PHILIPPINES COLLEGES of HEALTH & SCIENCES

AFPMC V. Luna General Hospital

Medical Intensive Care Unit (MICU)
NMC 204 (2008 - 2009)

CASE STUDY MYOCARDIAL

INFARCTION

GROUP D1

BELTRAN, JHON MARC

MARIANO, RYAN

TADIFA, JOLEEN

MR. EPHRAIM MIRAFUENTES

Clinical Instructor

CONTENTS OF CASE STUDY.

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I. Introduction
a. Background
b. General Objective
c. Importance of the study

II. Data Base

a. Client’s Profile
b. History
1. History of Present Illness
2. Past Medical History
3. Family Medical History
4. Social History
5. 11 Functional Health Pattern (Gordons)
c. Physical Assessment
1. Physical assessment (head to toe)
2. Diagnostic procedure done and to be done.
III. Anatomy and physiology
1. Laboratory Result and significances

IV. Pathophysiology and schematic diagram

V. Drugs study

VI. Nursing care management

1. Problem list
2. Nursing care plan (3 action and 3 potential)
3. Discharge Planning (M-E-T-H-O-D-S)

VII. References

VIII. Evaluation

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I. Introduction

a. Background

An intensive care unit (ICU), also sometimes known as a critical care unit or an intensive
therapy department is a special ward found inside most hospitals. It provides intensive care
(treatment and monitoring) for people who are in a critically ill or unstable condition. Patients in
ICUs need constant medical support to keep their body functions going. They may not be able to
breathe on their own, and may have multiple organ failure, so medical equipment takes the place
of these functions while they recover.

There are several circumstances in which a person may be admitted to intensive

care, for example, following surgery, or after an accident or severe illness. ICU beds are a
very expensive and limited resource because they provide specialized monitoring
equipment, a high degree of medical expertise and constant access to highly trained
nurses (usually one nurse for each bed). Being in an ICU can be a daunting experience
both for the patient and his or her friends and family. The healthcare professionals in
ICUs understand this and are there to help and support both patients and their families
during their time in intensive care.

Myocardial infarction (MI) is the irreversible necrosis of heart muscle secondary

to prolonged ischemia. This usually results from an imbalance of oxygen supply and
demand. The appearance of cardiac enzymes in the circulation generally indicates
myocardial necrosis. MI is considered, more appropriately, part of a spectrum referred to
an acute coronary syndromes (ACSs), which also includes unstable angina and non–ST-
elevation MI (NSTEMI). Patients with ischemic discomfort may or may not have ST-
segment elevation. Most of those with ST-segment elevation will develop Q waves.
Those without ST elevations will ultimately be diagnosed with unstable angina or
NSTEMI based on the presence of cardiac enzymes. MI may lead to impairment of
systolic function or diastolic function and to increased predisposition to arrhythmias and
other long-term complications.

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b. General Objective

1. Describe Critical Care as a collaborative, holistic approach that includes the patient,
family and significant others

2. Established priority critical measures instituted for any patient with a critical
conditions.

3. Differentiate, describe, and specify critical care measures and management for
admission due to coronary artery disease (Myocardial infarction).

4. Use of a Multidisciplinary Team to Find Simple Solutions. The team determined

that the following factors potentially increased a patient’s risk of
infection through the central catheter: choice of insertion site, skin
preparation material and technique, use of sterile barriers during
insertion, dressing maintenance and change techniques, and use of aseptic
technique during catheter access.

5. Have knowledge on safe drug administration (preparations/computations) and

correlate drug interaction to patient’s condition. Take good performers
and transform into great performers in the areas of service to patients, clinical
quality, staff satisfaction.

6. Evaluate the patient’s condition and provide nursing care according to the identified
needs, report unusual manifestation/ findings and complication.

c. Importance of the study

1.  Explain cardiac physiology in relation to cardiac anatomy and the conduction system
of the heart. Describe the essential components of heart anatomy and physiology to
include path of blood flow, the role of arteries, veins, and capillaries.

2. Incorporate assessment of functional health patterns and risk factors into the health
history and physical assessment of the patient with coronary artery disease.

3. Outline and define the physiologic/Pathophysiology sequence of events that lead to an

acute myocardial infarction (AMI).

4.  List the critical parameters of assessment and treatment emergency responders must
perform when first attending to a patient with an acute myocardial infarction.

5. Describe the information each of the following tests provide an critical care with
physician or cardiac specialist when presented with a patient with a suspected AMI.

6. Define the following as to their prevention or treatment of an MI.

7.  Describe the key roles the following health professionals provide in the care of a
patient with an acute heart attack:

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II. Data Base March 20, 2009

a. Client’s Profile

Name: A.P.G Age: 71 years old Sex: Male Reg. #: 901668

Address: # 405TNR, FTI Compound, Western Bicutan, Taguig City
Birthday: October 2, 1937 Birthplace: Bohol
Religion: 7th Day Adventist Status: Married Race: Filipino
Admitted to E.R.: March 4, 2009, assisted by Maj. Benejane.
Transferred to M.I.C.U.: March 7, 2009 Room #: 5 Rank: C/V/T
Diagnosis: Nosocomial Pneumonia; CAD, ACS, NSTMI, Killip II, HCVD, FC II,
Intracerebral he, (L) Basal Ganglia with intraventricular extension

b. History

1. History of Present Illness

The patient was not able to get up at early morning, as they notice. Then after
two hours he had vomited episodely and cramping, so, their relatives rush up at
Fort Santiago General Hospital. Then, they transferred at AFPMC V.Luna,
around 10:00 AM.

2. Past Medical History

He have a high blood pressure, not complaining for almost 10 years, he only
taking the drugs that given to him since the last consultation.

3. Family Medical History

He had history of hypertension and Diabetes Mellitus on paternal side.

4. Social History
According to his wife, he used to smoke 8-10 sticks per day and he
occasionally drinks any liquor. He sleeps 5 to 6 hours a day,
irregular habit time of sleep.

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5. 11 Functional Health Pattern (Gordons) in NANDA
1. Health perception-Health Management Pattern
The patient was never ask a consultation at the Physician as long as he can stand
alone and can walk. Until he woke up with vulnerable condition, the reason to
seek a health management.
2. Nutritional-Metabolic Pattern
He doesn’t care, too much, what should be the food to be intake, and what not
should be, too. He always telling his wife “ano na lang ang kakainin ko?!”. And
now he is feeding thru NGT with low salt, low cholesterol and 1,800kCal.
3. Elimination Pattern
He used to commode at least once a day before he admit MICU, according to his
wife. The physician ordered a Lactulose 30 cc to help him in bowel movement.
4. Activity-Exercise Pattern
The patient working as a carpenter, before his condition getting bad. At the
MICU, helping the patient turning side-to-side every two hours, ordered by the
physician, and do the passive R.O.M.
5. Sleep-Rest Pattern
According to his wife, he sleep for almost 5-6 hour with irregular habit time of
sleep. The patient had never awake, since he transferred at MICU.
6. Cognitive-Perceptual Pattern
He perform self-care within the level of ability to do the ADL and other activity.
Since he got an Intracerebral hemorrhage, he had disturbed perceptual abilities
due to neurological illness.
7. Self-Perception/self-concept Pattern
He took a healthy body for granted, a kind of denial of the eventuality of aging
and illness. Due to the threats to self-concepts about the self these condition may
pose.
8. Role-Relationship Pattern
He was hardworker and good father to his family. Because of his condition, he is
now lying at room # 5, MICU. His family involved in decision making processes
directed at appropriate solution for the situation crisis
9. Sexuality-reproductive Pattern
He had children by their own. Since, he got CAD, less frequency and satisfaction
their sexual activity
10. Coping-Stress Tolerance Pattern.
When the patient felt stress, he used to smoke. Although he know there is other
way to move the stress away.
11. Value-belief Pattern
They do visit their church together with their family aside from his son, working
on weekends. All we know, Adventist should not eat pork, but he still doing it.

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c. Physical Assessment March 20, 2009
1. Physical Assessment (head-to-toe) perform the latest assessment
General Survey:
Vital Signs BP – 110/80 RR - 40
Temp. 37.4˚C PR – 101 bpm
Unconscious patient lying on bed, with the position of semi-fowlers
Integument
Cold skin, from the body to lower extremity.
The head, right and left arm are enough heat skin.
Nails, delayed refill capillary
Moist skin on his face and neck
Head and neck
Skull and face, shape symmetry
Neck, no presence of contusions.
Eyes, yellow conjunctiva, unequal pupil 2-3 mm pupil on left
and 3-4 pupil on right
Ears, lesion on auricle of the Left ear
Nose, nasal flaring; placing an NGT (French 18) on his Left.
Mouth, placing an Endotracheal tube with 7.0, plastering on his right lips;
dry lips, yellowish teeth
Chest
RR- 40, auscultated chest with crackles sounds
Extra sounds on Heart sounds
Apical pulse rate: 101 bpm
Abdomen
no contour, no lesions
tympany over the stomach and gas
Extremity
Left arm infused IV Fluid
Right arm, no muscle tone, no strength muscle, +1 edema scale
Left and Right leg, are pale, cold & dry skin, delayed capillary refill
Genital
Penis, placing a foley catheter in orange.
Urine, yellow-orange, 200 cc at 4 hours.
Neurological
Glasgow Coma Scale: total score of 6
Eye: 2, he slightly his upper eyelid on pain
Motor: 3, flexes abnormally
Verbal: 1, no response
Level of conciousness: comatose

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2. Diagnostic procedure done, and possible to be done to the patient
Persistent chest pain, ST- segment changes on the electrocardiogram (ECG), and
elevated levels of total creatinine kinase (CK) and the CK-MB isoenzyme over a 72
hour usually confirm an MI. Cardiac troponins are useful in differentiating an MI
from skeletal muscle injury, or when CK-MB measurements are low and a small
MI has actually occurred. Auscultation may reveal diminished heart sounds,
gallops, and, in papillary dysfunction, the apical systolic murmur of mitral valve
area. When signs and symptoms are equivocal, assume that the patient has had an
MI until tests rule it out. Diagnostic test results include the following:
Serial 12-lead ECG: ECG abnormalities may be absent or inconclusive during
first few hours following an MI. When present, characteristics abnormalities
include serial ST-segment depression in subendocardial MI and ST-segment
elevation in a transmural MI.
Coronary Angiography: visualization reveals which vessels have been affected
and the extent of damage.
Serial serum enzyme levels: CK levels are elevated ; specifically, CK-MB or
troponin levels.
Myoglobin: because myoglobin always rises within 3-6 hours after an MI, lack of
an increase within 6 hours indicates that an MI hasn’t occurred.
Echocardiography: may show ventricular-wall motion abnormalities in patients
with a transmural MI.
Nuclear ventriculography (multigated acquisition scan or radionuclide
ventriculography) scanning: Nuclear scanning can identify acutely damaged
muscle by picking up radioactive nucleotide, which appears as a “hot spot” on
the film. It’s useful in localizing a recent MI.
Chest X-ray: venous congestion, cardiomegaly, and kerley’s B lines
Cardiac catheterization: show decrease cardiac output, increase in Pulmonary
arterial pressure, pulmonary artery wedge pressure and central venous pressure.
Auscultation: reveals holosystolic murmur and thrill. And also reveals a friction
rub.
ABG Analysis: reduced partial pressure of arterial oxygen.

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III. Anatomy and Physiology.

ANATOMY

1. Right Coronary
2. Left Anterior
Descending
3. Left Circumflex
4. Superior Vena Cava
5. Inferior Vena Cava
6. Aorta
7. Pulmonary Artery
8. Pulmonary Vein
9. Right Atrium
10. Right Ventricle
11. Left Atrium
12. Left Ventricle
13. Papillary Muscles
14. Chordae Tendineae
15. Tricuspid Valve
16. Mitral Valve

Coronary Arteries.
Because the heart is
composed primarily of cardiac muscle tissue that continuously contracts and relaxes, it must have
a constant supply of oxygen and nutrients. The coronary arteries are the network of blood vessels
that carry oxygen- and nutrient-rich blood to the cardiac muscle tissue. The blood leaving the left
ventricle exits through the aorta, the body’s main artery. Two coronary arteries, referred to as the
"left" and "right" coronary arteries, emerge from the beginning of the aorta, near the top of the
heart. The initial segment of the left coronary artery is called the left main coronary. This blood
vessel is approximately the width of a soda straw and is less than an inch long. It branches into
two slightly smaller arteries: the left anterior descending coronary artery and the left circumflex
coronary artery. The left anterior descending coronary artery is embedded in the surface of the
front side of the heart. The left circumflex coronary artery circles around the left side of the heart
and is embedded in the surface of the back of the heart. Just like branches on a tree, the coronary
arteries branch into progressively smaller vessels. The larger vessels travel along the surface of
the heart; however, the smaller branches penetrate the heart muscle. The smallest branches, called
capillaries, are so narrow that the red blood cells must travel in single file. In the capillaries, the
red blood cells provide oxygen and nutrients to the cardiac muscle tissue and bond with carbon
dioxide and other metabolic waste products, taking them away from the heart for disposal through
the lungs, kidneys and liver. When cholesterol plaque accumulates to the point of blocking the
flow of blood through a coronary artery, the cardiac muscle tissue fed by the coronary artery
beyond the point of the blockage is deprived of oxygen and nutrients. This area of cardiac muscle
tissue ceases to function properly. The condition when a coronary artery becomes blocked
causing damage to the cardiac muscle tissue it serves is called a myocardial infarction or heart
attack.

Superior Vena Cava. The superior vena cava is one of the two main veins bringing de-
oxygenated blood from the body to the heart. Veins from the head and upper body feed into the
superior vena cava, which empties into the right atrium of the heart.

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Inferior Vena Cava. The inferior vena cava is one of the two main veins bringing de-oxygenated
blood from the body to the heart. Veins from the legs and lower torso feed into the inferior vena
cava, which empties into the right atrium of the heart.

Aorta. The aorta is the largest single blood vessel in the body. It is approximately the diameter of
your thumb. This vessel carries oxygen-rich blood from the left ventricle to the various parts of
the body.

Pulmonary Artery. The pulmonary artery is the vessel transporting de-oxygenated blood from
the right ventricle to the lungs. A common misconception is that all arteries carry oxygen-rich
blood. It is more appropriate to classify arteries as vessels carrying blood away from the heart.

Pulmonary Vein. The pulmonary vein is the vessel transporting oxygen-rich blood from the
lungs to the left atrium. A common misconception is that all veins carry de-oxygenated blood. It
is more appropriate to classify veins as vessels carrying blood to the heart.

Right Atrium. The right atrium receives de-oxygenated blood from the body through the
superior vena cava (head and upper body) and inferior vena cava (legs and lower torso). The
sinoatrial node sends an impulse that causes the cardiac muscle tissue of the atrium to contract in
a coordinated, wave-like manner. The tricuspid valve, which separates the right atrium from the
right ventricle, opens to allow the de-oxygenated blood collected in the right atrium to flow into
the right ventricle.

Right Ventricle. The right ventricle receives de-oxygenated blood as the right atrium contracts.
The pulmonary valve leading into the pulmonary artery is closed, allowing the ventricle to fill
with blood. Once the ventricles are full, they contract. As the right ventricle contracts, the
tricuspid valve closes and the pulmonary valve opens. The closure of the tricuspid valve prevents
blood from backing into the right atrium and the opening of the pulmonary valve allows the blood
to flow into the pulmonary artery toward the lungs.

Left Atrium. The left atrium receives oxygenated blood from the lungs through the pulmonary
vein. As the contraction triggered by the sinoatrial node progresses through the atria, the blood
passes through the mitral valve into the left ventricle.

Left Ventricle. The left ventricle receives oxygenated blood as the left atrium contracts. The
blood passes through the mitral valve into the left ventricle. The aortic valve leading into the
aorta is closed, allowing the ventricle to fill with blood. Once the ventricles are full, they contract.
As the left ventricle contracts, the mitral valve closes and the aortic valve opens. The closure of
the mitral valve prevents blood from backing into the left atrium and the opening of the aortic
valve allows the blood to flow into the aorta and flow throughout the body.

Papillary Muscles. The papillary muscles attach to the lower portion of the interior wall of the
ventricles. They connect to the chordae tendineae, which attach to the tricuspid valve in the right
ventricle and the mitral valve in the left ventricle. The contraction of the papillary muscles opens
these valves. When the papillary muscles relax, the valves close.

Chordae Tendineae. The chordae tendineae are tendons linking the papillary muscles to the
tricuspid valve in the right ventricle and the mitral valve in the left ventricle. As the papillary
muscles contract and relax, the chordae tendineae transmit the resulting increase and decrease in

10
tension to the respective valves, causing them to open and close. The chordae tendineae are
string-like in appearance and are sometimes referred to as "heart strings."

Tricuspid Valve. The tricuspid valve separates the right atrium from the right ventricle. It opens
to allow the de-oxygenated blood collected in the right atrium to flow into the right ventricle. It
closes as the right ventricle contracts, preventing blood from returning to the right atrium;
thereby, forcing it to exit through the pulmonary valve into the pulmonary artery.

Mitral Value. The mitral valve separates the left atrium from the left ventricle. It opens to allow
the oxygenated blood collected in the left atrium to flow into the left ventricle. It closes as the left
ventricle contracts, preventing blood from returning to the left atrium; thereby, forcing it to exit
through the aortic valve into the aorta.

Pulmonary Valve. The pulmonary valve separates the right ventricle from the pulmonary artery.
As the ventricles contract, it opens to allow the de-oxygenated blood collected in the right
ventricle to flow to the lungs. It closes as the ventricles relax, preventing blood from returning to
the heart.

Aortic Valve. The aortic valve separates the left ventricle from the aorta. As the ventricles
contract, it opens to allow the oxygenated blood collected in the left ventricle to flow throughout
the body. It closes as the ventricles relax, preventing blood from returning to the heart.

PHYSIOLOGY.
The heart is the muscular organ of the circulatory
system that constantly pumps blood throughout the
body. Approximately the size of a clenched fist,
the heart is composed of cardiac muscle tissue
that is very strong and able to contract and relax
rhythmically throughout a person's lifetime. The
heart has four separate compartments or
chambers. The upper chamber on each side of the
heart, which is called an atrium, receives and
collects the blood coming to the heart. The atrium
then delivers blood to the powerful lower chamber,
called a ventricle, which pumps blood away from
the heart through powerful, rhythmic contractions.

The human heart is actually two pumps in one. The

right side receives oxygen-poor blood from the
various regions of the body and delivers it to the
lungs. In the lungs, oxygen is absorbed in the
blood. The left side of the heartreceives the
oxygen-rich blood from the lungs and delivers it to
the rest of the body.

Systole. The contraction of the cardiac muscle tissue in the ventricles is called systole. When the
ventricles contract, they force the blood from their chambers into the arteries leaving the heart.
The left ventricle empties into the aorta and the right ventricle into the pulmonary artery. The
increased pressure due to the contraction of the ventricles is called systolic pressure. Diastole.
The relaxation of the cardiac muscle tissue in the ventricles is called diastole. When the ventricles

11
relax, they make room to accept the blood from the atria. The decreased pressure due to the
relaxation of the ventricles is called diastolic pressure.

1. Sinoatrial node (SA node)

2. Atrioventricular node (AV node)
3. Common AV Bundle
4. Right & Left Bundle Branches

The Sinoatrial Node (often called the SA node or sinus node)

serves as the natural pacemaker for the heart. Nestled in the upper
area of the right atrium, it sends the electrical impulse that
triggers each heartbeat. The impulse spreads through the atria,
prompting the cardiac muscle tissue to contract in a coordinated
wave-like manner.

The impulse that originates from the sinoatrial node strikes the
Atrioventricular node (or AV node) which is situated in the
lower portion of the right atrium. The atrioventricular node in turn
sends an impulse through the nerve network to the ventricles,
initiating the same wave-like contraction of the ventricles.

The electrical network serving the ventricles leaves the atrioventricular node through the Right
and Left Bundle Branches. These nerve fibers send impulses that cause the cardiac muscle
tissue to contract.

A. Laboratory Result and significant

HEMATOLOGY

Lab Normal value March 04, March 07, March 19, March 19,
2009 (11:45) 2009 (17:30) 2009 (05:35) 2009 (17:35)
Hemoglobin M:13-18 gm/dL F:12- 14.4 16.0 13.2 13.3
. 16 gm/dL
Hematocrit M:42-52% 44% 39% 37% 40%
. F:35%-47%
Red Blood M:4.6-6.2 mill/mm3 4.99 5.11 5.01 4.35
Cell (RBC) F:4.2-5.2 mill/mm3
Leukocytes 4,500-11,000 x109/L 12.6 16.5 13.6 17.5
(WBC)
Platelet 150-450 x109/L 241 212 356 532
Blood Indices
MCV 84-96 cu µm 88.6 96.6 84.0 92.4
MCH 28-33 µµg/cell 28.9 31.2 29.2 30.5
MCHC 33%-35% 32.6 32.3 34.8 33.0
RBW 15.4 16.1 13.3 13.9

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COAGULATION (March 18, 2009)

Time : 14:30 Time : 15:00

Determination Lab.Result Lab.Result Normal Value Deteminatio Result Norml value
n
PT 12.4 12.4 10-14 sec. aPTT 18.4 22-35 sec
% activity 86.9 86.9 67-142% Clotting time 3 2-7 min
INR 1.09 1.09 2-3 Bleeding time 1 2-4 min

SERUM ENZYME LEVELS

Serum Nomal March March March March March March March

Enzyme Value 4,2009 7,2009 8,2009 11,2009 13,2009 15,2009 21,2009
Na+ 135-145 79 65 137.3 52 109 40 117
mEq/L
K+ 3.5-5.0 4.25 3.8 3.72 4.0 3.5 3.7 3.07
mEq/L
Cl+ 100-106 142.3 137 123.4 103 121
mEq/L
Creatinine 62-124 42
µmol/L
Troponin (-) (-)

Significances:

Hematology:

Hgb: still at normal ranges.

Hct: acute massive blood loss
RBC: decreasing due to side effects of the drugs.
WBC: Increasing due to immunocompromised, immune responses.
Platelet: increasing the fibrin that attract the platelet to increased
Blood indices:
MCHC: decreased in severe hypochromic anemia.

Coagulation:
Bleeding time: defective in platelet function
INR: prolonged in deficiency of fibrinogen; used to standardized the prothrombin
time and anti-coagulation therapy.

Serum enzyme levels:

Na+ : decreased; myxedema
K+ : decreased; GI losses, Vitamin D Deficiency
Cl+ : decreased; pneumonia, febrile condition.
Creatinine: decreased; check the status of the kidney
Troponin: negative; if increased the patient may experience myocardial
infarction.

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`IV. Pathophysiology & Schematic Diagram. In an MI, an area of the myocardium is
permanently destroyed; a condition in which the blood supply to the heart muscle is partially or
completely blocked. The heart muscle needs a constant supply of oxygen-rich blood. The
coronary arteries, which branch off the aorta just after it leaves the heart, deliver this blood. MI is
usually caused by the reduced blood flow in a coronary artery of an atherosclerotic plaque and
subsequent occlusion of the artery by a thrombus. Coronary artery disease can block blood flow,
causing chest pain. In unstable angina and acute MI are considered to be the same process but
different appoints along a continuum. specifically coronary atherosclerosis (literally “hardening
of the arteries,” which involves fatty deposits in the artery walls and may progress to narrowing
and even blockage of blood flow in the artery., As an atheroma grows, it may bulge into the
artery, narrowing the interior (lumen) of the artery and partially blocking blood flow. With time,
calcium accumulates in the atheroma. As an atheroma blocks more and more of a coronary artery,
An atheroma, even one that is not blocking very much blood flow, may rupture suddenly. The
rupture of an atheroma often triggers the formation of a blood clot (thrombus), the supply of
oxygen-rich blood to the heart muscle (myocardium) can become inadequate. The blood supply is
more likely to be inadequate during exertion, when the heart muscle requires more blood. An
inadequate blood supply to the heart muscle (from any cause) is called myocardial ischemia. If
the heart does not receive enough blood, it can no longer contract and pump blood normally.
Other causes of MI include vasospasm, (sudden constriction or narrowing) of a coronary artery,
decreased oxygen supply (e.g. from acute blood loss, anemia, or low blood pressure), and
increased demand for oxygen (e.g. rapid heart rate, thyrotoxicosis, or ingestion of cocaine). In
each case, a profound imbalance exists between myocardial oxygen supply and demand. The area
of infarction develops over minutes to hours. As the cells are deprived of oxygen, ischemia
develop, cellular injury occurs,, and the lack of oxygen results in infarction, or the death of cells.
The area of the heart muscle supplied by the blocked artery dies.

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V. DRUG STUDY

Brand Name Metoprolol

Generic Name Lopressor
Classification Antihypertensives
Action A selective beta blocker that selectively blocks beta1 receptors; decreases cardiac
output , peripheral resistance, and cardiac oxygen consumption; and depressed renin
secretion
Pt. dosage 100 mg tab, every 6 hours
ordered by
Physician
Indication Hypertension, initially 100 mg P.O. once daily; then up to 100 mg to 450 mg daily
divided in two or three doses.
Adverse CNS: fatigue, dizziness, depression. CV: hypotension, bradycardia, heart failure, AV
reaction block, edema. GI: nausea, diarrhea. Respiratory: dyspnea. Skin: rashes
Nursing  Always check patient’s apical pulse rate before giving drug.
consideration  Monitor blood pressure frequently.
 Beta blockers may mask tachycardia caused by hyperthyroidism. In patients with
suspected thyrotoxicosis, taper off beta blocker to avoid thyroid storm.
 When stopping therapy, taper dose for 1-2 weeks.
 Beta selectively is lost at higher doses. Watch for peripheral side effects.
 Take drugs exactly as prescribed with meals.
 Avoid driving and other task requiring mental alertness.
 Inform the Health provider before procedures or surgery
 Alert, if have a shortness of breath occurs

 Notify the prescriber, if you stop taking medication.

Brand Name Simvastatin

Generic Name Zocor
Classification Antilipemics
Action Inhibits HMG-CoA reductase, an early (and rate-limiting) step in cholesterol
biosynthesis.
Pt. dosage 40 mg tab OD HS
ordered by
Physician
Indication  To reduce risk of death from CV disease and CV events in patients at
high-risk for coronary events.

 To reduce total and LDL cholesterol levels in patients with homo-

zygous familial hyper- cholesterolemia.
Adverse CNS: Asthenia, Headache. GI: Abdominal pain, Constipation, Diarrhea, Nausea.
reaction Musculoskeletal: Myalgia. Respiratory: upper respiratory tract infection
Nursing  Use drug only after diet and other non-drug therapies prove ineffective. Patient
consideration should follow a standard low-cholesterol diet during therapy.
 Obtain liver function test results at start of therapy and then periodically. A liver
biopsy maybe performed if enzyme elevations persist.
 40 mg daily significantly reduces risk of death from coronary heart disease, non

1
 fatal MIs, stroke, and revascularization procedures.
 take drug with meals
 proper dietary management of cholesterol and triglycerides
 inform patients, adverse reaction occur, particularly muscles aches.

Brand Name Captopril

Generic Name Capoten
Classification Antihypertensives
Action Inhibits ACE, preventing conversion of angiotensin I to angiotensin II, a potent
vasoconstrictor. Less angiotensin II decrease peripheral arterial resistance, decreasing
aldosterone secretion, which reduces secretion, which reduces sodium and water
retention and lower blood pressure.
Pt. dosage 50 mg P.O. TID
ordered by
Physician
Indication  Left ventricular ventricular dysfunction after acute MI
Adverse CNS: dizziness, fainting, headache, malaise, fatigue, fever. CV: tachycardia,
reaction hypotension, angina pectoris Hematologic: abdominal pain, anorexia, constipation,
diarrhea, dry mouth, dysgeusia, nausea, vomiting Metabolic: hyperkalemia
Respiratory: dry, persistent, nonproductive cough, dyspnea Skin: urticarial rash,
maculopapular rash, pruritis, alopecia Other: angioedema
Nursing Monitor blood pressure and pulse rate frequently.
consideration Elderly patient may be more sensitive to hypotensive effects.
Assess patient for signs and symptoms of angioedema.
drug causes the most frequent occurrence of cough, compared with other ACE
inhibitors.
take drugs one hour before the meal
patient that have light-headedness is possible, especially during the first few days of
therapy. If fainting occurs, he should stop drug and call prescriber immediately.
tell patient to use caution in hot weather and during exercise, it can lead to light-
headedness and syncope.
urge patient to promptly report swelling of his face, lips, or mouth, or difficulty of
breathing.

Brand Name Isosorbide Dinitrate

Generic Name Isordil
Classification Antianginals
Action Thought to reduce cardiac oxygen demand by decreasing preload and after load and
afterload. Drug also may increase blood flow through the collateral coronary vessels.
Pt. dosage 10 mg tab TID
ordered by 5mg tab SL – PRN in chest pain
Physician
Indication Acute anginals attacks; to prevent situations that may cause anginal attacks.
Adverse CNS: headache, dizziness, weakness CV: orthostatic hypotension, tachycardia,
reaction palpitations, ankle edema, flushing, fainting EENT: S.L. burning GI: nausea, vomiting
Skin: cutaneous vasodilation, rash
Nursing monitor blood pressure and intensity and duration of drug response.
consideration drug may cause headache, especially at the beginning of therapy. Dosage may

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 reduced temporarily, but tolerance usually develops. Treat headache with aspirin and
acetaminophen.
methemoglobinemia has been seen with nitrates. Symptoms are those of impaired
oxygen delivery despite adequate cardiac output and adequate partial pressure of
oxygen.
caution patient to take drug regularly, as prescribed. Patient stopping the drugs may
cause spasm of the coronary arteries with increased angina symptoms and potential
risk of heart attack.
take drugs 30 minutes before the meals or 1-2 hours after meals.
avoid alcohol because it may worsen blood pressure effects.
instruct patient to store drug in a cool place, in a tightly container.

Brand Name Tylenol

Generic Name Acetaminophen
Classification Nonopioid analgesics and antipyretics
Action Thought to produce analgesia by blocking pain impulses by inhibiting synthesis of
prostaglandin in the CNS or of other substances that sensitize pain receptors to
stimulation. The drug may relieve fever through central action in the
hypothalamic heat-regulating center.
Pt. dosage 300 mg/ amp
ordered by
Physician
Indication mild pain and fever
Adverse Hematologic: hemolytic anemia, leucopenia, neutropenia, pancytopenia Hepatic:
reaction jaundice Metabolic: hypoglycemia Skin: rash, urticaria
Nursing  Alert: many OTC and prescription products contains acetaminophen; be aware
consideration of this calculating total daily dosage.
tell patient not to use for marked fever a (temperature higher than 39.5C)
warn patient that high doses or unsupervised long term used can liver damage.

VI. NURSING CARE MANAGEMENT

a. Problem List

3
 b. Nursing Care Plan

Action problem

ASSESSMENT NURSING PLAN OF INTERVENTION RATIONALE EVALUATION

DIAGNOSIS CARE
Subjective: Ineffective The patient  initially assess, assist in After rendering of
cardiac tissue will alleviate document, and determining nursing intervention,
“hindi normal perfusion and appears report to the cause and the patient had
yung vital signs related to comfortable physician the effect of the appears comfortable
niya” as reduced and is free of following: the chest discomfort and is free from pain.
verbalized by the coronary pain and other patient’s and provide a Blood pressure is
relative of the blood flow. sign and description of chest baseline data 110/80. Temperature
symptoms: discomfort, the for of 37.1˚C. But the RR
patient.
respiratory effect of it on characteristics 40 and PR 101 bpm
cardiovascular findings of
Objective: rate, cardiac are still compensating
perfusion change in ischemic pain
rate, and blood to maintain cardiac
blood pressure and and symptoms.
Auscultated pressure return output. The goal is
to heart sounds, partially met.
heart have extra
prediscomfort changes in LOC,
sound
level. decrease in urine
output and to the
shortness of
skin temperature,
breath
nad other
symptoms such as
cool & pale nausea, increase
skin
sweating, or
complaints of
unusual fatigue.

obtain a 12 –lead An ECG

ECG recording the during
symptomatic event, symptoms may
as prescribed by be useful in the
physician, to diagnosis of an
determine extension extension of MI.
of infarction.

administer Oxygen
oxygen at the level therapy
of prescribed. increases the
oxygen supply
to the
myocardium if
actual oxygen
saturation is less
administer than normal.

4
 medication therapy medication
as prescribed, and therapy is the
evaluate the first line of
patient’s response defense in
continuously. preserving
myocardial
tissue. The side
effects of the
medications can
be hazardous
and the patient’s
status must be
assessed.
ensure physical
rest; use the bedside
 physicals rest
commode with
reduces
assistance; backrest
myocardial
elevated to promote
oxygen
comfort; diet as
consumption.
tolerated; arms
Stress response,
supported during
this results, this
upper extremity
result, increase
activity; use of stool
myocardial
softener to straining
oxygen
stool. Provide a
consumption.
restful environment.

ASSESSMENT NURSING PLAN OF INTERVENTION RATIONALE EVALUATION

DIAGNOSES CARE
adventitious Ineffective After of assess, document can be used After of nursing
breath sounds airway nursing & report to the as a guide for intervention the
changes in clearance intervention physician on activity patient will clear the
respiratory rate related to the patient abnormal breath prescription and airway patency.
and rhythm copious will clear the sound a basis for
tracheobronchial airway patient health
secretions. patency. management.

maintain the to provide an

patency of oxygen needed
oxygenation therapy by the
physiologic
need of the
body.
Monitor Arterial
Blood Gases  to indicate
Analysis the
effectiveness of
oxygenation
therapy and

5
 changes that
need to improve
gas exchange.

suction retention of
tracheobronchial secretions lead
secretion to decrease of
oxygen supply
established the
turning patient as help to loosen
and “tapping back” , the secretions.
as prescribed by the
physician.

ASSESSMENT NURSING PLAN OF INTERVENTION RATIONALE EVALUATION

DIAGNOSES CARE
Objective: Decreased After of 8 >take vital signs >for bseline data. After of 8 hours
Cardiac hours of of nursing
Output nursing >Auscultate heart >Decreased cardiac output intervention the
>cold clammy related to sounds: results in diminished
skin alteraion of intervention weak/thready pulses. patient should
stroke the patient Irregularities suggest be display
> prolonged volume will be dysrhythmias, which may hemodynamic
capillary refill display require further stability. The
hemodynamic evaluation/monitoring. goal is partially
>crackles stability. met.
S3 is usually associated
sounds on chest Note with HF, but it may also be
development noted with the mitral
of S3, S4; insufficiency
(regurgitation) and left
ventricular overload that
can accompany severe
infarction. S4 may be
associated with myocardial
ischemia, ventricular
stiffening, and pulmonary
or systemic hypertension.

Indicates disturbances of
Presence of normal blood flow within
murmurs/rubs. the heart, e.g., incompetent
valve, septal defect, or
vibration of papillary
muscle/chordae tendineae
(complication of MI).
Presence of rub with an
infarction is also associated
with inflammation, e.g.,
pericardial effusion and
pericarditis.

6
 Crackles reflecting
>Auscultate breath pulmonary congestion may
sounds. develop because of
depressed myocardial
function.

>Heart rate and rhythm

respond to medication,
>Monitor heart activity, and developing
rate and rhythm complications.
Dysrhythmias (especially
premature ventricular
contractions or progressive
heart blocks) can
compromise cardiac
function or increase
ischemic damage. Acute or
chronic atrial
flutter/fibrillation may be
seen with coronary artery
or valvular involvement
and may or may not be
pathological.

>Increases amount of
oxygen available for
>Administer myocardial uptake,
supplemental reducing ischemia and
oxygen, as resultant cellular
indicated. irritation/dysrhythmias.

Cardiac index,
preload/afterload,
contractility, and cardiac
Measure cardiac work can be measured
output and other noninvasively with thoracic
functional electrical bioimpedance
parameters as (TEB) technique. Useful in
appropriate. evaluating response to
therapeutic interventions
and identifying need for
more
aggressive/emergency care.

Provides information
regarding
progression/resolution of
infarction, status of
review serial ventricular function,
ECGs. electrolyte balance, and
effects of drug therapies.

May reflect pulmonary

edema related to
ventricular dysfunction.
Enzymes monitor
Review chest x- resolution/extension of
ray. infarction. Presence of

7
 hypoxia indicates need for
supplemental oxygen.
Monitor laboratory Electrolyte imbalance, e.g.,
data, e.g., cardiac hypokalemia/hyperkalemia
enzymes, ABGs, , adversely affects cardiac
electrolytes. rhythm/contractility.
ASSESSMENT NURSING PLAN OF INTERVENTION RATIONALE EVALUATION
DIAGNOSES CARE
Objectives: impaired skin After assess, document for guiding After rendering of
integrity rendering of the skin patient. data. nursing care
physical related to nursing intervention the
immobilization prolonged bed intervention ask the physician to avoid patient will not be
pressure. the patient will if the patient will possible that can able to get a bed sore.
prolonged bed not be able to allowed to turn the trigger to his
pressure get a bed sore. patient on side-to disease.
side and the time
interval.

do the skin care to avoid

possible
complication on
skin.

ASSESSMENT NURSING PLAN OF INTERVENTION RATIONALE EVALUATION

DIAGNOSES CARE
Objective: risk for excess After of 8 >Auscultate breath > May indicate After of 8 hours of
fluid volume, hours of sounds for pulmonary nursing intervention
decreased presence of edema
>Decreasing organ perfusion nursing the patient had
crackles. secondary to
urinary output intervention cardiac monitor fluid status
the patient will decompensation. and reduce
>abnormal monitor fluid occurrence of fluid
breath sounds, status and excess. the goal is
reduce > Measure I&O, > Decreased met.
crackles noting decrease in
occurrence of cardiac output
output, results in
>dyspnea fluid excess. concentrated impaired kidney
appearance. perfusion,
Calculate fluid sodium/water
balance. retention, and
reduced urine
output.

> Sudden changes

>assess for edema in weight reflect
and weigh daily. alterations in fluid
balance.\

>Provide low- >Sodium enhances

sodium fluid retention and
diet/beverages. should therefore be
restricted during
active MI phase
and/or if heart failure

8
 is present.

Potential problem

POTENTIAL CONSIDERATIONS following discharge from care setting (dependent on

patient’s age, physical condition/presence of complications, personal resources, and life
responsibilities)

Activity intolerance —imbalance between myocardial oxygen supply/demand.

Grieving, anticipatory—perceived loss of general well-being, required changes in lifestyle,

confronting mortality.

Decisional Conflict (treatment)—multiple/divergent sources of information, perceived threat to

value system, support system deficit.

Family Processes, interrupted—situational transition and crisis.

Home Management, impaired—altered ability to perform tasks, inadequate support systems,

reluctance to request assistance.

c. Discharge Planning use METHODS

Medications
 Promotes adherence measures by thoroughly explaining the prescribed
medication regimen and other treatment measures.
 Warn the patients together with relatives about adverse reaction to drugs, and
advise them to watch the sign and symptoms of toxic (nausea, anorexia,
vomiting, and yellow vision)
Exercises
 Organize patient care and activities to maximize periods of uninterrupted
rest.
 Assist with range-of-motion exercise. And turn him, every two hours, as
ordered by physician.
 Don’t stress yourself, too much exercise. Enough, walk for 15 minutes.
Treatment
 Antiembolism stockings help prevent venostasis and thromboplebitis.
 Encourage participation in a cardiac rehabilitation program.
Health teaching
 Watch for sign and symptoms of fluid retention
(crackles, cough, tachypnea, and edema), which may indicate impending
HF. Carefully monitor daily weight, intake and output, respiration, serum
enzyme level and blood pressure.
Oxygenation and OPD follow up
 Oxygen administration at a modest flow rate for 3-6 hours.
Diet of the patient
 Review dietary restriction with the patient. A low sodium, low fat, or low
cholesterol diet and caffeine-free may be ordered, provide a list of food that

9
 he should avoid. Provide a clear liquid diet until nausea subsides. Ask
dietitian to speak to the patient’s family.
Spiritual and sexual teaching
 Counsel patient to resume sexual activity progressively.
 Encourages the family to seek out religious activities, pertaining to spiritual
issues.

VII. Referreces

Medical-Surgical Nursing, 11th edition,

Brunner & Suddarth’s (Smeltzer, Bare, Hinkle, Cheever)

Handbook of Diseases, 3rd edition, Sarah Y. Yuan

Nursing Drug Handbook 2008, 28th edition,

Wolter Kluwer/Lippincott William & Williams

http://www.cardioconsult.com

http://www.aacn.org

VIII. Evaluation

Mr. Ephraim Mirafuentes & Staff Nurse (MICU):

BELTRAN, JHON MARC

Highly competitive critical care nurse, that know how to assess, monitor and treat a
critically ill patient, the better that patient’s chances are for early intervention. All of
them excellence in the work environment. Their team using a method of habitual
concentration our staff nurses could develop qualities of excellence for an improved
outlook toward themselves, their work environment, and their profession. This improved
outlook would lead to improved morale followed by an increase in retention within the
unit, as well as progress in meeting our other goals. We recognized that our patient care,
the attitudes of our nurses and staff, the helpfulness of peers, and even the cleanliness of
the unit were based on tradition. During orientation, we learned what was expected of
them in their individual units, and they continued this process by orienting others to the
same routines. As we recognized, we needed to improve ourselves in reality, in the world
of Intensive care unit. Because we must aware that our work was in critical situation.

As we are the nursing student that would be excited to us learning to do many activities
in the role they accept, their life, around the Intensive care unit. We learned some
nursing skills that we can used in critical situation.

We, my group, are glad to be your nursing student. Thanks you so much.

Mariano, Ryan

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Medical Intensive Care Unit provides comprehensive and continuous care for patients
who suffer from a serious illness or medical problem as well as social and psychological
support for patients and their families. Their team includes board-certified, critical care
physicians , highly trained nurses and other specialists who are specifically trained in
critical care and provide round-the-clock care.

We learned some nursing skills using their equipment in an intensive care unit (ICU)
includes mechanical ventilation to assist breathing through an endotracheal tube or a
tracheotomy; intravenous lines for drug infusions fluids, nasogastric tubes, suction
pumps, drains and catheters; and a wide array of drugs including their medication
management.

Tadifa, Joleen

In MICU, patients are given 24-hour assessments by the healthcare team. Preparatory
orders for the ICU generally vary from patient to patient since treatment is
individualized. The initial workup should be coordinated by the attending ICU staff
(intensiv and ICU nurse specialist), pharmacists (for medications and IV fluid therapy),
and respiratory therapists for stabilization, improvement, or continuation of
cardiopulmonary care. Well-coordinated care includes prompt consultation with other
specialists soon after the patient is admitted to the ICU. The patient is connected to
monitors that record his or her vital signs (pulse, blood pressure, and breathing rate).
Orders for medications, laboratory tests, or other procedures are instituted upon arrival.
The staff are highly skilled for critically ill patients. Using their advanced patient
monitoring technology and sophisticated medical equipment, as providing continuous,
comprehensive care for patients with serious conditions. providing expert healthcare and
to treating patients with the compassion and respect they deserve.

Patients requiring intensive care usually require support for airway or respiratory
compromise (such as ventilator support), potentially lethal cardiac dysrhythmias.
Critical care nurse are giving their intensive care to the patient, support for the above are
usually admitted for intensive/invasive monitoring. Ideally, intensive care is usually
only offered to those whose condition is potentially reversible and who have a good
chance of surviving with intensive care support. Since the critically ill are so close to
dying, the outcome of this intervention is difficult to predict.

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