1. A care for client with Acute Coronary Syndrome
In partial fulfillment of Related Learning Experience (R.L.E)
Submitted By:
Roderos, Mitch Angela
BSN 4C GROUP II S.Y 2011-2012
Clinical Instructor
Ms. Virginia Lorda
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2. INTRODUCTION
Coronary artery disease (CAD) is an umbrella term used to cover any group of clinical
symptoms compatible with acute myocardial ischemia. Acute myocardial ischemia is chest pain
due to insufficient blood supply to the heart muscle that results from coronary artery disease
(also called coronary heart disease). also called coronary heart disease (CHD), a single largest
killer of American men and women in all cultural groups (American Heart Association [AHA
2003). According to the AHA, CHD caused more than 1 out of every 5 deaths in the United
States in 2000. From 1990 to 2000, the death rate from CAD declined 25%. Multiple factors can
be identified as contributing to the declined in CAD. These factor include more effective medical
treatment and an increase awareness and emphasis on reducing the major modifiable
cardiovascular risk factor (e.g., high blood pressure [BP], smoking, high cholesterol, obesity,
diabetes). (Principles of Medical Surgical Nursing Lemone, Burke Vol. 2 4the Edition 2007 page
974-975)
In Acute coronary syndrome, it is believed that the atherosclerotic plaque in the coronary
artery ruptures, resulting in platelet aggregation (―clumping‖), thrombus (clot) formation, and
vasoconstriction. The amount of disruption of atherosclerotic plaque determines the degree of
obstruction of the coronary artery and the specific disease process (unstable angina or
myocardial infarction [MI]. Between 10% and 30 % of the client with unstable angina progress
to having an MI in 1 year and 29% die of MI in 5 years (AHA, 2003).
Acute coronary syndrome (ACS) is a condition of unstable cardiac ischemia. ACs
includes unstable angina and acute myocardial ischemia with or without significant injury of the
myocardial tissue. As estimated 1.4 million Americans are admitted to the hospital annually with
ACS (Kasper et. al.., 2005).
Fast Facts:
Acute coronary syndrome (severe cardiac ischemia), a common cause of hospital
admission, includes unstable angina and acute myocardial infarction.
Unstable angina is characterized by injury to myocardial cells; with prompt
restoration of blood flow, muscle tissue recovers.
Myocardial infarction is characterized by necrosis and death of myocardial cells; scar
tissue forms and functional muscle is lost.
ACS is the most common identified cause of sudden cardiac death (American Heart
Association [AHA], 2005).
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3. A. DEMOGRAPHIC DATA
1. Client‘s name : Patient D.V
2. Gender: Male
3. Age, Birth date and Birth place: 59 years old, April 24,1952 at Tarlac
4. Marital Status: Single
5. Nationality: Filipino
6. Religion: Romasn Catholic
7. Address: 15 Natividad St. Bangkal Quezon City
8. Educational Background: College Undergraduate
9. Occupation: The client manages his own karinderya
10. Usual Source of Medical Care: Ospital ng Makati
B. SOURCE AND RELIABLITY OF INFORMATION
 Patient‘s Chart
 Patient Himself
C. REASON FOR SEEKING CARE
“Naninikip ang dibsdib” As verbalized by the patient
D. HISTORY OF PRESENT ILLNESS
November 20,2011
2 hours prtor to admission – Patient was watching television (FPJ movie) when patient
complained of chest pain radiating to the left sshoulder. No medication takeb few hour
persistence
Upon Admission - Patient‘s vital signs was taken and recorded of blood pressure of 130/70,
PR: 84, RR: 26, Temp: 36.4 with general survey of Levigne‘s sign, Facial Grimace and
Dyspnea
E. PAST MEDICAL HISTORY
Pediatric/Childhood/ Adult Illness: Mumps (7 y/o); Chiken Pox (17 y/o)
Injuries or accidents: The client recieved multiple injuries due to stampede (10 y/0)
Serious/ Chronic Illnesses: The client has Hypertension X4, HBP of 200/100 UBP 150/80
Hospitalizations: There was no recorded previous hospitalization for the past year 2010
Operations: No known operations
Immunizations: The client verbalized of having complete immunization of DPT, OPV,
BCG and Measles vaccine.
Allergies: No known Allergies
Medications prior to confinement: The client took Norvasc 10 g/tab
Last Examination Date: November 20, 2011
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4. F. FAMILY HISTORY
Father Mother
(+) HPN (+) HPN
(+) DM (+) Asthma
(
65 y/o 63 y/o 59 y/o 58 y/o
(+)
Asthma
27 y/o
(+)
Asthma
LEGEND
Male Female Client Deceased
1.) Heredo-Family Illness:
Maternal –
Patient B‘s mother is known to have High blood pressre and Asthma. Currently,
his older sister next to him has asthma and so as his only daughter started when
she was 2 years old.
Father-
Patient’t B‘s father has no known family illness running in their blood.
G. SOCIO-ECONOMIC
The client consists of a nuclear family and lives together with his aged mother,
wife and his daughter. The client states that he contributes for the family financial
expenses by the help of their Karinderya and his working daughter. Financial Resources
are adequate enough to provide for them for the expenses of their everyday living.
4

5. DEVELOPMENTAL HISTORY
Erik Erickson Age Task Patient’s Description
Psychosocial Theory
Generativity 30-65 years Erikson's analysis of this stage The client is presently
Vs. old middle was strongly oriented towards enjoying himself at his senior
Stagnation age parenting. Generatively years. The client states that
potentially extends beyond he enjoys managing their
one's own children, and also to karinderya to spend time and
all future generations, which to contribute in generating
gives the model ultimately a income. The client is well
very modern globally established from raising his
responsible perspective. daughter well.
Having children is not a
prerequisite for Generativity, The client stated the he had
just as being a parent is no lived his life productively.
guarantee that Generativity The client exhibits
will be achieved. Caring for generativity from Erickson‘s
children is the common psychosocial development.
Generativity scenario, but The client stated that he had
success at this stage actually worked hard on his younger
depends on giving and caring - years to have a stable life.
putting something back into He stated that he doesn‘t
life, to the best of one's have anything to ask for,
capabilities. except to have longer life to
spend his golden years with
Stagnation is an extension of his beloved family.
intimacy which turns inward in
the form of self-interest and
self-absorption. It's the
disposition that represents
feelings of selfishness, self-
indulgence, greed, lack of
interest in young people and
future generations, and the
wider world.
Adults need to create or
nurture things that will outlast
them, often by having children
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6. or creating a positive change
that benefits other people.
Success leads to feelings of
usefulness and
accomplishment, while failure
results in shallow involvement
in the world
H. REVIEW OF SYSTEMS
1. Regional Examinations
(December 1, 2011 9:30 am)
Vital Signs:
Temp : 37.51°c RR: 26 cpm PR: 86 cpm BP: 100/70mmHg
General Assessment:
 Patient is seen conscious and coherent; garbed in hospital gown,sitting on bed without
difficulty. Skin is clean and smooth with normal skin turgor. Nails are long but not
dirty and with normal capillary refill. Patient is with ongoing oxygen therapy via
Nasal Cannula regulated at 4 Liters per minute, and hooked with D5W 500 cc X 10
cc/hr Infusing well at his left matacarpal vein.
Date of System Normal Findings Actual Findings
Assessment
December 1,2011 Integumentary Smooth and good skin I:
turgor, no lesions or
 Brown color, no lesion, no swelling
any discoloration, no
and edema.
clubbing, no breaks
 Normal looking
&abnormal curvature.
 Visible veins on both arms
 Has a temperature of 37.51°c.
In nails:
 Long and clean nails and round
nails.
 Pink Nail bed
P:
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7.  Warm, soft, smooth, and has a good
skin turgor.
In nails:
 Hard, immobile, and smooth.
December 1,2011 Hair and Head No lesion, no I:
tenderness, no pain on
-His hair color is black, hair is evenly
palpation, no masses,
distributed,
no lumps, no nodules
or depression, -Has thick hair.
symmetrical
-No presence of parasite and dandruff.
-In scalp: Symmetrical and round and
no lesion.
P:
-Hair texture is smooth and soft.
-In head the texture is smooth and
firm.
December 1,2011 Eyes Eyelid intact, no I:
redness, swelling,
-Lid margins moist and light pink,
discharge or lesions.
lashes short, evenly spaced and curled
Eyeballs are moist &
outward.
glossy, conjunctiva
numerous small blood -Bulbar conjunctiva is clear with tiny
vessels. Sclera white. vessels visible, palpebral conjunctiva
Good eye contact. is light pink with no discharge, white
sclera.
- In PERRLA:
*Cornea is transparent and the shape
of the iris and pupil is round and
equal.
*The left and right eye has a good
reaction to light (constrict and dilate)
-In extra ocular movements:
*Both eyes coordinated well in all
directions.
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8. December 1,2011 Ears Ears are symmetrical I:
with 10 degrees angle.
-Equal size and similar appearance.
Color is same in facial
with no tenderness or -No lesions, brown in color same with
any nodule and his complexion.
without any presence
P:
of discharge.
-Warm, smooth, no nodules and no
tenderness in auricle and tragus.
December 1,2011 Mouth and 32 adult teeth are I & P:
Throat present with moist and
-Lips and surrounding tissue relatively
pink mucous
symmetrical.No lesions, swelling and
membrane without any
drooping.
lesions or swelling.
-Lip is light pink; moist, smooth and
with no lesions.
-Buccal mucosa is light pink, moist
and without lesions.-Gums are light
pink, and moist.
-In tongue:
*Moist, some papillae present,
symmetrical appearance, midline
fissures present and the color is pink
and color white at the center and no
lesions as well as the sides of the
tongue.
*Hard palate: slightly pink. *Soft
palate: pink, -Has 32 teeth and stained
with a hint of yellow color.
December 1,2011 Neck No tenderness on I:
palpation, no pain,
-Neck is symmetric with head
symmetrically align,
centered and without bulging masses.
no enlarged lymph
nodes, no tracheal P:
lateral deviation.
-Smooth skin, firm, and none tender
and none enlarged nodules.
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9. December 1,2011 Breast and No palpable nodules I:
Axillae and lesions. Breast is -Nipples have no discharges and not
firm and round. cracked.
December 1,2011 Respiratory Intercostals spaces are I:
even and relaxed;
-The color of his chest is similar to his
chest symmetry is
complexion.
equal, no pain or
tenderness, and no -With Chest in drawing
abnormal breath
-Chest symmetry is equal
sound.
-Thorax: is straight.
-The RR of the patient is 26cpm.
-Dyspneic, with Nasal Flaring
-Chest X-Ray impression of
pulmonary congestion
P: No pain or tenderness.
A: Lung is clear to auscultation on
inspiration and expiration.
December 1,2011 Cardiovascular No fatigue on simple PR : 86 bpm
activities, no
BP: 100/70 mmHg
arrhythmias and heart
murmurs. PR=60- I:-Neck veins are not distended.
100bpm.
P:
-No vibrations or palpitation in aortic,
pulmonic, or tricuspid area.
A:-No murmur sound heard.
Chest X-Ray reveals atheromatous
aorta
December 1,2011 Abdominal No pain, No palpable I:
masses and tenderness,
-Flat abdomen
Flat and round.
P:
-No tenderness, lesions and masses
9

10. December 1,2011 Musculoskeletal Have good range of -Does not need assistance to stand and
motion and no toes point straight ahead. Able to
limitation of shrug shoulders against resistance.
movements.
December 1,2011 Neurologic Have no tremors -No presence of tremors, oriented, no
paralysis. Oriented, no history of seizures, mental dysfunction
history of seizures, or hallucinations.
mental dysfunction or
hallucinations.
December 1,2011 Lympathic Has no bleeding No swollen lymph nodes.
tendencies, normal
lymph nodes.
2. Laboratory Studies/Diagnostics
11/20/11 Clinical Chemistry Section
Test Name S.I Unit Range Conversion Unit Result Interpretation
Result Result
Creatinine 157 Umol/L 53-115 1.78 mg/dL 0.60- Above Normal
1.30
AST 40 u/L 15-37 40 u/L 15 – 37 Above Normal
SGPT 39 u/L 30-65 39 u/L 30 - 65 Normal
Na 136 mmol/L 136-145 136 mmol/L 136-145 Normal
K 3.6 mmol/L 3.5-5.1 3.6 mmol/L 3.5-5.1 Normal
Chloride 102 mmol/L 98 - 107 102 mmol/L 98 - 107 Normal
11/24/11 Clinical Chemistry Section
Test Name S.I Unit Range Conversion Unit Result Interpretation
Result Result
BUN 17.4 mmol/L 2.5-6.4 48.74 mg/dl 7.0-18.0 Above Normal
Creatinine 154 Umol/L 53-115 1.74 mg/dl 0.60-1.30 Above Normal
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11. 11/27/11 Clinical Chemistry Section
Test Name S.I Unit Range Conversion Unit Result Interpretation
Result Result
Glucose (fasting) 2.10 mmol/L 4.1-5.1 30-45 mg/dl 73-99 Below Normal
Uric Acid 371 Ummol/L 165-428 6.22 mg/dl 2.6 – 7.2 Normal
Cholesterol Total 2.69 mmol/L 1.3-5.2 103.46 mg/dl 50-200 Normal
Triglycerides 0.60 mmol/L 0.17-1.70 53.33 mg/dl 15-150 Normal
HDL 0.66 mmol/L 1.04 - 25.38 mg/dl 40-60 Normal
1.55
LDL 1.64 mmol 1.89-3.09 63.08 mg/dl 72.69- Below Normal
118.85
AST (SGOT) 66 u/L 15-37 66 u/L 15-37 Above Normal
ALT (SGPT) 66 u/L 30- 65 66 u/L 30-55 Above Normal
11/28/11 Glycohemoglobin Test
Test Name Result Reference Range Interpretation
Glycohemoglobin Test 2.10 4.1-5.1 Below Normal
11/21/11
Test Name S.I Unit Range Conversion Unit Result Interpretation
Result Result
CK-MB 110 u/L 7-25 110 u/L 7-25 Above Normal
Damage to
cardiac cells,
indication of
myocardial
infarction
11/27/11
Test Name Result Interpretation
Troponin I Positive Indicates myocardial infarction
11/28/11
Test Name Result Interpretation
Troponin I Negative Does not indicate myocardial injury
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12. 11/20/11 Hematology
Laboratory (Date) Normal Value Result Interpretation/Significance
11/20/11
M - 14-18 g/dl 15 Normal
Hemoglobin F – 12 -16 g/dl
Hematocrit M – 0.40 – 0.54 0.55 Normal
F – 0.37 – 0.37
White Blod Cells 4.0 – 11.0 15.5 Above Normal
Red Blood Cells M – 5.0 -6.4 6.3 Below Normal.
DIFFERENTIAL COUNT
Segmenters 0.5 – 0.7 0.96 Above Normal
Lymphocytes 0.2 – 0.4 0.3 Above Normal
Monocytes 0.02 – 0.05 0.01 Above Normal
Platelet 150- 300 195 Normal
11/21/11
Blood Coagulation Test Reference Results Interpretation
Protrombin Time 10.4 – 14 13.9 Normal
% Activity 73-127% 72.6% Normal
INR 0.88 – 1. 21 1.21 Normal
Activated PTT 36.4 – 41.25 sec 46.1 sec Above Normal
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13. 3. Other Assessment Toolss
Procedure Indication Results Nursing intervention
11/26/11 The acid-fast stain is Microscopic Pre
an especially Examination :
Advise patient to drink a lot of fluids
important test for the
the night before the test. It makes the
Acid Fast Stain genus Mycobacteriu
test more accurate if it's done first
Specimen m, to rule out Negative
thing in the morning.
pulmonary
Advised patient not to take
tuberculosis.
antibiotics and some sulfonamides
because it may interfere with test
results, causing the results to be
falsely negative.
Prior to breakfast, the patient will be
asked to provide a 5-10 mL
specimen of sputum delivered into a
sterile cup with a screw top lid.
Intra
Asked patient to cough deeply and
spit
the substance that comes up from the
lungs (sputum) into a container.
Patient may be asked to inhale a mist
of salty steam in order to cough
more deeply and produce sputum.
Post
Place it in a sterile container, label
appripiately and immdiately forward
in the laboratory.
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14. Procedure Indication Results Nursing intervention
11/19/11 CT scanning or There are fluffy Pre
sometimes called infiltrates noted
Remove all Metal objects including
CAT scanning is a with accentuation
jewelry, eyeglasses, dentures and
X-ray noninvasive medical of the pulmonary
hairpins. Patient may also be asked
test that helps vasculature
to remove hearing aids and
physicians diagnose
removable dental work.
and treat medical
Instruct not to eat or drink anything
conditions. The heart is not
for several hours beforehand,
enlarged
CT scanning especially if a contrast material will
combines special x- be used in exam.
ray equipment with The aorta shows
sophisticated Intra
some calcifications
computers to produce A chest ct scan takes about 30
along it‘s walls
multiple images or mins., which includes preparation
pictures of the inside time
of the body. These Diaphragm and Patient mat lie on a narrow table
cross-sectional sinuses are intake that moves through the hole
images of the area While inside the scanner, an x-ray
being studied can tube moves around your body. You
then be examined on Impression: will wear soft buzzing, clicking or
a computer monitor, whirring noises as the scanner takes
Pulmonary
printed or transferred pictures
congestion and
to a CD. The technician will ask you to lie
edema R/O
still and hold your breath for short
pneumonia
periods. these measures help make
athermanous aorta
the picture as clear as possible the
scan itself
Post
CT exams are generally painless,
fast and easy.
After a CT exam, you can return to
your normal activities.
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15. Procedure Indication Results Nursing intervention
11/21/11 5:00 am Electrocardiogram Abnormal ECG Pre
Electrocardiogram (ECG) provides 12 Lateral Explain the procedure to the
vector views of the Infarction patient.
heart‘s electrical Anteroseptal Instruct patient to wear
activity as reflected by Infarction comfortable, loose-fitting clothing
electrical potential Marked right Instruct to remove all Metal
differences between axis deviation objects including jewelry,
positive and negative With runs of eyeglasses, dentures and hairpins.
electrodes placed in PVC Patient may also be asked to
the limbs and chest remove hearing aids and
wall. ECG is crucial removable dental work.
for establishing many In some instances, men may
cardiac diagnoses, require the shaving of a small
especially arrhythmias amount of chest hair to obtain
and myocardial optimal contact between the leads
ischemia. and the skin
Acute
11/21/11 12:00 pm anteroseptal Intra
Electrocardiogram infarction EKG leads are attached to the
Lateral body while the patient lies flat on
Infarction a bed or table. Leads are attached
Ventricular to each extremity (four total) and
Premature to six pre-defined positions on the
Contraction front of the chest. A small amount
of gel is applied to the skin, which
allows the electrical impulses of
the heart to be more easily
11/21/11 11:00 pm Prior to streptokinase Lateral transmitted to the EKG leads.
Electrocardiogram therapy Infarction Instruct that the test takes about
Anteroseptal five minutes and is painless.
Infaction
Poor right
progression
11/21/11 8:00 pm Acute anterior
Electrocardiogram infarction
Abnormal Q
Ventricular
premature
contraction
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16. I. FUNCTIONAL ASSESSMENT
HEALTH PERCEPTION-HEALTH MANAGEMENT
Prior to admission, patient sees health being able to do everyday things well
according to the manner he wants it. The client stated he doesn‘t easilly get sick and
when he does, he just let it subside not until if his condition worsens, that‘s the time when
he would visit the hospital. The client does not use any vitamins and medications. Client
has not experienced colds in the past month. The client stated that he would eat lots of
nutritious foods and keeping himself physically fit is his way to keep himself healthy
SELF-ESTEEM, SELF CONCEPT/SELF PERCEPTION PATTERN
Before the patient was admitted, he sees himself being able to do things according to
the manner he wants it. He does not mind his health not until the manifestation of discomfort
brought from his disease. Presently, the client verbalized difficulty of being sick; he stated
that he will find it hard to adjust from it. That client claims that he acquired his disease due to
over fatigue and abusing his body by work when he was young back then. The client
verbalizes a decrease in self-perception due to aging and performing strenuous activities due
to presence of exertional dyspnea.
ACTIVITY/EXERCISE PATTERN
Prior to confinement, the client claims his activities as sort of exercise by means of
managing their mini Karinderya for the whole day. Presently, the patient is confined in the
primary holding unit. The client assumes full self care on himself. The client is on bed rest
and does minimal activities.
Feeding 0 Grooming 0
Bathing 0 Gen. Mobility 0
Toiling 0 House 0
maintenance
Bed mobility 0 Dressing 0
Legends:
Level 0 – Self Care
Level I – Use of equipments
Level II– Assistance from another person
Level III –Requires assistance from another person or device
Level IV – Dependent and does not participate
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17. SLEEP/REST PATTERN
Before the client was admitted, the client stated that he is usually sleeps late because of
their Karinderya. The client states that he has 7 hours of sleep everyday without the any use of
sleeping aids. He stated that the client would take a nap at noon for about 2 hours.
Presently, The client has no difficulty of sleeping except from some external factors such
as the noise of other patients that he shares the ward with. The client does not use any sleeping
pills but prefers to play music in his radio to induce sleep. The client verbalizes of having siesta
after taking his lunch
NUTRITIONAL-METABOLIC PATTERN
The client eats three times a day with low salt and low fat diet. The client has good appetite
and has no known food allergies. Wound heals normally. He recalled that his last meal was
noodles and bread and half of one serving. The client has no known allergies and drinks 450 ml
of water noted on our 6- 2 morning shift last December 1, 2011. The client has no dental
problems, no foul odors and excess perspiration.
ELIMINATION PATTERN
The client states that he defecates once a day usually in the morning in soft brown stool
without difficulty and use of laxatives. The client urinates 3x day or more varying in his fluid
intake; he verbalizes no difficulty in voiding.
SEXUALITY/REPRODUCTIVE
The patient is not sexually active and was circumcised at the age of 12. The client is married
with his wife for almost 40 years. The client displays intimate close relationship to his wife. The
client states that he depends most on her wife for taking care of him and in giving him
medication and her attention at him, since he tends to be forgetful. The patient‘s wife is not
around during the interview.
INTERPERSONALRELATIONSHIPS/RESOURCES
The client is the youngest son among his 3 siblings. The client is married to his wife for 40
years and is a father to his only daughter. He stated that there are no family quarrels so far. The
client is a humorous person, that made gave them openness and good bonds. The client stated
that he decides on the facing family‘s major decisions with the help of his wife. The client stated
that he muses with his present life
COPING & STRESS MANAGEMENT/ TOLERANCE PATTERN
The client states the he has no stressful situation encountered presently. Since he stated
that he is feeling a lot better than his admission. The client states that whenever he encounters a
17

18. difficult situation, he would think about it several times prior to decision making. The client
verbalized that he can control his emotions.
VALUES/ BELIEFS
The Client is a Roman Catholic.. The client stated that he barely attends the church
because of several preoccupations. he believes that he got his illness as God ‗warning towards
his way of living. He stated that he will stop from over abusing his body and he would adhere to
healthy lifestyle.
PERSONAL/SOCIAL HISTORY
Habits: The client is known to be a hard-working man. Patient D.V stated that he cannot
tolerate not to do anything during his free time. He make sure that his goals are achieved at the
end of the day
Vices: The client stated does not consume alcoholic beverages and does not smoke.
Lifestyle: The client was known to live in a stressful lifestyle. The client states that he is skillful
Client’s usual daily life: The client‘s typical day is working as chef in his mini Karinderya that
run every day but closes half-day during Sundays. Patient D.V states that he prefers to be with
his family watching television or taking siesta during his free time.
Rank/Order in the family: the Client is ranked as the youngest son to his 3 siblings.
Travel: The client has no previous local and intonation travel for the past 4 months.
J. ENVIRONMENTAL HISTORY
The client lives together with his family composed of 4 house hold members. A
bungalow type of house with 209 square meters is owned by the patient residing near the
highway. The client narrated that it is a cemented house with 2 bedrooms and 1 bath
room. The house is fully ventilated and well lit of 12 windows. Their doors for about the
size of 180X1 meter. The client stated that their surroundings are well-sanitized. Their
electricity supply comes from Meralco and their water supply are from Deep well. They
order Mineral water for drinking. The client‘s residence is advantageous, since it is near
the public market, transportation, at school and Hospital.
18

19. K. PEDIATRIC HISTORY
L. MATERNAL AND BIRTH HISTORY
Birth date: April 24,1952 Hospital: Not assessed
Birth weight: Unrecalled
Type of delivery: Normal Spontaneous Delivery
Condition after birth: In fine stable condition
Mother:
Complications of delivery: None
Anesthesia drug guring labor: Unrecalled
Exposure to Teratogenic Agents during Pregnancy: None
19

20. I. PATHOPHYSIOLOGY
CLIENT-BASED
Predisposing Factor Precipitating Factor
Age (75 years old) Diet (Cholesterol
Gender (Male) rich foods)
Stressful Lifestyle
Plaque Formation
Atherosclerotic plaque ruptures or erodes
Thrombin is generated and Fibrin is deposited
Platelet Aggregation
Clots are being formed
Thickening and narrowing of arterial vessels
Obstruction in Blood Flow
Cells become ischemic
Myocardial cell contract less effectively Lactic acid is
Decrease O2 supply to
secreted
myocardium
Decrease Cardiac Output
Stimulate pain
Receptor
Decrease O2 supply to the different part of Chest Pain
the body
D.O.B. Pallor
Body Weakness
20

21. II. CONCEPT MAPPING
1. Ineffective Airway Clearance
related to increased
tracheobronchial secretions as
evidenced by productive cough
T/C Acute Coronary Syndrome Probably MI,
5. Risk for decreased cardiac Has CVD, Heart dysrhytmia not in failure
output related to degeneration 2. Ineffective tissue perfusion:
of cardiac muscle Patient B.R; 25 y/o Male. cardiopulmonary related to
Temp.: 37.5°c RR: 19cpm PR: 86 cpm BP: 100/70mmHg. reduced coronary blood flow
as evidenced by chest pain
 Dyspnea
 Productive cough in whitish sputum
 Chest X-Ray result of Pulmonary Congestion and Edema
 Weak looking
 Facial Grimace
 Presence of arrhytmias
 Positive Troponin I
 Elevated Ck-MB
 With Verbal Reports of Weaknhess
 With Exertional dypnea
 With verbal expression of worry
4. Anxiety related to fear of 3. Activity Intolerance related
death, change in health status to imbalance in oxygen supply
and demand as evidenced by
fatigue

22. III. PROBLEM LIST
Actual
Problem Number Problem Remarks
Ineffective Airway Clearance The client presently exhibits
1 related to increased dyspnea and productive cough in
tracheobronchial secretions as whittish secretions. Moreover,
evidenced by productive cough Pulmonary congestion is noted
upon chest X-ray.
2 Ineffective tissue perfusion: Presence of a Positive Troponin I
cardiopulmonary related to indicates myocardial injusry, thus
reduced coronary blood flow as a presence of a decrease in oxygen
evidenced by chest pain supple results in the failure to
nourish the tissues at capillary
level
3 Activity Intolerance related to Due to imbalance ratio of oxygen
imbalance in oxygen supply and of supply and demand and
demand as evidenced by verbal presence of productive cough has
reports of weakness led the patientInsufficient
physiological or psychological
energy to complete required or
desired daily activities
4 Anxiety related to fear of death Patient D.V verbalized a
and change in health status as generalized, unidentified feeling of
evidenced by verbal expression discomfort due to his experience
of worry of Chest Pain

23. Potential
Problem Number Problem Remarks
1 Risk for decreased cardiac The client is at reisk for decreased
output related to degeneration cardiac due to history of a positive
of cardiac muscle troponin I and elevated CK-MB
indicating a myocardial injury.
Therefore, it is possibible that
there may be presence of
inadequate blood pumped by the
heart to meet the metabolic
demands of the body due to
degeneration of cardiac muscle.

24. IV. NURSING CARE PLAN
Cues/Needs Nursing Planning Implementation Rationale Evaluation
Diagnosis
Subjective: Ineffective After 9 hour of Monitor Respirations and breath sounds, Indication of respiratory distress After 9 hours
noting rate and sounds and/or accumulation of
―Matatagalan pa Airway nursing of nursing
secretions
bago bumalik ang Clearance intervention, the intervention,
kulay ko‖ as related to client will be able the client
Elevated head of bed, changed position To decrease pressure on the
verbalized by the increased to demonstrate every 2 hours PRN diaghraphm was able to
patient tracheobronch behaviors to demonstrate
Kept area patient‘s sorrounding clean To prevent aggravation of
ial secretions maintain clear and free from draughts by means of condition behaviors to
instructing to reduce things and place
Objective: as evidenced airway maintain
only valuable things in his bed, and
 Dyspnea by productive fixed the patien‘t bed linen clear airway
 Productive
cough
cough in whitish Instruct patient to do deep breathing by To maximize effort on
sputum asking tha patient to inhale deeply and expectorating secretions.
 Chest X-Ray exhale slowly. and coughing exercises
result of
Pulmonary Encourage the patient to increase fluid Hydration can liquefy viscous
Congestion and intake for at least 2000 ml/day. Within secretions and improve secretion
Edema cardiac tolerance clearance.
 Weak looking
 Facial Grimace Asisted client with postural drainage To loosen viscous
and percussion if not contraindicated by
condition
Auscultate breath sounds and assess air To determine progress
movement

25. Administered bronchodilators as To provide pharmacological
prescribed by the physician. treatment and for fast recovery
Instruct home regimen interventions To provide cost reducing ways
such as boiling water and instruc the in improving expotorating
patient to inhale the steam to serve as an secretions.
alternative to nebulaization
Referred to respiratory therapist for To determine effectiveness of
adjunct treatment modalities. drug theraphy

26. Cues/Needs Nursing Planning Implementation Rationale Evaluation
Diagnosis
Subjective: Ineffective After 8 hours of Intially Assess, document and reposrt These data assist in After 8 hours
“Ang Sikip ng tissue Nursing the physician about the following: determining the cause and of Nursing
dibdib ko‖ as perfusion: intervention, the effect of the chest discomfort intervention,
verbalized by the cardiopulmon client will be and provide a baseline with the client
patient ary related to free from chest which post-therapy symptoms remained
reduced pain/discomfort can be compared. free from
Objective: coronary chest
 Presence of blood flow as a.) The patient‘s description of chest These data assist in pain/discomf
arrhytmias
evidenced by discomfort,including location, determining the cause and ort
 Positive
Troponin I chest pain intensity,radiation, duration, and effect of the chest discomfort
 Elevated Ck-
factors that and provide a baseline with
MB
 Chest Pain affect it. Other symptoms such which post-therapy symptoms
as nausea, diaphoresis, or complaints can be compared.
of unusual fatigue.
b.) The effect of chest discomfort on
MI decreases myocardial
cardiovascular
contractility and ventricular
perfusion—to the heart
compliance and may produce
(eg, change in blood pressure, heart
dysrhythmias. Cardiac output
sounds), to the brain (eg, changes in

27. LOC), to the kidneys (eg, decrease in is reduced, resulting in
urine output), and to the skin (eg, reduced blood pressure
color, temperature). and decreased organ
perfusion.The heart rate may
increase as a ompensatory
mechanism to maintain
cardiac output.
 Obtain a 12-lead ECG recording during An ECG during symptoms
symptomatic event, as prescribed, to may be useful in the
determine extension of infarction. diagnosis of an extension of
MI.
 Administer oxygen as prescribed
Oxygen therapy may increase
the oxygen supply to the
myocardium if actual oxygen
saturation is less than normal.

28.  Adminiser medications as prescribed Medication therapy is the first
line of defense in preserving
myocardial tissue. The side
effects of these medications can
be hazardous and the patient‘s
status must be assessed
 Ensure physical rest: use of the Physical rest reduces myocardial
bedsidecommode with assistance; oxygen consumption. Fear and
backrest elevated to promote comfort; anxiety precipitate the stress
diet as tolerated; arms supported during response; this results in
upper extremity activity; use of stool increased
softener to prevent straining at stool. levels of endogenous
Provide a restful environment, and allay catecholamines,which increase
fears and anxiety by being supportive, myocardial oxygen
calm, and competent. Individualized consumption.
visitation is based on patient response. Also, with increased
epinephrine,
the pain threshold is decreased,
and pain increases myocardial
oxygen consumption

29. Cues/Needs Nursing Planning Implementation Rationale Evaluation
Diagnosis
Subjective: Activity After 8 hours of Determine factors The client marks to have After 8 hours
―Mabilis akong Intolerance nursing intervention, contributing to fatigue pulmonary congestion and under of nursing
hingalin kahit sa pag related to the client will observation to have acute intervention,
gawa ng mga simpleng imbalance in participate willingly coronary syndrome the client
bagay‖ as verbalized by oxygen supply in necessary and participated
the patient and demand as desired activities. Evaluate client‘s percieved To provide comparative baseline willingly in
evidenced by limitations by asking past data and to provide information necessary
verbal reports activities and present about needed intervention and desired
Objective: of weakness activities activities.
 With Verbal Reports Assess cardiopulmonary Manifestations results The client
of Weaknhess response to physical activity, intolerance of activity verbalized of
 With Exertional including vital signs before, incorporating
dypnea during and after activity such
 Facial grimace exercises and
Provide and monitor To provide an increase in exposure to
response to supplemental oxygen supply sunlight in
exygen his daily
living

30. Assist client wit activities To protect the client from injury
when walking to the wash
room, getting up in bed and
lying back to bed
Provide intervals of rest To minimize occurrences of
between activities fatigue
Encourage and acknowledge Helps to minimize frustration
the difficulty of the situatio and rechannel energy
of the client
Encouraged patient to expose Sunlight is rich in Vitamin D and
himself in sun light around 7- will help the client to increase
8 am vitality
Assist and provide passive To maintain and enhance muscle
and active ROM tone of client

31. Cues/Needs Nursing Diagnosis Planning Implementation Rationale Evaluation
Subjective: Anxiety related to After 8 hours Assess, document, and report to These data provide information After 8 hours
―Mamamatay na fear of death and of nursing the physician the patient‘s and about the psychological well- of nursing
ata ko‖ as change in health intervention family‘s level being and a baseline. Causes of intervention
verbalized by the status as evidenced the client will of anxiety and coping anxiety are variable and the client
patient by verbal manifest mechanisms. individual, and may include acute manifest
expression of worry reduction of illness, pain, disruption of ADL reduction of
Objective: anxiety and anxious family members anxiety
 With verbal can transmit anxiety to the
expression of patient.the nurse must also It was
worry identify strategies to reduce the observed an
 Decreased family‘s fear and anxiety. increase of
mental social
concentration Assess the need for spiritual If a patient finds support in a interaction to
counseling religion, religious relatives and
and refer as appropriate. Counseling other people.
Allow patient and family to Unresolved anxiety serves as the
express anxiety and fear: stress response that increases
a. By showing genuine interest myocardial oxygen consumption.
and concern
b. By facilitating

32. communication (listening,
reflecting, guiding)
c. By answering questions
The presence of supportive family
Encourage the presence of the members may reduce both
family relative to assist patient‘s and
in reducing the patient‘s level of family‘s anxiety.
anxiety
Encourage active participation
in a cardiac rehabilitation Prescribed cardiac rehabilitation
program by educating the uses may help to eliminate fear of
of his medications, the need for death, reduce anxiety, and
diet modification and exercise enhance feelings of wellbeing.
Teach stress reduction
techniques. Such as
a.) Deep Breathing Stress reduction may help to
b.) Pursed Lip Breathing reduce myocardial
c.) Music Therapy by oxygen consumption and may
means of listening to enhance feelings of well-being.
music available in his
resources

33. Cues/Needs Nursing Diagnosis Planning Implementation Rationale Evaluation
Subjective: Risk for decreased At the end of 1 Keep client on bed or chair rest Decreased oxygen consumption At the end of
―Sa awa ng Diyos cardiac output week of in position of comfort. and risk for decompensation. 2 weeks of
e gumaan na kahit related to nursing nursing
papano ang degeneration of intervention, Administer high-flow oxygen To increase oxygen available for intervention,
pakiramdam ko‖ cardiac muscle the client will via mask as indicated cardiac function/tissue perfusion the client will
as verbalized by display displayed
the patient hemodynamic Decrease Stimuli, provide quiet To promote adequate rest hemodynamic
stability. environment. stability
Objective:
 Presence of Elevate legs when in sitting To enhance venous return
arrhytmias
position.
Provide fluids/electrolytes as To minimize dehydration and
indicated dysrhtmias.
Encourage changing positions To reduce risk for orthostatic
slowly, dangling legs before hypotension
standing
Early detection in changing in
Monitor vital signs, watch out these parameters promotes timely
for circulatory failure. intervention.

34. MEDICAL-SURGICAL MANAGEMENT
i. Pharmacotherapeutics
DRUG NAME MECHANISM OF INDICATION SIDE EFFECTS NURSING IMPLICATION PATIENT TEACHING
ACTION
Generic Name: Binds to opiate Moderate to severe CNS: dizziness, headache,  Assess type, location, duration  Instruct patient on how and when to ask for
receptors in the pain. Also sedation, confusion, and intensity of pain pain medication.
Morphine Sulfate CNS. Alters the provides: dysphoria, euphoria, floating  Assess blood pressure, pulse,  May cause drowsiness or dizziness. Advice
perceptions of the Analgesia during feeling, hallucinations, and respiration before and patient to call for assistance when
response to painful labor, sedation EENT: blurred vision, periodically during ambulating and to avoid activities requiring
Brand Name: stimuli while before surgery, diplopia, miosis (high doses) administration. If respiratory alertness until response to the medication is
producing supplement to . RESP: respiratory rate is <10/min, assess level of known.
generalize CNS balance analgesia. depression. orthostatic sedation. Physical stimulation  Caution patient to change positions slowly
Classification: depression. hypotension, palpitations, may be sufficient to prevent to minimize orthostatic hypotension.
patients. GI: dry mouth, nausea, significant hypoventilation.  Advice patient that frequent mouth rinses,
Narcotic vomiting, constipation, ileus.  Assess previous analgesic good oral hygiene, and sugarless gum or
Analgesic urinary urgency. clammy history. It may induce candy may decrease dry mouth.
feeling, sweating. physical withdrawal symptoms  Encourage patient to turn, cough, and
Dosage: dependence, psychological breathe deeply every 2 hr to prevent
TIV prn for Chest dependence, tolerance, atelectasis.
Pain  Advise patient to avoid concurrent use of
alcohol or other CNS depressant

35. DRUG NAME MECHANISM OF INDICATION SIDE EFFECTS NURSING IMPLICATION PATIENT TEACHINGS
ACTION
Generic Name: Inhibits platelet Treatment of CNS: Headache, dizziness,  Assess for symptoms of stroke,  Instruct to Avoid taking OTC medications
aggregation by patients at risk for weakness, syncope, flushing MI during treatment containing aspirin or NSAIDs without
Clopidogrel blocking ADP ischemic events— CV: Hypertension, edema  Monitor liver function studies: consulting health care professional.
receptors on history of MI, Dermatologic: Rash, AST, ALT, bilirubin,  Instruct patient to take medication as
Brand Name: platelets, ischemic stroke, pruritus creatinine if patient is on long- ordered
preventing peripheral artery GI: Nausea, GI distress, term therapy  Advise patient to notify health care
Plavix clumping of disease constipation, diarrhea, GI  Monitor blood studies: professional promptly if fever ,chills ,sore
platelets Treatment of bleed CBC,Hgb, Hct, protime, throat or unusual bleeding occurs
Classification: patients with acute Other: Increased bleeding cholesterol if the patient is on
coronary risk long-term therapy;
Platelet syndrome thrombocytopenia and
Aggregation neutropenia may occur.
Inhibitors  Assess for symptoms of
Dosage: stroke,peripheral vascular
disease or MI
75 g/ tab Precautions:
 Bleeding disorders, recent
surgery, hepatic impairment,
pregnancy

36. DRUG NAME MECHANISM OF INDICATION SIDE EFFECTS NURSING IMPLICATION PATIENT TEACHING
ACTION
Generic Name: Acts on blood vessels, It used for the Orthostatic hypotension;  Assess respiratory status  Avoid hazardous activities and requiring
GI, respiratory system symptomatic relief of palpitations; bradycardia;  Monitor CBC during long activities with alertness
Diphenhydramine by antagonizing the allergic conditions tachycardia; reflex term therapy  Avoid alcohol, other depressants
effects of histamine including urticaria tachycardia;  Assess movement disorder  Inform patient that drug may cause dry
H1- receptor site; and angio edema, extrasystoles; faintness.  Assess nausea and mouth
Brand Name: decreases allergic rhinitis, and Drowsiness; sedation; vomiting
response by blocking conjunctivitis, and in dizziness, disturbed  Assess for allergic
Benadryl histamine; causes pruritic skin coordination. Nasal reaction (skin itching,
increase heart rate, disorders. It is used stuffiness; dry mouth; rash, inflammation )
Classification: vasodilation, for its anti- emetic nose and throat; sore  Avoid alcohol
secretions; significant properties in the throat.
Antihistamine CNS depressant treatment of nausea
and vomiting,
Dosage:
1 tab

37. DRUG NAME MECHANISM OF INDICATION SIDE EFFECTS NURSING IMPLICATION PATIENT TEACHING
ACTION
Generic Name: Convert Acute CNS: Intracranial Assess patient carefully for bleeding every 15 min during  Explain purpose of
plasminogen to Coronary Hemorrhage, epistaxis, the 1st hr of therapy, every 15-30 min during the next 8hr, medication and the need
Streptokinase plasmin, which is Thrombosis, gingival bleeding, and at least every 4hr for the duration of therapy. for close monitoring to
then able to degrade Massive periorbital edema, GI Inquire about previous reaction to anistreplase or patient and family.
fibrin present in Pulmonary bleeding, streptokinase therapy. Assess patient for hypersensitivity  Instruct the patient to
Brand Name: clots. Lysis of Emboli, bronchospasms, reaction (rash,dyspnea, fever, changes in facial color, report hypersensitivity
throbi in coronary AcuteIschemic hemoptysis, allergic swelling around the eyes, wheezing). If these occur, reactions and bleeding or
arteries, with Stroke, reactions, ecchymoses, inform physician promptly. Keep epinephrine, an bruising
Classification: preservation of Occluded flushing antihistamine, and resuscitation equipment close by in the  Explain the need for bed
ventricular Central venous event of an anaphylactic reaction. rest during therapy to
Dosage: function. Lysis of access Assess neurologic status throughout therapy. Altered avoid therapy.
pulmonary emboli sensorium may be indicative of intracranial bleeding.  Instruct patient to avoid
1 tab or deep vein Assess intensity, character, location, and radiation of chest unnecessary procedures
thrombosis pain. Note presence of associated symptoms (nausea, that is prone to bleeding
vomiting diaphoresis.) or bruising such as
Monitor heart sounds all breath frequently. Inform shaving and vigorous
physician if sign of CHF occur (rales/crackles,dyspnea, S, tooth brushing
heart sounds jugular venous distension, relived CVP).
Monitor ECG continuously. Notify physician if significant
arrhythmias occur.

38. DRUG NAME MECHANISM OF INDICATION SIDE EFFECTS NURSING IMPLICATION PATIENT TEACHING
ACTION
Generic Name: It increases neuronal General CNS: Transient, mild  Discuss risk of fetal abnormalities with  Avoid hazardous activities
membrane Indications drowsiness initially; sedation, patients desiring to become pregnant. and requiring activities with
Diazepam permeability to - Short-term depression, lethargy, apathy,  Assess for hypersensitivity. alertness
chloride ions by management of fatigue, disorientation,  Reduce dose of opioid analgesics with IV  Avoid alcohol, other
binding to anxiety restlessness, confusion, diazepam; dose should be reduced by at depressants
Brand Name: stereospecific - Insomnia delirium, headache, slurred least one-third or eliminated.  Inform patient that drug
benzodiazepine associated with speech, dysarthria, stupor,  Instruct not to stop taking the drug without may cause dry mouth
Valium receptors on the anxiety rigidity, tremor, mild consulting the health care provider.  Instruct about side effects of
postsynaptic GABA - Sleepwalking paradoxical excitatory  Observe the 15 rights of drug drug: Drowsiness, dizziness,
Classification: neuron within the - Night terrors reactions, extrapyramidal administration. GI upset, dreams, difficulty
CNS and enhancing - Premedication symptoms, visual and auditory  Do not administer intrarterially; may concentrating, fatigue,
Antiepileptic, the GABA before disturbances produce arteriospasm, gangrene. nervousness, crying
Anxiolytic, inhibitory effects anaesthesia CV: Bradycardia, tachycardia,  Carefully monitor P. BP, respiration during  Instruct to take drug exactly
Skeletal muscle resulting in - Adjunct in the CV collapse, hypertension and IV administration. as prescribed.
relaxant hyperpolarisation management of hypotension, edema  Change from IV therapy to oral therapy as
and stabilization seizures Dependence: Drug dependence soon as possible.
Dosage: - Muscle with withdrawal syndrome  Do not use small veins for IV injection.
spasms
5g TIV

39. DRUG NAME MECHANISM OF INDICATION SIDE EFFECTS NURSING IMPLICATION PATIENT TEACHING
ACTION
Generic Name: Potentiate inhibitory Prevention of CNS: Dizziness,  Assess for signs of bleeding and  Advise patient to report any
effect of antithrombin ischemic headache, Insomnia hemorrhage (bleeding gums: nosebleed symptoms of unusual
Enoxaparin on factor Xa and complications from CV: Edema GI: unusual bruising black tarry stools bleeding or bruising
thrombn. Prevents unstable angina, Constipation,Nausea, hematuria fall in hematocrit or blood dizziness itching rash fever
Brand Name: thrombus prevention treatment of deep reversible increase in pressure guaiac positive stools); bleeding swelling or difficulty
vein thrombosis in liver enzymes GU: from surgical site notify physician if these breathing to health care
Lovenox patients at risk for urinary retention occur,. professional immediately.
thromboembolism Derm: ecchymoses,  Assess for evidence of additional or  Instruct patient not to take
Classification: complications due to pruritus, rash,urticaria increased thrombosis symptoms depend on aspirin or NSAIDs without
severly restricted Hemat: bleeding, area of involvement. Monitor neurogical consulting healt care
Anticoagulant, mobility during acute anemia, status frequently for sign of neurological professional while on
AntiThrombotic illness thrombocytopenia impairement may required urgent therapy.
Misc: Fever statement.
Dosage:  Monitor for hypersensitivity reactions
60 g SQ BID report signs of physician.

40. DRUG NAME MECHANISM OF INDICATION SIDE EFFECTS NURSING IMPLICATION PATIENT TEACHING
ACTION
Generic Name: Inhibits activity of Short-term treatment CNS:Headache , 1. Assessment  Tell patient to swallow
acid (proton) pump of active dizziness,asthenia, vertigo, History: tablets or capsules whole
Pantaprazole and binds to duodenal ulcer; insomnia, apathy, Hypersensitivity to omeprazole or and not to open, crush, or
hydrogen-potassium First-line anxiety,paresthesias, any of chew them.
Brand Name: adenosine therapy in treatment dream abnormalities its components; pregnancy, lactation  Instruct patient to take drug
triphosphatase at of Dermatologic: Physical: 30 minutes before meals.
Protonix secretory surface of heartburn or Rash,inflammation, Skin lesions; reflexes, affect;  Caution patient to avoid
gastric parietal cells symptoms of urticaria, pruritus, urinary hazardous activities if he
Classification: to block formation of gastroesophageal alopecia, dry skin output, abdominal exam; respiratory gets dizzy.
Proton Pump gastric acid.. reflux GI: auscultation  Instruct to avoid beverages
Inhibitors, Gastric disease (GERD); Diarrhea, Interventions rich in nicotine, caffeine and
Acid suppressor Short-term abdominal pain, 2. Administer before meals. Caution patient alcohol which stimulate
treatment of active nausea, vomiting, to swallow capsules whole,not to open, stomach acid or delay ulcer
Dosage: benign constipation, dry chew, or crush them. healing.
gastric ulcer; GERD, mouth, tongue atrophy Dosage adjustments may be necessary in
severe Asians and patients with hepatic
erosive esophagitis, impairment.
poorly Administer antacids with omeprazole, if
responsive needed
symptomatic GERD;

41. DISCHARGE HEALTH TEACHING
Content Strategy
M-medication To adhere in prescribed  Instruct patient to take the prescribed
therepautic regimen for medications as ordered by the physician.
health maintainance and  Instruct patient to avoid taking OTC drugs
resistance. unless given with medical advice
 Encourage patient to include atleast 30 minutes
To promote a healthy
E-exercise of walking or jogging or perfrom tolerated and
lifestyle, maximizing the
preferred activities as a means of exercise
level of health and increase
the body‘s immunity.
 Educate client by adhering maintainance
T-treatment Attending the follow up theraphy, appropriate diet and having exercise
check up. will reduce likelihood of occurances and
aggravation of disease.
H-health Health teaching about the  Instruct the patient about home-made
teaching disease, exercise and diet. interventions in reducing blood pressure such
as:
a.) Pineapple or Calamansi juice to reduce
blood pressure
b.) Chewing of raw or fried garlic after meals
c.) Refrain from consumption of caffeineted
beverages, such as coffee and chocolate
O-OPD Instruct that they need to  Emphasize the importance of adhering to
have a health check up. medications and attending follow-up check up.
 Encourage patient to adhere to weekly blood
pressure monitoring

42. D-diet Maintain and ensure  Instruct patient to avoid consumption of salty
adequate intake for and fatty foods.
noursihment,  Instructed patient to limit consumption of high
caloric foods such as rice to reduce occurences
of high blood pressure and increase in blood
sugar.
S-signs and If any signs of symptoms are  Advise patient to refer to health care
symptoms present go to the nearest professional for sudden onset of blurry vision,
hospital for check up. intense head ache, chest pain unrelieved with
rest and medications
V. ONGOING APPRAISAL
Patient D.V, a 59 year old male, has been admitted to Ospital ng Makati last November
20, 2011 with the chief complaint of chest pain. Upon assessment, it was observed that the
patient is conscious, with general survey of Levigne‘s sign, Facial Grimace and Dyspnea
. The client is admitted in Emergency Room and inserted of D5W 500cc X 10cc/hr at left
metacarpal vein with laboratory tests rendered such as CBC, PTT, BUN, Creatinine, Serum
Na, K, Trop I, CK-MB, ECG, and CBG. Chest X-Ray was ordered and for oxygen therapy at
4 liters per minute.
Patient D.V was initially treated with morphine TIV for his chest pain, ISDN 80 cc D5W
+ 20 g, Clopidgogrel 75 g/Tab,. The patient is ordered for streptokinase therapy 1-5 MIV in
90 ml D5W. Prior to therapy, the given Diphenhydramine 50 g TIV, Hydrocholine 100g IV,
Diazepam 5g TIV for anxiety, Pantaprazole 10 g TIV OD and Enoxaparin 60 g SQ BID
. Presently, the patient‘s condition is stable. Negative of Troponin I, Normal Cholesterol
Therapy due to streptokinase therapy and for 2-D echocardiogram with heplock inserted and
latest vital signs of Temp.: 37.5°c RR: 19cpm PR: 86 cpm BP: 100/70mmHg.