Question

Mr. Lopez a 58-year-old male a retired bank employee, a smoker consumes 1 pack per day for 15 years,

drinks alcohol occasionally, hypertensive and live a sedentary lifestyle was rushed in to hospital for chief

complaints of severe chest pain, In the ER he was given 0xygen 7-10 LPM via oxygen mask, nitroglycerin

given for 3 doses after 45 minutes the pain still there. Morphine administered stat. Vital Signs as follows:

BP– 150/100, PR – 123 with cardiac arrhythmia, RR – 20, T – 37.8C.

Doctor’s order:

PNSS1L X 42 gtts/min.

Nitroglycerin drip to titrate

Amlodipine 10 mg OD PM

Omeprazole 40 mg IV

Monitor vital signs Q1 hour

Monitor I and O Q 1 hour

Medical Diagnosis: Myocardial Infarction

Laboratory:

CBC – normal

Urinalysis – normal

LDL – elevated

HDL- decrease

Triglyceride – elevated

Total Cholesterol – elevated

TROPONIN T – elevated

DIAGNOSTICS:

ECG – ST segment elevated, T wave inverted

Present Medical History

1 day prior to admission patient experience dizziness, palpitations and tachycardia, he just took a rest and

stay to his room all day. 1-hour PTA patient experience stomach pain, cold clammy skin, and diaphoresis.

Past Medical History

Patient has coronary artery disease 2 years now, the pain started when the patient joins the fun run

organized by his company. At first he experiences slight chest pain, pallor and sweating, and easily relieved

by rest, and a single dose of Nitroglycerin 5 mg sublingual, he was advised to quit smoking and given

maintenance medication for hypertension, after a couple of months he consulted a doctor for experiencing

moderate chest pain and difficulty in breathing and given a maintenance nitroglycerin 5 mg sublingual, for

chest pain, Losartan 50 mg. OD in AM, Amlodipine 5 mg. OD in PM. The patient continues to eat foods to

avoid. He loves to eat pork sisig, lechon, shrimp, and fatty foods like adobo and grilled pork chop. Most of

the time he forgot to comply to his maintenance medication.

Family History

(-) Tuberculosis

(+) Hypertension

(-) Cancer

(+) Cardiovascular disease

(+) DM

(-) Asthma

1. Make a priority Nursing care plan (ADPIRE, Assessment, Diagnosis, Planning-short term and long term goal, Intervention-Rationale, Evaluation) for this case.

Answer 1

Make a priority Nursing care plan (ADPIRE, Assessment, Diagnosis, Planning-short term and long term goal, Intervention-Rationale, Evaluation) for this case.

Assesment	Nursing diagnosis	goal	Interventions	evaluation
Severe chest pain not relieved by 3 doses of nitroglycerin , restlesness.Pulse rate 123/mt ECG- ST elevation with T wave inversion, cardac arrythemia	Acute pain telated to decreased perfusion to myocardial cells	short term goal-patient reports relief of pain long term - client maintains comfort and tolerate activity level	Administer Inj. Morphine as per prescription to reduce pain, anxiety and decrease myocardial workload. Administer Oxygen via nasal mask or cannula at 7-10LPM to enhance myocardial cell oxygenation and reduce cell ischemea. Administer Nitroglycerin drip at 4-5 drpos /mt . Nitroglycerin releases nitric oxid which cause coronary artery dialation and enhance coronary artery blood flow, oxygen and nutrients. Also reduce cardiac workload by reducing preload. Administer PNSSL at 42gtts/mt.This drug attenuate the damaged myocardial ischemia and infarction by inhibiting Thromboxan A2(TXA2) and ET( endothelin) then increasing myocardial blood flow and improving cardiac function. Obtain 12 lead ECG to know the cardiac rythm status and coronary artery blood flow. Monitor Blood presssure beacuse nitroglycerin cause generalized vasodialation which may cause hypotension. check pulse rate provide bed rest and calm and quit environment -to reduce stress. Evaluate pain for severity, location, radiation to evaluate therapeutic effect of drugs and to prevent further ischemia and complications .	Patient verbalizes no pain. Relaxed and takes rest. Patient vital signs with in normal limit.
presence of severe chest pain. cold and clammy skin, presence/ abscence of peripheral pulses,Assess conscious state monitor PaO2, intake and output	Ineffective tissue perfusion(cardiac) related to coronary artery block	short term- maintains stable signs of effective cardiac perfusion long term- patient relives chest pain and tolerate exercise, and other activities	Monitor vital signs frequently to determine baseline data to prepare treatment plan Monitor ECG to know the cardiac rythum , Because patient is risk for decreased cardiac output due to ventricular arrythmias. Administer Nitroglycerine drip and titrate according to the level of pain percieved by the patient to improve coronary circulation. Administer PNSSL to improve coronary artery blood flow by reducing thromboxane and endothelin. Administer O2 to enhance oxygenation of myocardial cells and prevent further cellular ischemia Monitor perfusion status by checking pripheral pulse, skin for warmthness. it indicates intactness of adequate peripheral circulation. Monitor intake out put hourly. Renal perfusion is the indicator of adquate cardiac output, if patient maintain urine output 30ml/hr. Monitor lung sounds- to rectify ventilation perfusion mis-match. Cardiac arrythmia and myocardial cell death may cause pulmonary edema. Provide complete bed rest during acute period to reduce cardiac workload and reduce oxygen demand.	Patient regain normal cardiac rythum maintain adequate urine output. peripheral tissues are warmth and pulses are felt and normal. Patient report confort and no pain .
Blood pressure 150/100mm Hg, ECG- cardiac arrythmia , ST segment elevation pulse rate 123/mt and irregular. severe chest pain,	Risk for complications , arrythmia, cardiogenic shock, cardiac arrest, pulmonary edema related to decreased myocardial tissue perfusion and loss of contractility	short term-Maintains normal cardiac output and improves myocardial perfusion long term- maintain optimum cardiac output to meet metabolic need.	Monitor ECG- to identify rythum status and related complications. monitor blood pressure, pulse rate continuously to know the cardiac output . Monitor lung sounds, beacause crackles present if fluid accumulation occurs in the lungs due to pulmonary edema. Administer prescribed medications as per the order T.Amlodipine 10 mg oral to reduce blood pressure T.Omeprazole 40mg 30 mts before meal to enhance absorption and reduce gastric irritation. Monitor intake and output , peripheral perfusion . Repeat serum cholesterol and lipid profile. Elevated profile increase risk of coronary occlusion by forming atheroma. Keep emergency trolly aside of the patient to provide emergency care if needed	Patient maintain normal cardiac output free from complications
chronic smoker, alcoholic, Took plenty of fast food , not following regular medication regimen. High level of LDL and total cholesterol.Blood pressure 150/80 mmHg. high blood glucose.	Ineffective therapeutic regimen management related to lack of knowledge regarding risk factors,management of CAD	Short term- regain normal blood pressure. resume normal serum cholesterol and lipid profile. long term patient agree to resume healthy practices comply regular medications.	Provide nutritious diet with moderate protien and low carbohydrate and low fat . It should be easily digestable . Discuss with need for lifestyle changes. Restrict animal meat and deep fried foods- it will increase cholesterol. Avoid eating fast foods it contains high fat . Quit smoking - smoke contain  nicotin it will cause vasoconstriction and increase risk of coronary artery disease Take one -two peg per day. Follow DASH diet . increase intake of fibre contained foods such as  plenty of Vegetables, fruits in diet , cereal grains, legumes and omega 3 containing food such as fish tuna.Add soluble fibre , particularly oats bran, legumes.Use low fat oil, olive oil ,canola oil. Avoid high salt contained food - which will increase sodium and water retension and blood pressure. Daily sodium intake should not exceed more than 2gm/day. Limit Carbohydrate contained food instead add wheat and wheat products in regular diet along with vegetables. These food contains fibre prolong the  absorption of glucose from  intestine. Vegetables contain rich of fibre, minerals and vitamins and less in carbohydrate. Do regular blood check-up. perform regular exercises- to maintain ideal body weight , exercise helps to burn fat. increase blood flow. Avoid constipation- straining may  demand more cardiac output. Explain about medications regimen and to take medications regularly. Failure in taking medications may cause recurrent extended episodes of infarction and related complications. Take medic allert card with you. If pain experience have sublingual nitroglycerine 5mg, maximum 3 dose. seek immediate medical care. Do not skip Antihypertensive drug. Omeprazole should take 30 mts before meal.	Patient desribes risk factors and management of Coronary artery disease. Patient verbalizes importance of complying with medications.
Patient is restless, anxious, BP 150/100mmHG, tachycardia	Anxiety related to percieved or actual threat of death or pain	short term- Reduces anxiety and take rest Long term- follows coping mechanisms effectively to reduce anxiety	Assess the level of anxiety to plan interventions . Administer Inj.Morphine as per orderr.It helps to reduce anxiety and calm the patient Talk to the patient and help them to ventilate their feeling- it helps to reduce anxiety . Reassure the patient and provide feedback- it will helps to resduce stress and fear.   Teach the patient to use coping mechanism effectively, allow him to talk with relatives- to reduce stress and enhance comfort. Provide calm and quiet environment teach him muscle relaxation exercises, deep breathing exercises. To enhance self control.	patient effectively used coping mechanism. Talk to the relatives. Uses excercises when necessary.