Question

Patients Profile

Name:	Patient James
Age:	58 years old
Sex:	Male
Nationality:	Filipino
Religion:	Roman Catholic
Address:	Quezon City
Marital Status:	Single
Chief Complaints:	“Sumasakit and dibdib ko. Nawawala pero pabalikbalik. Mga anim na buwan na na ganito and nararamdaman ko” (“Pain on my chest” on and off for the past six months”.)
Admitting Diagnosis:	Angina Pectoris

History of Present Illness

            Mr. James is a 58 year old insurance broker who seeks consultation to FUMC due to an episode of "chest pain" that he experienced earlier in the day during a golf game. Although he minimizes the severity of the pain and attributes it to being "out of shape," his wife insisted that he see a physician because he has had similar episodes during the past six months. Mr. James was admitted for treatment and management with the following medications:

1. Aspirin 325 mg q4h PRN

2. Nitro-Patch Patch 2x a day q12h

3. Inderal (Propranolol) 80mg q12h

4. Atorvastatin 20mg OD PO

5. Amlodipine 5mg OD PO

Mr. James describes the pain as being more of a discomfort or heaviness. It is localized to "my breast bone" and does not radiate. Today, following a brief rest, the pain subsided and he returned to his golf game. Previous episodes of the heavy feeling tended to occur following large meals and one occasion, while dancing at a wedding. None of the episodes lasted more than "several minutes."

Although Mr. James did not experience nausea or vomiting today, he notes many episodes in the past of feeling a burning sensation in his chest. He describes the sensation as being "like acid behind my breast bone." This feeling occurs most often late at night when he lays down. Usually he has had a large meal or drank alcohol. The sensation does not radiate.

Patient's perspective: When asked about how he feels about these episodes, he admits to being concerned about his health and longevity, considering his father died at age 52 of "heart problems." He says, business is poor, my kid is always in trouble. "Who’s going to take care of things?"

Past Medical history: Not significant

Past Surgical History: None

Family History:   Father died of "heart problems" at the age of 52.

Social History: Mr. James smokes at least 1 pack of cigarettes per day. He drinks 2-3 cocktails per nights to "settle my nerves."

Medications:    Vitamins

Allergies:    None

Review of systems:   No significant problems

Physical Examination

Mr. James is a short, moderately obese man who appears somewhat anxious but is in no apparent distress. He is wearing clean casual shirt/pants. Vital sings: BP right arm 162/94; left arm 160/92. Weight 176lbs; Height 5’7". Respiratory rate is 16/minute. Temperature, 98.4F. Examination of cardiovascular system reveals a regular, apical heart rate of 86/minute. S1 is heard best at the apex; a loud S2 is heard best in the R2ICS and L parasternal border. A questionable S4 is heard at the apex. There are no murmurs or apical prominence. There is no peripheral edema.

Lungs are clear to percussion and auscultation. An indirect hernia is noted in the right inguinal region. The abdomen is examination is negative for abnormalities.

Laboratory Tests:

CBC: WBC = 5,600/mm3, hemoglobin = 15.2g/dL, hematocrit = 45%, platelet count = 320,000/mm3

Chemistries: Glucose 110mg/dL, Blood Urea Nitrogen (BUN) 11mg/dL, Creatinine 0.9mg/dL

Urinalysis: Specific gravity: 1.016; Protein, Glucose, Ketones = negative.

Chest X-ray: Normal

Questions:

1. What are your discharge plan or recommendation to C.D. using the mnemonic
METHOD

a. M-Medication
b. E-Environment/Exercise
c. T-Treatment
d. H-Health Teaching
e. O-Observation/Out-patient
f. D-Diet

2. Trace the pathophysiology of the disease.

3. Nursing considerations while taking the drug.

4. Make at least 2 nursing care plan based on your assessment that needs to prioritize.

Answer 1

Discharge recommendations

Medication:as a nurse be sure that patient understood all medication include the dose of drugs, route ,action and adverse effect.

__educate them to always look the expiry date of all medicine ,the expired drug should change immediately.

___advice them to report immediately to notice any worsening side effects of drug.

___educate them to not to skip any dosage.

___advice them to seek medical care immediately if worsening of symptoms occurs after taking of medicine.

:environmental /exercise: activities that cause angina is different from one person to another .Advice them to notice activities that cause chest pain and try to avoid such kind of activities.

Moderate exercise is recommended for heart disease patients that is 30 to 60 min every day .

:teaching:teaching is most important method to prevention of complication.

__teach about complication of chest pain if we does not provide proper attention at right time, this will seriously affect the life of the patient.

:Health teaching :health education is important part for effective patient care.

Health education regarding modifiable and non modifiable risk factors for heart disease and educate the ways to reduce the modifiable risk factors that is smoking cessation help to prevent recurrence of disease and stopping the alcohol intake.

Educate them to reduce weight.

:Observation /out patient _this include common warning signs the patient should observe and notify his doctor immediately .

Encourage patient to keep a record of episodes of chest pain, duration and severity and it should see the doctor .

Seek emergency treatment if patient have severe chest pain that is radiating to shoulder back and neck.

:Diet: diet modification is important to manage the angina. Modification include,

_eat less fat and cholesterol food.

_eat lean protein like fish, legumes etc,.

_eat less sodium (salt) diet to controlling blood pressure.

_eat more fresh fruits and vegetables and use low fat dairy products .

2)pathophysiology

When the demand for myocardial oxygen exceeds the ability of the coronary arteries to supply the heart with oxygen, myocardial ischemia occur. Angina or chest pain is the clinical feature of reversible myocardial ischemia..

Reason for insufficient blood flowing is narrowing of coronary artery due to atherosclerosis.. The myocardium become hypoxic within 10 min of occlusion then aerobic metabolism changing to anaerobic metabolism.

Anaerobic metabolism leads to lactic acid accumulation and it cause pain to heart muscle.if restore the circulation change to aerobic metabolism and cellular repair begin.

3)Nursing consideration while taking the drug

:always check dose, route ,and expiry date of drug.

:educate patient to not to skip the drug.

:advice patient to lie semi Fowler position while taking sublingual nitroglycerin .

:nitroglycerin should kept in a tightly closed dark glass bottle.

:check therapeutic response of drugs.

:monitor for adverse reaction.