules; also

transport small

amount of

carbon dioxide

To measure the

amount of RBCs

in the blood and

123 g/L

3.5410^12/L

LowA Low hemoglobin level indicates

anemia.

Low

It is associated with anemia.

PRETEST:


2.) Explain the

purpose for the

laboratory anddiagnostic test to

the patient


the test requires

blood sample

taken with the use

of the syringe


that the specimen

collection takes

approximately 5-

10 minutes


seated or in the

supine position.

The patients arm


66/137

10^12/L aid in the

diagnosis and

classification of

anemia,

polycythemia or

dehydration. To

determine needs

for further test

such as WBC

differential and

bone marrow

biopsy. To

monitor

response to

chemotherapy

and radiationtherapy. Assist

in determining

the cause of an

elevated WBC

is in extension.

DURING THE TEST:

6.) Ask the patient to

open and close

hand a few times

to help make the

veins more visible

7.) Cleanse the skin

with 70% alcohol,

and allow it to air-

dry

POSTTEST:

8.) Instruct the patient

to continue

compression of

the puncture sitefor 2 to 5 minutes

or until bleeding

stops

9.) Assess the

patients arm to

ensure that


67/137

Hemoglobin

Male: 140-180

MCH ( Mean

Corpuscular

Hemoglobin)

Normal value:

27.0-33.0 pg)

MCV (Mean

Corpuscular

Volume)

Normal value: 80-

A test used to

determine the

amount of

hemoglobin in

the blood. Hgb is

the pigment part

of the

erythrocyte, and

the oxygen-

carrying part of

the blood.

It measures the

weight of

hemoglobin in

each cell

It indicates the

relative size of

Red Blood Cells

123

34.7

106.1 fl

Low

It indicates anemia.

High

It is associated with macrocytic

anemia.

High

It is associated with macrocytic

anemia.

subdermal

bleeding has

ceased.

10.) If a

hematoma

develops at the

site, apply warm

compress


68/137

96 fl

MCHC (Mean

Corpuscular

Hemoglobin

Concentration)

Normal value: 5-

10.0 g/dl

Leukocytes

Normal value: 5-

10 10^g/L

NeutrophilsNormal value:

0.55-0.65 10^g/dl

Lymphocytes

Normal value:

Concentration of

hemoglobin in

the average Red

Blood Cell

To assess

presence of

inflammation

and infection.

It responds totissue damage

or infection

Lymphocytes

are a type of

32.7 g/dl

8.4 10^g/dl

0.77 10^g/dl

0.11 %

Normal

Normal

High

It is high because our patient has

infection

Low


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0.25-0.40 %

Monocytes

Normal value:

0.02-0.06 %

Eosinophils

Normal value:

0.01-0.05 %

Basophils

white blood cells

present in a

vertebrate's

immune system,

and responsible

for protecting the

body against the

damage caused

by bacterial and

viral infections.

To determine

whether there is

allergy or

parasitic

infections

It contains large

0.10 %

0.01 %

A low lymphocyte count indicates

that the body's resistance to fight

infection has been substantially lost

and one may become more

susceptible to certain types of

infection

High

There is presence of infection in our

patient

Normal


70/137

Normal value:

0.000-0.005 %

Hematocrit

Normal value:

Male: 0.40-0.48

%

Thrombocytes

Normal value:

amount of

histamine. It

helps body resist

systemic allergic

reactions and

anaphylactic

states.

It measures

percentage by

volume of

packed red

blood cells in awhole blood

sample.

It is necessary

0.01 %

0.38 %

High

Due to presence of infection, the

patients body releases

antihistamine to fight the antigens.

Low

Since the patient is anemic, his

body contains low level of red blood

cells and hematocrit also is low

normal


71/137

150-300 10^g/dl for blood clotting 163 10^g/dl

DATE COMPONENT RATIONALE RESULT INTERPRETATION/SIGNIFICANCE NURSINGRESPONSIBILITY

AUG

UST

10,

2011

Color

Normal: Brown

Consistency

Normal: soft,well-formed

Parasite/ ova

Normal:negative/ no

parasite found

The normal color

of the feces is

brown.

Dark Brown

Well-formed

No ova/parasiteseen

Normal

Normal

Normal

1.) Tell patient to

urinate first to

prevent any urine

from mixing with

his feces later on.

2.) Provide proper

containers

3.) Instruct patient

that he must also

wear gloves when

it's time to handle

stool and transfer

it to a safer

container

4.) Instruct to wash

the perineal area

after transferring

the specimen


72/137

5.) Instruct patient to

wash hands after

the collection of

the specimen

6.) Instruct patient

that the collected

samples must be

brought to the

laboratory as soon

as possible


73/137

Echocardiography (ECG)Also known as a cardiac ultrasound, it uses standard ultrasound techniques to image two-

dimensional slices of the heart. Echocardiography is used to diagnose cardiovascular diseases. It can provide a wealth of

helpful information, including the size and shape of the heart, i ts pumping capacity and the location and extent of any

damage to its tissues. It is especially useful for assessing diseases of the heart valves. Echocardiography also helps

determine whether any chest pain or associated symptoms are related to heart disease.

ECHOCARDIOGRAPHIC AND VASCULAR LABORATORY

Echocardiography Result

Left ventricle LV function Result normal value

Lvsd 12 LVEDV (92-125ml) A0 33mm 30-35mm

LVEDd 38 LVESV LA 37 30-35mm

Pwd 12 SV MPA 25

LVESd 25 EF

PWc 13 LV Mass

IVSs 15 HR

CO


74/137

EPSS

Right ventricle

RVEDD 27

RA 29

Doppler spectral data

Valves maximum velocity (m/sec) gradients

Mitral 0.6/0.68 1.86/0.57

Aorta 0.76 2.3

Tricuspid 0.49/0.57 1.09/0.34

Pulmonary 0.73 2.12

PAT 135msec

Findings:

-concentric left ventricular hypertrophy with hypokinesia of lateral posterior left ventricular tree wall from mid to apex with

doppler evidence of relaxation abnormalities. Ejection fraction is 64%.


75/137

-normal right ventricular dimension with adequate wall motion and contractility.

-normal left and right atrial dimensions

-thickened mitral and aortic valve leaftlets without restriction of motion, aortic annular calcification

-thickened tricuspid and pulmonic valve leaflets with good opening and closing motion.

-normal main pulmonary artery and aortic root dimensions.

-Doppler: Reversed E/A ratio

note: there are frequent ectopic beats during the study

Nursing Responsibility:

1.) Instruct patient to remove all clothing and jewelry in the area to be examined.2.) Instruct patient wear a gown during the procedure

3.) instruct patient not to eat or drink for as many as six hours before the procedure

Urinalysis- is the microscopic, physical and chemical examination of urine. There are a number of tests that are conducted

under this to help in the detection and the measurement of a number of compounds that are passed through the urine


76/137

Component Rationale Results Interpretation/significance Nursing responsibility

WBC

Reference

range: 0-11/UL

RBC

Reference

range: 0-11/UL

Epith.cells

coronary artery disease (metabilism)

Documents