A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II - Uncontrolled
I. INTRODUCTION
Acute Coronary Syndrome is defined as a spectrum of conditions involving chest
discomfort or other symptoms caused by lack of oxygen to the heart muscle (the
myocardium). The unification of these manifestations of coronary artery disease under a
single term reflects the understanding that these are caused by a similar
pathophysiology (sequence of pathologic events) characterized by erosion, fissuring, or
rupture of a pre-existing plaque, leading to thrombosis (clotting) within the coronary
arteries and impaired blood supply to the heart muscle. It encompasses a range of
thrombotic coronary artery diseases, including unstable angina and both ST-segment
elevation and non–ST-segment elevation myocardial infarction. Diagnosis requires an
electrocardiogram and a careful review for signs and symptoms of cardiac ischemia. In
acute coronary syndrome, common electrocardiographic abnormalities include T-wave
tenting or inversion, ST-segment elevation or depression (including J-point elevation in
multiple leads), and pathologic Q waves. If prompt actions are not done complications
such as Myocardial Infarction may take place. (http://www.mayoclinic.com/health/acute-
coronary-syndrome/DS01061/DSECTION=symptoms)
The risk factors for acute coronary syndrome are similar to those for other types
of heart disease. It includes Older age (older than 45 for men and older than 55 for
women), high blood pressure, high blood cholesterol, cigarette smoking, lack of physical
activity, type 2 diabetes, family history of chest pain, heart disease or stroke. Signs and
symptoms include Chest pain (angina) that feels like burning, pressure or tightness and
lasts several minutes or longer, Pain elsewhere in the body, such as the left upper arm
or jaw (referred pain), nausea, vomiting, shortness of breath (dyspnea), and sudden,
heavy sweating (diaphoresis) (http://www.mayoclinic.com/health/acute-coronary
syndrome/DS01061/DSECTION=symptoms)
According to the morbidity rate, taken from the records of the Department of
Health for region X, the occurrence of cardiovascular diseases per 100,000 populations
is 3,356. This data is taken from the 2001-2005, a 5 year-average record. While the
occurrence rate for cardiovascular disease for region X by 2006 is recorded to be 4,373
per 100,000 populations.(http://www.dh.gov.uk/en/index.htm http://www.dh.gov.uk/en
/index.htm)
On the other hand, Diabetes Mellitus is a condition in which the pancreas no
longer produces enough insulin or cells stop responding to the insulin that is produced,
so that glucose in the blood cannot be absorbed into the cells of the body. Symptoms
include frequent urination, lethargy, excessive thirst, and hunger. The treatment
includes changes in diet, oral medications, and in some cases, daily injections of insulin.
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A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II - Uncontrolled
The most common form of diabetes is Type II, It is sometimes called age-onset
or adult-onset diabetes, and this form of diabetes occurs most often in people who are
overweight and who do not exercise. Type II is considered a milder form of diabetes
because of its slow onset (sometimes developing over the course of several years) and
because it usually can be controlled with diet and oral medication. The consequences of
uncontrolled and untreated Type II diabetes, however, are the just as serious as those
for Type I. This form is also called noninsulin-dependent diabetes, a term that is
somewhat misleading. Many people with Type II diabetes can control the condition with
diet and oral medications, however, insulin injections are sometimes necessary if
treatment with diet and oral medication is not working. Diabetes is the third leading
cause of death in the United States after heart disease and cancer.
(http://www.medicinenet.com/diabetes_mellitus/page4.htm#tocf)
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A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II - Uncontrolled
II. SCOPE AND LIMITATIONS OF THE STUDY
This case study tackles about Acute Coronary Syndrome specifically on the case
of patient JB. It includes essential concepts in relation to the said condition such as the
patient’s profile and health history, nursing assessment and clinical manifestations, drug
study and diagnostic exams done. The anatomy and physiology is also included as well
as the pathophysiology of Acute Coronary Syndrome with its associated factors. The
Medical and Nursing Management along with the discharge plans and other relevant
data are also being covered.
The scope of the plan encompasses during the course of duty last June 29, 30
and July 1 of year 2011 wherein the assigned students who have assessed the client
with cumulative interaction and good rapport to the patient and significant others.
Nursing Management covers the above mentioned dates which encompasses the
client’s Recovery Phase. Data gathering about the Laboratory results covers from June
29 to 30, 2011
The areas of concerns are limited to the discussions of Acute Coronary
Syndrome with uncontrolled diabetes type II and the quality of Nursing Care to the
patient. The quantity and quality of the information are limited to the data gathered from
the client, significant others and his medical records.
OBJECTIVES OF THE STUDY
The study aims to explore the concepts about the condition and the quality of
nursing care being rendered to our client that was diagnosed with Acute Coronary
Syndrome and uncontrolled diabetes type II.
In order to learn more about the health condition of the patient, the study wants
to fathom about the predisposing and precipitating factors, anatomy and physiology and
the pathophysiology of the condition experienced by the client. Basically, the main goal
of this study in relation to knowledge is to identify the nursing interventions after the
condition of patient.
The study aims to critically analyze the qualitative and quantitative data gathered
in order to establish connection between the different manifestations experienced by the
patient with that of the disease process. To be able to improve skills, the students also
endeavors to come up with nursing care plans that will alleviate patient’s condition. The
presentors also intend to compare and contrast the ideal management for Acute
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A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II - Uncontrolled
Coronary Syndrome with that of the actual management. In addition, the study seeks to
disseminate essential information to everybody for awareness.
Furthermore, by this study, the provider will be able to exercise that attitude of
determination and in order to come up with a successful study
SIGNIFICANCE OF THE STUDY
The study is significant to the following people: the client, the client’s family, and
nursing students
The study is significant to the client, because it enlightens the client’s queries and
doubts regarding her condition. Allowing him to understand the situation of his
present state, this would allow him to be more aware of the importance of following the
treatment regimen.
Client’s family must also be aware of the condition of the client. With the study,
the client’s family will be able to participate in the client’s treatment, and they will be
able realize the importance of the support system in participating in the client’s care.
The study is also important to the nursing students, since it allows them to
explore the client’s condition, giving them firsthand experience in observing the
manifestations of the disease condition and allowing them to apply theoretical
knowledge regarding nursing managements for the manifested signs and symptoms.
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A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II - Uncontrolled
III. CLIENT’S PROFILE
A. Socio-demographic Date
Patient JB is a 54-year old male, Protestant, married to his 50-year old
wife and is currently residing at Opol, Misamis Oriental was admitted last June
29, 2011 due to chest pain at Northern Mindanao Medical Center – Intensive
Coronary Care Unit.
B. Vital Signs
Upon assessment, the patient’s vital signs were: BP: 110/80 mmHg,
Temperature: 36.2 degree Celsius, PR: 58 beats per minute (bradycardia), and
RR: 25 cycles per minute (tachypnea) and 27 cycles per minute (tachypnea)
upon exertion. The patient weighs 62 kilograms and is 160 centimeters tall
C. Health Pattern Assessment
Aside from the current condition, patient also complained of non-productive
cough and prostate enlargement. Generally, he looks normal and able to
ambulate and change positions as well. There was no history of tobacco and
illicit drug use as well as alcohol consumption yet he’s taking a cupful of coffee
everyday for almost 30years. No allergies were reported.
Past Medical History
Client JB has been previously hospitalized twice. First was last July
2009 at Cagayan de Oro Medical Center with the diagnosis of Myocardial
Infarction and the second admission was in Northern Mindanao Medical
Center last November 2009 due to left cerebrovascular disease. He also
has the family history of Diabetes Mellitus on both maternal and paternal
side and taking metformin 500mg to control increase blood glucose level
taken BID. He was also diagnosed to have Benign Prostate Hypertrophy
(BPH) and was given tamsulosin hydrochloride 400mg OD taken every
morning.
History of Present Illness
Client JB was climbing the stairs upon reaching the second plight of
it, he felt intense pain on his left chest that radiated to his left shoulder
associated with shortness of breathing. He was then brought to the
Emergency Room subsequently, thus caused him to be admitted last June
29, 2011. His diagnosis was Acute Coronary Syndrome, ST Elevation,
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A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II - Uncontrolled
Myocardial Infarction (STEMI) Anterior Wall, Killips-1, Diabetes Mellitus
Type II - Uncontrolled.
Physical Assessment
Client JB has an oxygen inhalation @ 2 LPM via nasal cannula and
an intravenous fluid of PNSS1L regulated at 10 cc per hour infusing well at
the right arm. Capillary Blood Glucose Monitoring was also done to the
patient: on the first day, he has blood glucose of 172mg/dl then the next
day it became normal with a value of100mg/dl.
HEENT:
Head, hair and scalp Normocephalic with fine hair and clean scalp.
Eyes: sclera, pupils Sclerae are anicteric, pupils are equal in size and
reaction to light. Periorbital region is not sunken
or edematous. Cornea and lens are not opaque
and conjunctiva is pale.
Ears and tympanic membrane Equal in size with no discharges and has equal
auditory function. Intact tympanic membrane.
Nose No nasal flaring noted. Septum is medial. Mucosa
is pink in color. Gross smell is normal and
symmetrical.
Mouth, lips, tongue, teeth and
oral mucosa
Lips are pink but oral mucosa is pale. No lesions
noted in the mouth. Tongue is midline. Teeth are
complete with plaques noted. Gums are pinkish.
Throat and neck Trachea and uvula are midline. Thyroids are non
palpable. Tonsils are not inflamed.
Facial movements Symmetrical.
Cognitive/ Neurological Assessment
Level of consciousness Conscious, coherent and responsive
Orientation Oriented to time, place and person
Emotional state Calm, but upon exertion he feels dizzy and
answers questions inappropriately.
Primary language Visayan
Educational attainment College graduate of Criminology at Ateneo de
Davao University
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A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II - Uncontrolled
Nutritional and Metabolic Pattern
At home, Client JB usually eats three times a day with red meat
and rice, but after he was diagnosed with stroke and myocardial infarction
he was consuming fish, vegetables, and rice with good appetite yet still
cannot resist fatty foods and sweets too. He drinks water and other fluids
at most 10 glasses a day. He takes no vitamins or mineral supplement at
all.
Upon hospital stay, his diet was on low salt low fat, full diabetic diet
with no nausea and vomiting reported.
Elimination Pattern
Patient JB usually follows a pattern in defecating, he used to
defecate once every morning; his stool appears soft in consistency, yellow
to brown in color and in minimal amount with no discomforts upon
defecating.
He urinates at about 6-8 times a day with amber to yellow colored
urine and in moderate amount and with no difficulty. He has an enlarged
prostate and had difficulty urinating before but it subsided after taking due
medications.
Abdominal configuration Symmetrical, no superficial veins, with no lesions
and scars
Bowel sounds Normoactive upon auscultation
Percussion Tympanic and dullness noted on right upper
quadrant
Activity-Exercise Pattern
He used to be very active before but after the diagnosis of
myocardial infarction, his activities and exercises were restricted but he
could still walk for no more than one kilometer and can perform tolerable
exercises. Upon overexertion, pain is felt radiating to the left shoulders
with a pain scale of 6/10 sometimes felt at night which takes for a minute.
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A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II - Uncontrolled
His leisure activities include watching TV and socializing with his children
and friends.
CARDIOVASCULAR STATUS
Chest pain, radiation Positive chest pain at the left side that radiates to the
left shoulder, palpitations noted at some times
Point of maximal impulse,
Precordial area
5th intercostal space, midclavicular line
Flat
Heart sounds Distinct and regular, no murmurs noted
Peripheral pulses Regular and symmetrical
Capillary refill time 2 seconds, no clubbing noted
RESPIRATORY STATUS
Breathing pattern Irregular (tachypnea)
Lung expansion Symmetrical
Vocal/tactile fremitus Symmetrical
Percussion Resonant
Breath sounds Rales crackles at inspiration
Cough Non - productive with colorless sputum, minimal in
amount and viscous in consistency
Sleep and Rest Pattern
Client JB usually sleeps about 6-8hours a day with naps during day
time. He said this number of hours is adequate enough for his activities
the following day. He does not have any history of sleep disturbances but
he prays and meditates before sleeping to promote a good and sound
sleep.
Role and Relationship Pattern
Client JB is married to his 50- year old healthy wife and a father to
two healthy kids. The eldest is 20 years old and has graduated Computer
Science Studies and the second age 14 who is currently a fourth year high
school student. He lives with his family. Client JB reported to have a
Diabetes Mellitus in both maternal and paternal side but confused why he
has developed Myocardial Infarction.
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A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II - Uncontrolled
Value and Belief Pattern
Client X is a Protestant; in fact he is a community facilitator of their
church. He strongly believes that without God he will be nothing. He gets
his strength in facing his condition from his faith that gives him hope. He
believes his hospitalization interferes with his religious rites but he finds
ways to communicate with God through prayers as an alternative.
Moreover, he considers his church mates as his support group and they
visited him quite often.
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A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II - Uncontrolled
REVIEW OF SYSTEMS
10
Chest pain of 6/10
Pale conjunctiva
Pale oral mucosa
Copious non-productive
cough
Prostate Enlargement
Abnormal decrease of heart rate of
58 bpm (bradycardia)
Abnormal increase of RR of 25 cpm (at
rest) and 27cpm (upon exertion)
Pain radiating to shoulders
CBG shows abnormal increase of blood
glucose of 172mg/dl (first day) and normal
blood glucose of 100mg/dl (second
day)
A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II - Uncontrolled
IV. ANATOMY AND PHYSIOLOGY
Every cell in the human body needs energy in order to function. The body’s
primary energy source is glucose, a simple sugar resulting from the digestion of foods
containing carbohydrates (sugars and starches). Glucose from the digested food
circulates in the blood as a ready energy source for any cells that need it. Insulin is a
hormone or chemical produced by cells in the pancreas, an organ located behind the
stomach. Insulin bonds to a receptor site on the outside of cell and acts like a key to
open a doorway into the cell through which glucose can enter. Some of the glucose can
be converted to concentrated energy sources like glycogen or fatty acids and saved for
later use. When there is not enough insulin produced or when the doorway no longer
recognizes the insulin key, glucose stays in the blood rather entering the cells.
Anatomy of the pancreas:
The pancreas is an elongated, tapered organ located across the back of the
abdomen, behind the stomach. The right side of the organ (called the head) is the
widest part of the organ and lies in the curve of the duodenum (the first section of the
small intestine). The tapered left side extends slightly upward (called the body of the
pancreas) and ends near the spleen (called the tail).
The pancreas is made up of two types of tissue:
Exocrine tissue
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A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II - Uncontrolled
o The exocrine tissue secretes digestive enzymes. These enzymes are
secreted into a network of ducts that join the main pancreatic duct, which
runs the length of the pancreas.
Endocrine tissue
o The endocrine tissue, which consists of the islets of Langerhans, secretes
hormones into the bloodstream.
Functions of the pancreas:
The pancreas has digestive and hormonal functions:
The enzymes secreted by the exocrine tissue in the pancreas help break down
carbohydrates, fats, proteins, and acids in the duodenum. These enzymes travel down
the pancreatic duct into the bile duct in an inactive form. When they enter the
duodenum, they are activated. The exocrine tissue also secretes bicarbonate to
neutralize stomach acid in the duodenum.
The hormones secreted by the endocrine tissue in the pancreas are insulin and
glucagon (which regulate the level of glucose in the blood), and somatostatin (which
prevents the release of the other two hormones.
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A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II - Uncontrolled
CARDIOVASCULAR SYSTEM
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A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II - Uncontrolled
The right and left coronary arteries most often arise independently from individual
ostia in association with the right and left aortic valve cusps.
The left anterior descending (LAD) and left circumflex (LCX) coronary arteries
arise at the left main coronary artery bifurcation; they supply the anterior LV, the bulk of
the interventricular septum (anterior two thirds), the apex, and the lateral and posterior
LV walls. The right coronary artery (RCA) generally supplies the right ventricle (RV), the
posterior third of the interventricular septum, the inferior wall (diaphragmatic surface) of
the left ventricle (LV), and a portion of the posterior wall of the LV (by means of the
posterior descending branch).
When the posterior descending coronary artery (PDA), which supplies the
posterior interventricular septum, arises from the LCX artery, the circulation is called left
dominant. Most often, the PDA arises from the RCA; this anatomy is called right-
dominant circulation.
In two thirds of patients, the first branch of the RCA is the conus artery, which
supplies the conus arteriosus (RV outflow tract); occasionally the conus arteriosus
arises from a separate orifice.
In 60% of patients, the sinus node artery arises from the proximal RCA, and in
40% of patients, it arises from the LCX artery. The anterior branches supply the free
wall of the RV, and the acute marginal branches supply the RV. When the RCA extends
to the crux (the origin of the PDA), it supplies the atrioventricular (AV) node (90%);
otherwise, the AV node is supplied by the LCX.
Therefore, obstruction of the RCA commonly affects the sinus node and the AV
node, resulting in bradycardia, with or without heart block. Not surprisingly, RCA
occlusion frequently manifests with sinus bradycardia, AV block, RV myocardial
infarction, and/or inferoposterior myocardial infarction (of the LV).Heart is a hollow
muscular organ that pumps blood through the body. The heart, blood, and blood
vessels make up the circulatory system, which is responsible for distributing oxygen and
nutrients to the body and carrying away carbon dioxide and other waste products. The
heart is the circulatory system's power supply. It must beat ceaselessly because the
body's tissues-especially the brain and the heart itself-depend on a constant supply of
oxygen and nutrients delivered by the flowing blood. If the heart stops pumping blood
for more than a few minutes, death will result.
The human heart is shaped like an upside-down pear and is located slightly to
the left of center inside the chest cavity. About the size of a closed fist, the heart is
made primarily of muscle tissue that contracts rhythmically to propel blood to all parts of
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A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II - Uncontrolled
the body. This rhythmic contraction begins in the developing embryo about three weeks
after conception and continues throughout an individual's life. The muscle rests only for
a fraction of a second between beats. Over a typical life span of 76 years, the heart will
beat nearly 2.8 billion times and move 169 million liters (179 million quarts) of blood.
STRUCTURE OF THE HEART
The human heart has four chambers. The upper two chambers, the right and left
atria, are receiving chambers for blood. The atria are sometimes known as auricles.
They collect blood that pours in from veins, blood vessels that return blood to the heart.
The heart's lower two chambers, the right and left ventricles, are the powerful pumping
chambers. The ventricles propel blood into arteries, blood vessels that carry blood away
from the heart.
A wall of tissue separates the right and left sides of the heart. Each side pumps
blood through a different circuit of blood vessels: The right side of the heart pumps
oxygen-poor blood to the lungs, while the left side of the heart pumps oxygen-rich blood
to the body. Blood returning from a trip around the body has given up most of its oxygen
and picked up carbon dioxide in the body's tissues. This oxygen-poor blood feeds into
two large veins, the superior vena cava and inferior vena cava, which empty into the
right atrium of the heart.
The right atrium conducts blood to the right ventricle, and the right ventricle
pumps blood into the pulmonary artery. The pulmonary artery carries the blood to the
lungs, where it picks up a fresh supply of oxygen and eliminates carbon dioxide. The
blood that is oxygen-rich returns to the heart through the pulmonary veins, which empty
into the left atrium. Blood passes from the left atrium into the left ventricle, from where it
is pumped out of the heart into the aorta, the body's largest artery. Smaller arteries that
branch off the aorta distribute blood to various parts of the body.
A. THE HEART VALVES
Four valves within the heart prevent blood from flowing backward in the heart. The
valves open easily in the direction of blood flow, but when blood pushes against the
valves in the opposite direction, the valves close. Two valves, known as atrioventricular
valves, are located between the atria and ventricles. The right atrioventricular valve is
formed from three flaps of tissue and is called the tricuspid valve. The left
atrioventricular valve has two flaps and is called the bicuspid or mitral valve. The other
two heart valves are located between the ventricles and arteries. They are called
semilunar valves because they each consist of three half-moon-shaped flaps of tissue.
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A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II - Uncontrolled
The right semilunar valve, between the right ventricle and pulmonary artery, is also
called the pulmonary valve. The left semilunar valve, between the left ventricle and
aorta, is also called the aortic valve.
B. THE MYOCARDIUM
Muscle tissue, known as myocardium or cardiac muscle, wraps around a scaffolding
of tough connective tissue to form the walls of the heart's chambers. The atria, the
receiving chambers of the heart, have relatively thin walls compared to the ventricles,
the pumping chambers. The left ventricle has the thickest walls-nearly 1 cm (0.5 in)
thick in an adult-because it must work the hardest to propel blood to the farthest
reaches of the body.
C. THE PERICARDIUM
A tough, double-layered sac known as the pericardium surrounds the heart. The
inner layer of the pericardium, known as the epicardium, rests directly on top of the
heart muscle. The outer layer of the pericardium attaches to the breastbone and other
structures in the chest cavity and helps hold the heart in place. Between the two layers
of the pericardium is a thin space filled with a watery fluid that helps prevent these
layers from rubbing against each other when the heart beats.
D. THE ENDOCARDIUM
The inner surfaces of the heart's chambers are lined with a thin sheet of shiny, white
tissue known as the endocardium. The same type of tissue, more broadly referred to as
endothelium, also lines the body's blood vessels, forming one continuous lining
throughout the circulatory system. This lining helps blood flow smoothly and prevents
blood clots from forming inside the circulatory system.
E. THE CORONARY ARTERIES
The heart is nourished not by the blood passing through its chambers but by a
specialized network of blood vessels. Known as the coronary arteries, these blood
vessels encircle the heart like a crown. About 5 percent of the blood pumped to the
body enters the coronary arteries, which branch from the aorta just above where it
emerges from the left ventricle. Three main coronary arteries-the right, the left
circumflex, and the left anterior descending-nourish different regions of the heart
muscle. From these three arteries arise smaller branches that enter the muscular walls
of the heart to provide a constant supply of oxygen and nutrients. Veins running through
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A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II - Uncontrolled
the heart muscle converge to form a large channel called the coronary sinus, which
returns blood to the right atrium.
FUNCTION OF THE HEART
The heart's duties are much broader than simply pumping blood continuously
throughout life. The heart must also respond to changes in the body's demand for
oxygen. The heart works very differently during sleep, for example, than in the middle of
a 5-km (3-mi) run. Moreover, the heart and the rest of the circulatory system can
respond almost instantaneously to shifting situations-when a person stands up or lies
down, for example, or when a person is faced with a potentially dangerous situation.
17
LEGEND:
Predisposing Factors
Precipitating Factors
Disease Process
Management
Diagnostic Examination
Signs and symptoms
Compensatory Mechanism
A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II - Uncontrolled
V. PATHOPHYSIOLOGY
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Predisposing Factors:
Sedentary Lifestyle
Eating habits consuming organ meats and fatty foods
Age (54 years old)
Gender (male)
Family History of DM
Predisposing Factors:
Sedentary Lifestyle
Eating habits consuming organ meats and fatty foods
Age (54 years old)
Gender (male)
Family History of DM
Precipitating Factors:
Poor compliance to medication
Precipitating Factors:
Poor compliance to medication
Increase blood glucose level within the serum
Beta cells response poorly to hyperglycemia
Scanty amount of insulin being released Increase glucagon release
Increase breakdown of lipids
Continuous increase in serum blood glucose
Increased cell division causing further mutations
Activation of the k-ras oncogene
P53 mutations which prevent apoptosis
Prolong lifespan of affected cells
Continuous replication of affected cells
Increases number of malignant cells
Abnormal increase in
blood glucose level of 139mg/dl
Abnormal increase in
blood glucose level of 139mg/dl
CBG shows blood glucose
level of `72mg/dL
CBG shows blood glucose
level of `72mg/dL
Administered metformin (Glucophage) 500mg 1
tab. OD BID
Administered metformin (Glucophage) 500mg 1
tab. OD BID
Administered atorvastatin
(Lipitor) 80mg, 1 tab,
PO, OD at HS
Administered atorvastatin
(Lipitor) 80mg, 1 tab,
PO, OD at HS
A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II - Uncontrolled
===========================>
19
Increase blood concentration which leads to its viscosity
Clot formation and lipid deposition on the anterior coronary artery
Sluggish flow going to the heart
Plaque formation in the intimal lining of the anterior coronary artery
Increase hydrostatic pressure on the coronary artery
Anaerobic metabolism is initiated
Ischemia on the myocardium
Presence of surgical wound.
Presence of surgical wound.
Susceptible to infection
Ketosteril 1cap. PO BID
Ketosteril 1cap. PO BID
Abnormal
decrease in
lymphocytes 7.1 and 7.9
Abnormal
decrease in
lymphocytes 7.1 and 7.9
NPO stateNPO statePossible increase in acid production within the GI lining
Activation of pain
mediators
1. celecoxib 1.5gm IVTT every 6 hours
2. paracetamol 60mg IVTT every 6 hours
3. ketorolac 30mg IVTT every 8 hours
4. tramadol 500mg IVTT every 6 hours
1. celecoxib 1.5gm IVTT every 6 hours
2. paracetamol 60mg IVTT every 6 hours
3. ketorolac 30mg IVTT every 8 hours
4. tramadol 500mg IVTT every 6 hours
1.omeprazole 20mg PO every 6 hours
2. ranitidine 500mg IVTT every 8 hrs.
1.omeprazole 20mg PO every 6 hours
2. ranitidine 500mg IVTT every 8 hrs.
Partial blockage of the anterior coronary artery
The fibrous cap (plaque) protrude in the intimal lining
Chest pain radiating to
the shoulders
Pain scale of 6/10
Chest pain radiating to
the shoulders
Pain scale of 6/10
Collateral circulation is stimulated to help perfuse the myocardium
Increase respiratory rate of 25cpm (at rest) and 27cpm (upon exertion)
Provide oxygen inhalation at 2LPM via
nasal cannula
Provide oxygen inhalation at 2LPM via
nasal cannula
Lactic acid production
Still insufficient to supply blood to the heart
Intravenous PNSS at 10cc/hr
Intravenous PNSS at 10cc/hr
Patient JB climbed two flights of stairsPatient JB climbed two flights of stairs
A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II - Uncontrolled
20
Platelet activation
Change in platelet shape ↑ Expression of Platelet GP IIb/IIIa
Platelet adhesion to subendothelial matrix
Platelet degranulation
Enhances platelet
aggregation
Converts fibrinogen to
fibrin
Formation of
thrombin
Plaque ruptures
Release of Thromboxane A2,
Serotonin and other platelet
aggregatory agent
Exposure of subendohelial matrix
Enhanced affinity to fibrinogen
Platelet aggregation
Plasma Coagulation
System activationStabilization of fibrin clot
Hardening of the coronary artery
Pale mucosa
Pale conjunctiva
Pale mucosa
Pale conjunctiva
Abnormal decrease of RBC (3.58), Hct (31.5) ,
and Hgb (11.1)
Abnormal decrease of RBC (3.58), Hct (31.5) ,
and Hgb (11.1)
A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II - Uncontrolled
VI. LABORATORY RESULTS
Hematology Report
(06/29/11)
TEST RESULTS REFERENCE VALUES INTERPRETATION
Hgb 11.1 13.7-16.7 g/dL A decrease in rbc may also decrease hemoglobin
since rbc carries oxygen to the blood. A Low
hemoglobin may also indicate anemia.
21
Abnormal decrease
of blood pressure
of 58bpm
Abnormal decrease
of blood pressure
of 58bpm
1. Administered enoxaparin (Clexane) 0.4cc SC every 12 hours
2. clopidogrel (Plavix) 75 mg, 1 tab PO at HS
3. aspirin (Atria SR) 80mg, 1tab, PO, OD after PC
1. Administered enoxaparin (Clexane) 0.4cc SC every 12 hours
2. clopidogrel (Plavix) 75 mg, 1 tab PO at HS
3. aspirin (Atria SR) 80mg, 1tab, PO, OD after PC
Coronary occlusion Further deprivation of
oxygen supply to the
Infarction on the myocardium takes place
Impaired repolarization of the myocardium
Abnormal ST elevation
seen in the ECG
Abnormal ST elevation
seen in the ECG
Decrease cardiac contractility
Decrease ventricular function
Decrease cardiac output
Decrease perfusion to the system
O2 inhalation
O2 inhalation
A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II - Uncontrolled
Hct 31.5 37.0- 47.0 gm% A low hematocrit level indicates that a person does not
have a sufficient volume of red blood cells.
WBC 12, 300 5,000-10,000 cell/mm3 A high blood count indicates is not a specific disease
by itself but indicates infection, systemic illness,
inflammation, allergy, leukemia and tissue injury.
DIFFERENTIAL
COUNT:
Segmenters 55 45-70% Within Normal Range
Lymphocytes 40 18-45% Within Normal Range
Monocytes 5 4-8% Within Normal Range
Platelet count 329, 000 144,000-372,000 cell/mm3 Within the normal range which connotes the clotting
factor is good.
RBC 3.58 4.7-6.1 10^6/uL A decrease Red blood cell production may indicate
anemia and low oxygen levels due to poor heart or
lung function.
MCV 81.6 80.0-96.0 fL Within Normal Range
MCH 30 27.0-31.0 pg Within Normal Range
22
A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II - Uncontrolled
MCHC 25.2 32.0-36.0% A low MCHC number might indicate the presence of
anemia, but other factors will be measured as well
before making this diagnosis. The mean corpuscular
volume indicates the size of the red blood cells in a
person's body.
Hematology Report
(06/30/11)
TEST RESULTS REFERENCE VALUES INTERPRETATION
Hgb 14.0 13.7-16.7 g/dL Within the Normal Range.
Hct 39.6 37.0- 47.0 gm% Within Normal Range
23
A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II - Uncontrolled
WBC 11,000 5,000-10,000 cell/mm3 It is beyond normal range. Increase in the WBC count
may indicate infection.
DIFFERENTIAL
COUNT:
Segmenters 56 45-70% Within the Normal Range
Lymphocytes 20 18-45% Within the Normal Range
Monocytes 5.0 4-8% Within the normal range.
Platelet count 376, 000 144,000-372,000 cell/mm3 Within the normal range thus, the clotting factor is
good.
RBC 4.0 4.7-6.1 10^6/uL Within the normal Range
MCV 83.6 80.0-96.0 fL Within the Normal Range
MCH 28.0 27.0-31.0 pg Within the Normal Range
MCHC 36.0 32.0-36.0% Within the Normal Range
Others Laboratory Examinations
(06/29/11)
24
A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II - Uncontrolled
Diagnostic/Laboratory
Procedures/Tests
Purposes Result Analysis and Interpretation
1. ECG The electrocardiogram (ECG or
EKG) is a diagnostic tool that
measures and records the
electrical activity of the heart in
exquisite detail. Interpretation of
these details allows diagnosis of a
wide range of heart conditions.
These conditions can vary from
minor to life threatening.
ST segment elevation Myocardial injury causes the T wave to
become enlarged and symmetric. As the
area of injury becomes ischemic, myocardial
repolarization is altered and delayed,
causing T wave to invert. The injured
myocardial cells depolarize normally but
repolarize more rapidly than normal cells,
causing the ST segment to rise at least 1
mm above isoelectric line.
2. CK-MB CK-MB is a more sensitive marker
of myocardial injury than total CK
activity, because it has a lower
basal level and a much narrower
normal range. It is the most
specific index for the diagnosis of
acute MI.
2 ng/mL (Reference Value: 0-
3 ng/mL)
NORMAL
3. Creatinine The test is done to evaluate kidney
function. Creatinine is removed
1.9 mg/dL (Reference Value: Any condition that impairs the function of
the kidneys will probably raise the creatinine
25
A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II - Uncontrolled
from the body entirely by the
kidneys. If kidney function is
abnormal, creatinine levels will
increase in the blood (because
less creatinine is released through
your urine).
0.59-1.21) level in the blood. The most common
reasons for developing raised creatinine
levels will be when the filtration mechanism
becomes gradually damaged by long-term
raised blood pressure or diabetes.
4. Glucose The test is done to evaluate the
blood glucose within the
circulation.
139 mg/dL (Reference Value:
59.9 – 110.1)
The abnormal decrease of the blood
glucose level denotes the so-called
hyperglycemia where the concentration of
blood increases which results to its
viscosity.
VII. DRUG STUDY
26
A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II - Uncontrolled
DRUG ORDER
(Generic name, brand
name, classification,
dosage, route,
frequency)
MECHANISM OF
ACTIONINDICATIONS
CONTRAINDICATIONS ADVERSE EFFECTS
OF THE DRUG
NURSING
RESPONSIBILITIES/
PRECAUTIONS
GENERIC NAME:
atorvastatin
BRAND NAME:
Lipitor
CLASSIFICATION:
Lipid-lowering agents
HMG-CoA inhibitor
DOSAGE: 80mg 1 tab
ROUTE: PO
FREQUENCY:
ONCE A DAY
Inhibit an enzyme, 3-
hydroxy-
3methylglutaryl-
coenzyme A (HMG-
CoA) reductase, which
is responsible for
catalyzing an early step
in the synthesis of
cholesterol.
Secondary
prevention of
cardiovascular
disease (decrease
risk of MI, stroke,
revascularization
procedures,
angina, and
hospitalizations for
CHF) in patients
with clinically
evident CHD.
Patients hypersensitive
to atorvastatin and
active liver disease or
unexplained persistent
in aspartate
aminotransferase (AST)
or alanine
aminotransferase (ALT)
CNS: dizziness,
headache, insomnia,
weakness
EENT: rhinitis
CV: chest pain,
peripheral edema
Resp: bronchitis
GI: abdominal cramps,
constipation, diarrhea,
flatulence, heartburn,
elevated liver enzyme,
nausea
GU: erectile dysfunction
1. Confirm patient through
asking his name and
looking on his name
bracelet.
2. Obtain a dietary history,
especially with regard to fat
consumption.
3. Evaluate serum
cholesterol and triglyceride
levels before initiating,
during, and after the
therapy, if possible.
4. Explain to the patient
what the drug is for.
5. Administer drug before
27
A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II - Uncontrolled
TIMING : 8pm
patient goes to sleep.
28
A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II - Uncontrolled
DRUG ORDER
(Generic name, brand
name, classification,
dosage, route,
frequency)
MECHANISM OF
ACTIONINDICATIONS
CONTRAINDICATIONS ADVERSE EFFECTS
OF THE DRUG
NURSING
RESPONSIBILITIES/
PRECAUTIONS
GENERIC NAME:
clopidogrel bisulfate
BRAND NAME:
Plavix
CLASSIFICATION:
Antiplatelet agent
Platelet aggregation
inhibitor
DOSAGE: 75mg 1 tab
ROUTE: PO
FREQUENCY: Once a
Inhibits platelet
aggregation by
irreversibly inhibiting
the binding of ATP to
platelet receptors
thereby, decreases
occurrence of
atherosclerotic events.
Reduction of
atherosclerotic
events in patients
with MI.
1. Hypersensitivity to
clopidogrel bisulphate
2. Pathologic bleeding
(e.g. peptic ulcer,
intracranial hemorrhage
3. Severe liver
impairment
4. Patients with rare
galactose intolerance
CNS: depression,
dizziness, headache,
fatigue
EENT: epistaxis
CV: chest pain, edema,
hypertension
Resp: cough, dyspnea
GI: GI bleeding,
abdominal pain,
diarrhea, dyspepsia,
gastritis, constipation
Derm: rashes, purpura,
pruritus, bruising
Hematology: bleeding,
neutropenia
Metabolic:
1. Confirm patient through
asking his name and
looking on his name
bracelet.
2. Explain to the patient
what the drug is for.
3. Administer drug before
patient goes to sleep.
4. Monitor the vital signs
prior, during and after
therapy.
5. Ensure patient’s safety
through side rails up.
6. Keep patient’s skin intact
29
A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II - Uncontrolled
Day
TIMING: HS (8PM)
hypercholesterolemia
Muskuloskeletal:
arthralgia, back pain
Miscellaneous: fever,
hypersensitivity reaction
by positioning patient every
2 hrs.
30
A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II - Uncontrolled
DRUG ORDER
(Generic name, brand
name, classification,
dosage, route,
frequency)
MECHANISM OF
ACTIONINDICATIONS
CONTRAINDICATIONS ADVERSE EFFECTS
OF THE DRUG
NURSING
RESPONSIBILITIES/
PRECAUTIONS
GENERIC NAME:
aspirin
BRAND NAME:
Artria S.R.
CLASSIFICATION:
antipyretics, nonopioid
analgesics
salicylates
DOSAGE:80mg 1 tab
ROUTE: PO
FREQUENCY: Once a
Produce analgesia and
reduce inflammation
and fever by inhibiting
the production of
prostaglandins
Prophylaxis of
transient ischemic
attacks and MI,
fever, mild to
moderate pain
1. Hypersensitivity to
clopidogrel bisulphate
2. Pathologic bleeding
(e.g. peptic ulcer,
intracranial hemorrhage
3. Severe liver
impairment
4. Patients with rare
galactose intolerance
EENT: tinnitus,
GI: GI bleeding,
abdominal pain,
nausea, vomiting,
diarrhea, dyspepsia,
epigastric distress,
anorexia, hepatotoxicity
Hematology: increase
bleeding time,
anemia,hemolysis
Miscellaneous: allergic
reactions; anaphylaxis
and laryngeal edema
1. Confirm patient through
asking his name and
looking on his name
bracelet.
2. Explain to the patient
what the drug is for.
3. Assess pain: location,
type, and intensity before
and at the peak of drug
action after administration.
4. Administer drug after
lunch.
5. Monitor the vital signs,
especially temperature (for
31
A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II - Uncontrolled
Day
TIMING: after lunch
fever) prior, during and after
therapy.
32
A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II - Uncontrolled
DRUG ORDER
(Generic name, brand
name, classification,
dosage, route,
frequency)
MECHANISM OF
ACTIONINDICATIONS
CONTRAINDICATIONS ADVERSE EFFECTS
OF THE DRUG
NURSING
RESPONSIBILITIES/
PRECAUTIONS
GENERIC NAME:
enoxaparin sodium
BRAND NAME:
Clexane
CLASSIFICATION:
anticoagulants
antithrombotics
DOSAGE: 4000iu
(40mg) per 0.4 ml
ROUTE: subcutaneous
FREQUENCY:
Potentiate the inhibitory
effect of antithrombin
on factor Xa and
thrombin. Thus,
preventing thrombus
formation.
Treatment of acute
ST- segment-
elevation MI and
prevention of
venous
thromboembolism.
(VTE)
1. Hypersensitivity to
specific agents or pork
products
2. Hypersensitivity to
enoxaparin sodium
3. Active bleeding
4. History of heparin-
induced
thrombocytopenia
CNS: dizziness,
headache, insomnia
CV: edema
GI: vomiting,
constipation, nausea,
reversible increase in
liver enzymes
GU: urinary retention
Derm: ecchymosis,
pruritus, rash, urticaria
Hematology: bleeding,
anemia,
thrombocytopenia
Local: erythema at
injection site, irritation,
pain, hematoma
1. Confirm patient through
asking his name and
looking on his name
bracelet.
2. Explain to the patient
what the drug is for.
3. Assess for signs of
bleeding and hemorrhage
(bleeding gums, nosebleed,
black tarry stools,
hematuria). Notify physician
if such manifestations
occur.
4. Administer the drug in a
33
A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II - Uncontrolled
Q 12H
TIMING: 8am-8pm
slow manner,
subcutaneously.
5. Alternate injection site to
avoid hypertrophy
34
A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II - Uncontrolled
DRUG ORDER
(Generic name, brand
name, classification,
dosage, route,
frequency)
MECHANISM OF
ACTIONINDICATIONS
CONTRAINDICATIONS ADVERSE EFFECTS
OF THE DRUG
NURSING
RESPONSIBILITIES/
PRECAUTIONS
GENERIC NAME:
omeprazole
BRAND NAME:
Prisolec
CLASSIFICATION:
Antiulcer agent
Proton-pump inhibitor
DOSAGE: 40mg
ROUTE: IVTT
FREQUENCY: Q 24H
TIMING: 8pm
Binds to an enzyme on
gastric parietal cells in
the presence of acidic
gastric pH, preventing
the final transport of
hydrogen ions in the
gastric lumen.
Reduction of risk of
GI bleeding in
critically ill patients
and condition
where inhibition of
gastric acid
secretion may be
beneficial
1. Hypersensitivity to
omeprazole
2. Metabolic alkalosis
3. Hypocalcemia
CNS: dizziness,
headache, drowsiness,
fatigue, weakness
CV: chest pain
GI: abdominal pain,
acid regurgitation,
constipation, diarrhea,
flatulence, nausea,
vomiting
Derm: itching, rash
Miscellaneous: allergic
reaction
1. Confirm patient through
asking his name and
looking on his name
bracelet.
2. Obtain a skin test prior to
initial administration.
3. Explain to the patient
what the drug is for.
4. Inform the patient that
administration may cause
pain on IV site.
5. Administer the drug in a
slow manner, intravenously.
35
A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II - Uncontrolled
DRUG ORDER
(Generic name, brand
name, classification,
dosage, route,
frequency)
MECHANISM OF
ACTIONINDICATIONS
CONTRAINDICATIONS ADVERSE EFFECTS
OF THE DRUG
NURSING
RESPONSIBILITIES/
PRECAUTIONS
36
A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II - Uncontrolled
GENERIC NAME:
metoprolol
BRAND NAME:
Lopresor
CLASSIFICATION:
Antianginals,
antihypertensive agent
Beta blockers
DOSAGE: 50mg 1 tab
ROUTE: PO
FREQUENCY:
BID
TIMING: 8am-6pm
Unknown. A Selective
beta blocker that
selectively blocks beta-
adrenergic receptors;
decreases cardiac
output, peripheral
resistance, and cardiac
oxygen consumption;
and depresses rennin
secretion.
Early intervention in
acute MI
1. Hypersensitivity to
metoprolol
2. Uncompensated CHF
3. Pulmonary edema
4. Cardiogenic shock
5. Bradycardia or heart
block
CNS: fatigue, dizziness,
drowsiness, anxiety,
weakness nervousness,
nightmares, insomnia
EENT: blurred vision,
stuffy nose
Resp: bronchospasm,
wheezing
CV: hypotension,
peripheral
vasoconstriction,
bradycardia, CHF,
Pulmonary edema
GI: constipation,
diarrhea,
flatulence,gastric pain,
heartburn, dry mouth,
nausea, vomiting,
Derm: itching, rash
GU: erectile
dysfunction, urinay
1. Confirm patient through
asking his name and
looking on his name
bracelet.
2. Explain to the patient
what the drug is for.
3. Monitor vital signs before,
during, and after
administration. Take apical
pulse before administering.
If HR is <60bpm, inform
physician.
4. Monitor intake and output
accurately.
5. Monitor HGT as
prescribed.
6. Administer drug with or
after meals.
7. Assess for signs and
37
A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II - Uncontrolled
frequency
Derm: rashes
Endo: hyperglycemia,
hypoglycaemia
MS: arthralgia, back
pain
Miscellaneous: drug-
induced lupus
syndrome
symptoms of CHF
(dyspnea, rales/crackles,
peripheral edema, jugular
venous distention) and
prompt physician if these
occur.
38
A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II - Uncontrolled
DRUG ORDER
(Generic name,
brand name,
classification,
dosage, route,
frequency)
MECHANISM OF
ACTIONINDICATIONS
CONTRAINDICATIONS ADVERSE EFFECTS
OF THE DRUG
NURSING
RESPONSIBILITIES/
PRECAUTIONS
GENERIC NAME:
lactulose
BRAND NAME:
Duphalac
CLASSIFICATION:
laxative
osmotics
DOSAGE: 3.3g/5ml
30 ml
ROUTE: PO
Increases water
content and softens
the stool, lowers pH of
the colon, which
inhibits diffusion of
ammonia from the
colon into the blood,
thereby reducing
blood ammonia.
Prophylaxis for
pending constipation
to avoid valsalva
maneuver causing
then more agitation to
the patient.
1. Hypersensitivity to
lactulose
2. Galactosemia
3. Bowel obstruction
GI: belching, cramps,
distention, flatulence,
diarrhea
Endo: hyperglycemia
1. Confirm patient
through asking his
name and looking on
his name bracelet.
2. Explain to the
patient what the drug
is for.
3. Assess for bowel
distention, presence of
bowel sounds, and
normal pattern of
bowel function.
3. Monitor vital signs
before, during, and
39
A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II - Uncontrolled
FREQUENCY:
HS
TIMING: 8pm
after administration.
4. Monitor HGT as
ordered.
5. Monitor intake and
output accurately.
Assess the color,
consistency, and
amount of stool
produced.
6. Administer drug
before sleeping hours.
7. Provide safety
measures; keep side
rails up at all times.
40
A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II - Uncontrolled
DRUG ORDER
(Generic name,
brand name,
classification,
dosage, route,
frequency)
MECHANISM OF
ACTIONINDICATIONS
CONTRAINDICATIONS ADVERSE EFFECTS
OF THE DRUG
NURSING
RESPONSIBILITIES/
PRECAUTIONS
GENERIC NAME:
metformin HCl
BRAND NAME:
Glucophage
CLASSIFICATION:
Antidiabetics
biguanides
DOSAGE: 500mg 1
tab
ROUTE: PO
Decreases hepatic
glucose production,
decreases intestinal
glucose absorption
and increases
sensitivity to insulin.
Management of type 2
diabetes mellitus
1. Hypersensitivity to
metformin
2. Metabolic acidosis
3. Sepsis
4. Dehydration
5. Hypoxemia
6. Hepatic impairment
7. Renal dysfunction
GI: abdominal
bloating, diarrhea,
nausea, vomiting,
unpleasant metallic
taste.
Endo:
hypoglycaemia
F and E: lactic
acidosis
Misc: decreased
vitamin B12 levels
1. Confirm patient
through asking his
name and looking on
his name bracelet.
2. Explain to the
patient that metformin
only controls
hyperglycemia and
does not cure DM.
3. Assess for bowel
distention, presence of
bowel sounds, and
normal pattern of
41
A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II - Uncontrolled
FREQUENCY:
TID
TIMING: 8am-6pm
bowel function.
4. Monitor vital signs
before, during, and
after administration.
5. Administer
metformin with meals.
6. Monitor HGT as
ordered.
7. Monitor intake and
output accurately.
42
A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II - Uncontrolled
ASESSMENT DATA
(Subjective and Objective)
NURSING DIAGNOSIS
(Problem and Etiology)
GOAL AND OBJECTIVES NURSING INTERVENTIONS AND
RATIONALE
EVALUATION
“Murag naai plemas
nagpikit diri sa akong
tutunlan nga dili nako
magawas” as verbalized by
the patient.
Objective:
Abnormal increase of
RR of 25cpm
(tachypneic)
Non – productive
cough
Abnormal breath
sounds heard upon
auscultation (rales on
inspiration)
Ineffective Airway
clearance related to
retained copious
secretions in the
tracheobronchial tract.
Short-Term Goals:
Within 3-5 minutes of
thorough nursing
intervention the patient will
be able to:
a) Improve respiratory
status from 25cpm
(tachypneic) to
normal range of RR
(12 – 22cpm)
b) Expectorate
gradually secretions.
Long-Term Goals:
After 8 hours of the course
of duty, the client will be
able to:
INDEPENDENT:
1. Auscultate breath sounds.
R – This will serve as a baseline
data for the effectiveness of the
actions done.
2. Assist patient on moderate high
back rest.
R – To maximize lung expansion
promoting then proper exchange
of gases.
3. Demonstrate and instruct proper
and effective deep breathing and
coughing exercises.
R – To effectively expectorate
copious secretions lodge in the
Short- Term Goals:
Goals met. After 5 minutes of
thorough nursing intervention
the patient was able to
improve respiratory status
from 25cpm to a normal range
of RR (22cpm) and gradually
expectorated secretions.
Long-Term Goals:
Goals partially met. After 8
hours of thorough nursing
interventions the client was
able to maintain the
respiratory status within the
normal range (12 – 22cpm).
Although, there are clear
43
A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II - Uncontrolled
a) Maintain the
respiratory status
within the normal
range (12 – 22cpm)
b) Expectorate all
copious secretions
lodge within the
tracheobronchial tract
as manifested by
clear breath sounds.
airways.
4. Instruct patient to increase fluid
intake within the cardiac tolerance.
R – This will soften the copious
secretions for easy expectoration.
5. Do chest tapping at appropriate
intervals.
R – To dislodge secretions from
smaller airways to larger airways
for easy expectoration.
6. Turn the patient into sides every 2
hours and/or appropriate intervals.
R – This will prevent respiratory
complications and allows the
release of pressure on the back
especially on the sacral area and
other bone prominences that may
create ulceration.
breath sounds heard upon
auscultation, there are times
that patient coughs roughly
which may denote the
existence of secretions within
the tracheobronchial tract.
.
44
A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II - Uncontrolled
DEPENDENT:
1. Provide oxygen inhalation, as
ordered, at 2LPM via nasal cannula.
R - To adequately provide oxygen
unto the client preventing then
tachypnea.
45
A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II - Uncontrolled
ASESSMENT DATA
(Subjective and Objective)
NURSING DIAGNOSIS
(Problem and Etiology)
GOAL AND OBJECTIVES NURSING INTERVENTIONS AND
RATIONALE
EVALUATION
Subjective:
“Usahay kay naa
gapitik-pitik sa
akong dughan” as
verbalized by the
patient.
“Usahay pud kay
gahanguson ko..” as
verbalized by the
patient.
Objective:
Abnormal decrease of HR
of 58bpm (bradycardia)
Abnormal increase of RR
of 25cpm (tachypneic)
ST elevation on the ECG
Decreased Cardiac
Output related to
altered preload as in
decrease venous return
secondary to ST
Elevation Myocardial
Infarction (STEMI)
Short- Term Goals:
Within 5 – 10 minutes of
thorough nursing
intervention, the client will
be able to:
a) Improve heart rate
from 58bpm
(bradycardia) to
normal range of HR
(60 – 100bpm).
b) Improve respiratory
status of the client
from 25cpm
(tachypneic) to
normal range of RR
(12 – 22cpm).
INDEPENDENT:
1. Monitor Vital Signs frequently
especially HR and RR.
R – This will serve as a baseline
data for the effectiveness of the
actions done.
2. Assist client in moderate high
back rest.
R – To maximize lung expansion
promoting then proper exchange
of gases.
3. Provide quiet environment and
decrease stimuli.
R – To promote adequate rest and
to avoid agitation in the client
Short- Term Goals:
Goals met. After 10 minutes
of thorough nursing
intervention, the client was
able to improve heart rate
from 58bpm to normal range
of HR (67bpm), improve
respiratory status of the
client from 25cpm to normal
range of RR (22cpm).
Long- Term Goals:
Goals partially met. After 16
hours of duty, the patient
was able to maintain HR
within the normal range (60 –
46
A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II - Uncontrolled
of the client
Long- Term Goals:
At the end of 16 hours of
duty, the patient will be able
to:
a) Maintain HR within
the normal range (60
– 100bpm)
b) Maintain respiratory
status of the client
within the normal
range (12 – 22cpm)
c) See significant
progress unto the
client’s ECG of
normal PQRST
waves.
decreasing then oxygen demand.
4. Allow client to rest in appropriate
intervals.
R – This would decrease oxygen
consumption using it instead for
the myocardium for better cardiac
contractility to increase cardiac
output.
5. Assist client in elevating the legs
when sitting.
R – To promote effective venous
return, increasing then cardiac
output because of the ample
oxygenation of the myocardium.
6. Provide psychological support,
clarify and inform client about the
current condition and
misconceptions about the disease
too.
100bpm), maintain
respiratory status of the
client within the normal range
(12 – 22cpm) but we weren’t
able to see progress of the
ECG because there was no
follow-up order.
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A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II - Uncontrolled
R – It helps client to overcome the
fear of unknown and lessens
anxiety because anxiety
increases agitation affecting then
our normal body physiology
causing then decrease cardiac
output.
DEPENDENT:
1. Administer enoxaparin 0.4cc, SC
every 12hours; aspirin 80g 1 tab,
OD p.c. lunch; and clopidogrel 75g 1
tab, OD at HS, as ordered.
R – prevention of thrombosis and
somehow preventing the
thickening of clot formation
within the coronary artery which
causes the blockage of the blood
vessels impeding then the
oxygenation to the myocardium,
decreasing the CO.
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A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II - Uncontrolled
2. Administer lactulose 30cc OD at
HS, as ordered.
R – This will act as a prophylaxis
for the patient to prevent valsalva
maneuver during defecation
because in doing so, it will affect
cardiac rate and further agitate
the patient not to mention it
impedes blood flow causing then
cardiac anomalies and decreases
CO as well.
3. Provide oxygen inhalation at
2LPM via nasal cannula, as ordered.
R – This would help in providing
easy access of oxygen supply for
the body to avoid overexertion
during its compensatory action to
improve cardiac output.
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A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II - Uncontrolled
COLLABORATIVE:
1. Refer to the dietician for low salt,
low fat diet.
R – To help client in the
management of STEMI and DM
Type II, improving then cardiac
functioning of the client.
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A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II - Uncontrolled
ASESSMENT DATA
(Subjective and Objective)
NURSING DIAGNOSIS
(Problem and Etiology)
GOAL AND OBJECTIVES NURSING INTERVENTIONS AND
RATIONALE
EVALUATION
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A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II - Uncontrolled
Subjective:
“Usahay paspas ang
pitik sah akong
dughan ug mura ko
ganerbioson” as
verbalized by the
patient.
Objcetive:
Abnormal decrease of
heart rate of 58bpm
Abnormal decrease of
respiratory rate of
25cpm
Abnormal increase of
blood glucose level of
172mg/dl. (CBG)
Abnormal increase in
blood glucose level of
139mg/dL (labs)
Ineffective tissue
perfusion
(cardiopulmonary)
related to sluggish
blood flow due to
increase viscosity of
blood circulation
secondary to Diabetes
Mellitus
Short-Term Goals:
At the end of 8 hours of
thorough nursing
intervention, the client will
be able to:
a.) Establish and
maintain normal vital
signs of heart rate
60-100bpm from
58bpm.
b.) Establish and
maintain normal
respiratory rate of
12-22cpm from
25cpm.
Long-Term Goals:
At the end of 16 hours of
thorough nursing
intervention, the client will
INDEPENDENT:
1. Elevate peripheries or extremities
R – To promote venous return to
the heart.
2. Demonstrate and assist patient in
active and passive range-of –motion.
R – To increase the blood flow by
improving circulation and prevent
formation of thrombus.
3. Turn patient at appropriate
intervals.
R – Bed mobility improves
circulation in the body.
4. Instruct patient to have a complete
bed rest without toilet privilege.
R – To prevent overexertion and
fatigue.
Short- Term Goals:
Goals Met. At the end of 8
hours of thorough nursing
intervention, the client was
able to established and
maintain normal vital signs of
HR (67bpm) and RR (22cpm).
Long – Term Goals:
Goals met. At the end of 16
hours of thorough nursing
intervention, the client was
establish and maintain normal
blood glucose within the
normal range (100mg/dL) from
172mg/dL (CBG) and
139mg/dL (labs) and
maintained heart rate (60 –
100bpm) and respiratory rate
(12 – 22cpm) within the
normal range.
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A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II - Uncontrolled
be able to:
a.) Establish and
maintain normal
blood glucose within
the normal range
( 70 – 110mg/dL)
from 172mg/dL
(CBG) and
139mg/dL (labs)
b.) Maintain heart rate
(60 – 100bpm) and
respiratory rate (12
– 22cpm) within the
normal range.
DEPENDENT:
1. Administer metformin
(Glucophage) 50mg,p.o at TID as
ordered.
R – This anti-diabetic agent aids in
lowering down blood glucose
level.
COLLABORATIVE:
1. Refer to dietician for full diabetic
diet.
R – To avoid worsening of the
condition leading to its
complication, Diabetic
Ketoacidosis.
ASESSMENT DATA
(Subjective and Objective)
NURSING DIAGNOSIS
(Problem and Etiology)
GOAL AND OBJECTIVES NURSING INTERVENTIONS AND
RATIONALE
EVALUATION
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A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II - Uncontrolled
Subjective:
“Gasakit usahay
akong dughan” as
verbalized by the
patient.
Objective:
Pain Scale :6/10
Restless
Guarding on the left
chest.
Acute pain (left chest)
related to partial
blockage of the
coronary artery
secondary to acute
coronary syndrome
Short-Term
Within 10 - 15 minutes of
nursing care and
interventions, the patent
will:
1. Report controlled
pain as evidenced
by a decreased pain
scale from 6/10 to
0/10.
2. Demonstrate use of
relaxation skills.
Long-Term
After 8 hours of thorough
nursing intervention, the
client will be able to report
relieved of pain.
INDEPENDENT:
1. Monitor V/S which is usually
altered when patient is in acute pain.
R - Changes in vital signs may
indicate acute pain and
discomfort.
2. Provide comfort measures to the
patient such as providing appropriate
ventilation.
R - To promote relaxation.
3. Assist patient to find position of
comfort.
R - Position affects the patient’s
ability to relax and rest/sleep
effectively.
4. Teach patient deep-breathing
exercise to help refocus attention and
enhance coping abilities.
R - This reduces muscle tension
Short- Term Goals:
Goals met
After 15 minutes of Nursing
interventions, the patient
reported pain was relieved as
evidenced by a pain scale of
0/10 and demonstrated
relaxation techniques such as
deep breathing exercise.
Long-Term Goals:
Goal partially met
After the 8-hour shift, the
patient reported relieved pain
with a pain scale of 0/10.
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A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II - Uncontrolled
ASESSMENT DATA
(Subjective and Objective)
NURSING DIAGNOSIS
(Problem and Etiology)
GOAL AND OBJECTIVES NURSING INTERVENTIONS AND
RATIONALE
EVALUATION
Subjective:
“Dili na nako
mabuhat kayo akong
gabuhaton sa una
nga wa pako
nagsakit” as
verbalized by the
patient.
“Dali rako kapuyon
ug kung masobraan,
hanguson dayon ko”,
as verbalized by the
patient.
Objective:
Activity Intolerance
(Level 1) related to
imbalance between
oxygen supply and
demand secondary to
inability of the heart to
pump out adequate
amount of blood.
Short-Term Goals:
After 5 hours of nursing
interventions, the client will
be able to:
a.) Verbalize
acceptance the
need for activity
modification.
b.) Improve the
respiratory status of
the client from
27cpm (upon
exertion) to normal
range (12 – 22cpm)
c) Improve client’s
INDEPENDENT:
1. Allow rest in between activities
R – This will decrease oxygen
consumption and to avoid
overexertion.
2. Inform the client about the recent
medical condition.
R – This will clarify thought of the
client’s and gain cooperation
along the way.
3. Assist client in doing activity
modification. ( i.e. instead of
buying/cooking meals, he can
Short-Term Goals:
Goals met. After 5 hours of
nursing interventions, the
client will be able to verbalize
acceptance the need for
activity modification, improved
the respiratory status of the
client from 27cpm (upon
exertion) to normal range
(22cpm), improved client’s
responses from restless to
coherent by answering
questions appropriately and
perform activities within the
cardiac tolerance.
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A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II - Uncontrolled
Pallor mucosa and
conjunctiva
Abnormal decrease of
RBC (3.58); Hgb
(11.1); and Hct (31.5).
Abnormal increase of
RR of 27cpm upon
exertion (tachypnea)
Restless
responses from
restless to coherent
by answering
questions
appropriately.
d) Perform activities
within the cardiac
tolerance.
Long-Term Goals:
After 16 hours of nursing
interventions, the client will
be able to:
a. Maintain RR within
the normal range
(12 – 22cpm)
b. Maintain client’s
responses upon
doing activities ( i.e.
don’t feel dizzy
easily)
prepare the utensils and plates)
R – This will encourage client in
his health management. In this
manner, it would gain client’s
compliance to activity
modification and this will be more
achievable rather than setting
your own activities.
4. Promote comfort measures and
provide relief of pain non-
pharmacologically.
R – To enhance ability to
participate in activities.
5. Increase exercise/activity levels
gradually. (i.e from the bed to sitting
position on the bed to chair and
assist in ambulation)
R – To conserve energy and
increase activity competency.
Long-Term Goals:
Goals met. After 16 hours of
nursing interventions, the
client will be able to maintain
RR within the normal range
(12 – 22cpm), maintained
client’s responses upon doing
activities ( i.e. don’t feel dizzy
easily), continuously do
modified activities within the
cardiac tolerance, improved
client’s laboratory results of
RBC from 3.58 to normal
range ( 4.0); Hgb from 11.1 to
normal range (14.0); and Hct
from 31.5 to normal range
(39.6).
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A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II - Uncontrolled
c. Continuously do
modified activities
within the cardiac
tolerance.
d. Improve client’s
laboratory results of
RBC from 3.58 to
normal range ( 4.2 –
5.4); Hgb from 11.1
to normal range
(12.0 – 16.0); and
Hct from 31.5 to
normal range (37.0
– 47.0)
6. Assist client in Active and Passive
Range of Motion.
R – To initiate gradual; activity to
the client.
DEPENDENT:
1. Provide oxygen inhalation at
2LPM via nasal cannula, as per
doctor’s order
R – To give adequate oxygen flow
especially during exertion.
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A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II - Uncontrolled
ASESSMENT DATA
(Subjective and Objective)
NURSING DIAGNOSIS
(Problem and Etiology)
GOAL AND OBJECTIVES NURSING INTERVENTIONS AND
RATIONALE
EVALUATION
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A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II - Uncontrolled
Risk factors:
Dietary Intake (still
consumes sweet, salty,
fatty and carbohydrate-
rich foods)
Stress
Sedentary lifestyle
(lack of exercise)
Risk for Unstable
Blood Glucose
Short term Goal:
After 30 minutes of nursing
interventions, the patient
will be able to:
Verbalize
understanding of the
factors that may
lead to unstable
glucose such as
eating sweet, salty,
fatty and
carbohydrate-rich
foods.
Long term Goal:
After 16 hours of nursing
interventions, the patient
will be able to:
a.) Maintain a normal
glucose level; 70-
110 mg.
INDEPENDENT:
1. Ascertain client’s knowledge or
understanding of condition and
treatment needs.
R: To know what are the
information to be given
2. Provide information on balancing
food intake and anti-diabetic agents.
R: To enhance the efficacy of the
medication
3. Review client’s common situations
that contribute to glucose instability.
R: Multiple factors can play a role
at any time , such as missing
meals and infection
5. Encourage client to read labels
and choose foods described as
having a low glycemic index, higher
fiber, and low fat content.
Short- Term Goals:
Goal met. After 30 minutes of
nursing intervention, the
patient was able to verbalize
understanding of the factors
that may lead to unstable
glucose such as eating sweet,
salty, fatty and carbohydrate-
rich foods.
Long term Goal:
Goal met. After 16 hours of
nursing interventions, the
patient was able to maintain a
Normal glucose level; (indicate
the CBG)
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A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II - Uncontrolled
R: These foods produce a slower
rise in blood glucose
6. Discuss how client’s anti-diabetic
medications work.
R: Drugs and combinations of
drugs work in varying ways with
different blood glucose control
and side effects. Understanding
drug actions can help client avoid
or reduce risk of potential for
hypoglycemic reactions.
7. Encourage client to develop a
system for self-monitoring
R - To provide a sense of control
and enable client to follow own
progress.
Dependent:
1. Administer metformin 500 mg PO
tid as ordered.
R – This anti-diabetic agent aids in
lowering down blood glucose 60
IX. DISCHARGE PLANNING
MEDICATIONS
Discuss to the patient and family the dosage, frequency, and adverse effects of
the drugs. Explain that the drugs used for effective control of elevated BP will
likely produce adverse effect.
Explain to the patient and family members the importance of taking medicines.
The patient will able to take medications as what had been prescribed by the
physician religiously and be able to follow directions as instructed by the nurse.
In patients with self-administer insulin, demonstrate patient the appropriate
preparation and administration techniques.
ECONOMIC STATUS
Inform the patient to avail to some government programs such as philhealth.
Explain to significant others that the rehabilitation may be prolonged to be able to
for the family to prepare financial needs.
Have occupational therapist to help re-learn everyday activities or ADL.
TREATMENT
Emphasized the importance of regular follow-up check-ups and as instructed by
physician.
Advised patient and family members to seek medical advise if any unusuality
arises
Reinforced the importance of having blood sugar checked every day.
Admit patient in cardiac rehabilitation, this is a monitored exercise and education
program that can help the patient return to an active lifestyle.
HEALTH TEACHING
Encouraged client to do at least 30 minutes of walking a day as a form of
exercise.
Encouraged client to quit smoking and offered nicotine replacement. Cessation of
cigarette smoking reduces the progression of disease, as shown by lower rates
of amputation and lower incidences of rest ischemia in patients who quit, and it
reduces the risks of myocardial infarction and death from other vascular causes.
Instructed to monitor blood sugar regularly. Adjustments in diet, medication and
exercise can be made accordingly.
Encouraged to stick to the monitoring protocol prescribed by the doctor.
Generally, blood is monitored before meals and at bedtime.
Safety precaution should be maintained to prevent foot injury such as do not
wear open shoes or walk barefoot
Teach to the patient signs and symptoms of diabetic neuropathy and emphasize
the need for safety precautions because neuropathy decreased sensation can
hide sense injuries.
Adjust of activities to avoid over exertion and fatigue, allow rest periods
OUT-PATIENT
The patient could avail his medication from government hospitals that he could
get some benefits.
He will also avail the services offered by the barangay health center and at the
botikang bayan
Instruct patient to seek regular medical check-up
DIET
Eat a variety of foods as recommended in the Diabetes Food Pyramid to get a
balanced intake of the nutrients your body needs - carbohydrates, proteins, fats,
vitamins, and minerals.
Reduce the amount of fat you eat by choosing fewer high-fat foods and cooking
with less fat.
Eat more fiber by eating at least 5 servings of fruits and vegetables every day.
Eat fewer foods that are high in sugar like fruit juices, fruit-flavored drinks,
sodas, and tea or coffee sweetened with sugar.
Use less salt in cooking and at the table. Eat fewer foods that are high in salt,
like canned and packaged soups, pickles, and processed meats.
SPIRITUALITY
Encouraged patient and Family members to go to church every Sunday and to
continue to seek God’s guidance and enlightenment.
Emphasized the importance of prayers in healing
Encouraged to ask for divine assistance in everything and to
encouragecontinuing to pray to God.
Encouraged to continue to have a positive outlook in life.
Encouraged to keep faith in God and not to give up easily when hardtimes come
X. RELATED LEARNING EXPERIENCE
Taking up nursing course have entitled the group to become disciplined in
everything that we do. As much as we want to think that the nursing life is easy to
somehow lessen the stress and sometimes burden but it’s not working. This have made
us realize that it’s better to accept the idea that nothing is easy and hence, molding
ourselves to become disciplined is one way of passing this difficult road to success.
Our duty at the Intensive Care Unit of Northern Mindanao Medical Center is
probably the busiest duty we’ve ever had unlike in CUMC Intensive Care Unit its
opposite due to fewer patients admitted. But despite it, we have taken it as an
opportunity to take advantage of our duty time in improving our clinical skills and as well
as improving our knowledge. We’ve learned a lot in the clinical area and so it’s definitely
worth our exhaustion.
The entire process of making this case study may have not been easy for all of
us but fortunately, we’ve manage to deal with the problems properly and thus, we were
able to finish this case study in the best way we could. Whether the outcome of this
case study is good or bad, we must take it as a lesson and a parameter to continue
seeking knowledge and improving our skills.
This case study enabled the group to identify nursing intervention which are
appropriate to promote the well-being of the patient and as well as the medical
management for the case.
We would like to thank Mr. Hamed Fabre, for giving his best to teach us and to
mold us in becoming good and competent nurses in the future. Furthermore, this
rotation would have not been successful without the guidance of our almighty God!
XI. REFERENCE
BOOKS:
Doenges, M.E., Moorhouse, M.F., & Geissler, A.C, (2002). Nursing Care
Plans Guidelines for Individualizing Patient Care, (6th ed.). Thailand
Doenges, M.E., Moorhouse, M.F., & Geissler, A.C (2006). Nurse’s pocket
Guide; Diagnoses, Prioritized Interventions, and Rationales. (10thed.).
Philadelphia, Pennsylvania
Smeltzer, Suzanne C., RN, Edd, FAAN, & Bare, Brenda G., RN, MSN,(2004).
Textbook of Medical-Surgical Nursing, (10th ed.), Philadelphia
Karch, Amy M. ; 2006 Lippincott’s Nursing Drug Guide, 8th edition. Lippincott
Williams & Wilkins.
Nurses’ Pocket Guide, 10th edition F.A. Davis.
Nursing Care Plans, 7th edition F.A. Davis Doeuger, Moorhouse, Murr.
Patient’s Chart
Black, Joyce M. et. al, Medical-Surgical Nursing: Clinical Management for
Positive outcome. 7th edition. Philadelphia, W.B. Saunders. 2005
Malseed, Roger T. ; Springhouse Nurses’ Drug Guide 2004, 5th edition.
Davis drug handbook, 10th edition
Drug handbook by Saunders
Medical-Surgical Nursing (Clinical Management for Positive Outcomes) 8th
edition By: Joyce Black and Jane Hokanson Hawks
Nursing Care of Infants and Children by Wong
INTERNET:
http://cpmcnet.columbia.edu/dept/gi/.html
http://www.drstandley.com/labvalues
http://www.google.com.ph/search?anatomy&meta=
http://www.merck.com/ l
http://www.wpro.who.int/countries/2009/phl/health_situation.htm
www.cureresearch.com/c/cerebral_palsy/stats-country.htm?ktrack=kcplink
http://www.tuberculosistextbook.com/tb/tbchild.htm
(http://www.mayoclinic.com/health/acute-coronary
syndrome/DS01061/DSECTION=symptoms)
http://www.mayoclinic.com/health/acute-coronary
syndrome/DS01061/DSECTION=symptoms