cardiac dysrhthmia secondary to digitalis toxicity, mitral valve prolapse with severe mitral...

8/7/2019 cardiac dysrhthmia secondary to digitalis toxicity, mitral valve prolapse with severe mitral regutgitation

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TABLE OF CONTENTS

PAGE NO.

CHAPTER 1 INTRODUCTION

CHAPTER 2 OBJECTIVES OF THE STUDY

CHAPTER 3 HEALTH HISTORY

CHAPTER 4 PHYSICAL ASSESSMENT

CHAPTER 5 GORDONS FUNCTIONAL HEALTH PATTERN

CHAPTER 6 DEFINITION OF COMPLETE MEDICAL DIAGNOSIS

CHAPTER 7 ANATOMY AND PHYSIOLOGY AND PATHOPHYSIOLOGYCHAPTER 8 LABORATORY AND DIAGNOSTIC STUDIES/ EXAMINATIONS

CHAPTER 9 COURSE IN THE WARD

CHAPTER 10 NURSING CARE MANAGEMENT

CHAPTER 11 DRUG STUDY

CHAPTER 12 PROGNOSES/ EVALUATION

CHAPTER 13 DISCHARGE PLAN

BIBLIOGRAPHY


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I. INTRODUCTION

Last July 25, 2010, our group was handled by Ms. Julita Apusaga for our duty at Jose P. Rizal Memorial District Hospital. With six students consisting our group, we were assigned to the Medical Ward to apply the theories that we havelearned in class and to practice our skills in executing our responsibilities asnurses.

It was made clear that each student would have at least two patients everyday and from the first day of the duty, it was Mrs. ET who has caught our attention. After the endorsement at the first day, we knew that this could be our potential patient for our case study since she had the most unusual conditionamong the other patients that we would be handling.

Mrs. ETs willingness and cooperation allowed us to easily create rapportwith her which aided our gathering of facts regarding her condition. She was notreluctant in answering our questions except when she was having shortness of breath and had to rest for a while. She was assured of the confidentiality of our work and she understood the importance of conducting this case study.

Our group was able to care for Mrs. ET for three days. We were supposedto handle this patient for six consecutive days, but due to the schedule and somechanges in the assignments of patients, we only cared for Mrs. ET on July 25,29, and 30.

Consequently, we chose Mrs. ETs condition as the one to be presented tohelp us deepen our knowledge regarding heart diseases specifically cardiacdysrhythmia. Through this, we would be learning from an actual condition of anactual patient and not merely from the book. Also, studying Mrs. ETs diseasewould be of great help to us when we soon become registered nurses and wouldbe handling patients with similar condition.


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II. OBJECTIVES OF THE STUDY

General Objective:

U tilizing the nursing process, this study is directed towards the promotion of learning and awareness in health, disease and illness prevention as well as the care for a patient with cardiac dysrhythmia secondary to digitalis toxicity, mitral valve prolapsedwith severe mitral valve regurgitation. It also aims to enhance our knowledge, skills aswell as the attitude in caring for a patient with the mentioned condition.Specific Objectives:

This case study seeks to provide all that can be gathered from the patientregarding her condition with the following specific objectives:

y To give a brief introduction about cardiac dysrhythmia, digitalis toxicity, mitralvalve prolapsed and mitral valve regurgitation as well as their signs andsymptoms.

y To identify the risk factors for the occurrence of cardiac dysrhythmia, digitalistoxicity, mitral valve prolapsed and mitral valve regurgitation

y To describe the clinical manifestations associated with cardiac dysrhythmia,digitalis toxicity, mitral valve prolapsed and mitral valve regurgitation

y To be aware of the medical management in the treatment of cardiac dysrhythmia,digitalis toxicity, mitral valve prolapsed and mitral valve regurgitation

y To apply the principles of nursing management to the care of a patient who hadcardiac dysrhythmia, digitalis toxicity, mitral valve prolapsed and mitral valveregurgitation


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III. HEALTH HISTORY

Hospital Case Number: 1119759Patients Name: Mrs. ETSex: FemaleAge: 55 years oldAddress: Sampiruhan, Calamba, LagunaDate of Birth: November 8, 1955Place of Birth: Calamba, LagunaNationality: FilipinoCivil Status: Married

Religion: Born Again ChristianOccupation: U nemployedEducational Background: High School graduate

Attending Physician: Dr. Bambo

Level of Consciousness:

Alert: Oriented: Responds to verbal: Drowsy: Disoriented: Responds to pain:

Lethargic: Asleep: Easily aroused:

Chief Complaints:

Difficulty of Breathing

Final Diagnosis:

Cardiac dysrhythmia secondary to Digitalis Toxicity, Mitral Valve Prolapse withsevere Mitral Regurgitation


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PRESENT HISTORY

Three days prior to admission, Mrs. ET experienced shortness of breath andchest pain. She consulted a private MD where his usual medications were prescribedsuch as Digoxin 0.1mg tab OD, Furosemide 40mg tab OD, Losartan 25mg OD, ASA80mg OD, and ISDN as needed for her chest pain.

Two days prior to admission, Mrs ET still experienced shortness of breath andchest pain.

Few hours prior to admission, she experienced the above-mentioned symptomsassociated with dizziness, nausea, and headache with occasional vomiting of previouslyingested food without abdominal pain, which prompted her to seek medical help.

PAST HISTORYMrs.ET has been hypertensive since 2005. She consulted a physician who gave

her a maintenance drug ( Losartan ). Previously, she was admitted in PGH for chestpain last 2007. She was managed as a case of unstable angina and dischargedallegedly improved with take home medications including Enalapril, Metoprolol,Simvastatin, ISMN, ASA, ISDN, which was discontinued after one year and was thenlost to follow-up.

After 3 years, she consulted again with a private MD on January 2010 and theMD prescribed Digoxin, Furosemide, Losartan, ASA, ISDN.

On May 22, 2010 she experienced difficulty of breathing and was admitted inPGH, she was diagnosed with the following: Cardiac Dysrythmia secondary to DigoxinToxicity; Acute Renal Failure secondary to Pulmonary Congestion secondary toDecompensated Heart Failure due to: Mitral Valve prolapsed with severe MitralRegurgitation and Ischemic Heart Disease; Hypotension Stage II in relativeHypotension; Pre Renal Azotemia secondary to Renal Hypoperfusion; Dyslipidemia andObese Type 1.

FAMILY HISTORY

The Patients parents allegedly both have Heart Diseases and Hypertension.


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GENOGRAM


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GENOGRAM

ET is the only daughter of Mrs. M and Mr. A who both died several years ago. Mrs. M

died because of Rheumatic Heart Disease at the age of 64 while Mr. A died because of Heart

Attack at the age of 72. ET was married to Mr. B and beared 2 children named JM, a 37 year old

driver, and HM, a 35 year old security guard. Mr. B died while asleep in the year 1982. A year

after, Mrs. ET got married for the second time to Mr. RT. He is currently 60 years old and

claimed that he has a high blood pressure and prostate enlargement. Mr. RT and Mrs. ET had a

child born in 1984 named RRT who is now a 24 year old professor in the University of the

Philippines.

All of the family members are Born Again Christians.


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IV. PHYSICAL ASSESSMENT

VIT AL SIGNS AND AN TH ROPOME T RIC MEASUREMEN T S:

Date: July 28, 2010

y T= 34.4 o C (AX)y PR= 72 bpm (radial); 89 bpm (apical)y RR= 31 cpmy BP= 90/ 60 mmHg

GENERAL SURVEY

U pon conduction of the physical assessment, Mrs. ET showed signs of distressbut was generally calm when we were talking to her. Her body built was classified as

endomorph upon observation and her gait was noted as coordinated although her speech was slightly slurred. She was alert and oriented when we talked to her. It wasalso observed that she had fair grooming.

SKIN:

Her skin appeared pallor but smooth. When assessed, her skin turgor was foundto be good. Mrs. ETs skin was a bit cold especially on edematous areas found on bothfeet. It was a non-pitting edema.

HEAD:

Mrs. ETs head was measured and resulted to 24 inches which was classified asnormocephalic. Her head was also inspected to be symmetrical. Her hair was even andthe scalp was clean from dandruff. Neither lacerations nor discolorations were noted.Likewise, no masses were assessed upon palpation.

EYES:Mrs. ETs eyelids were inspected and were found to be symmetrical. There was

no edema present on the periorbital region including the patients eyelids although theywere observed to be dark in color. Also, her conjunctivas were inspected to be pinkish.


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Due to the unavailability of a Snellens chart, Mrs. ETs eyesight was assessedthrough a simple reading test. When asked to read from a newspaper, she did not haveany trouble or difficulty in reading without her eyeglasses.

EARS:

Mrs. ETs ears were symmetrical upon inspection. No purulent or serousdischarge was present and no foul smelling in the external canal was noted. Her grosshearing was assessed by allowing her to hear a sound from both ears. Based uponMrs. ETs response, her gross hearing was noted as symmetrical.

NOSE:

Mrs. ETs nose was also assessed and the septum was observed to be inmidline. The mucosa was pink with no discharges. Her gross smelling was assessed byletting the patient smell a cotton ball soaked with alcohol. Pinching one nostril at a time,Mrs. ET was asked if she can smell the alcohol. Her gross smelling was noted assymmetrical by the patients response of equal strength of smell of the alcohol for bothnostrils. Both sides were also palpated to be patent.

MOUTH:

Mrs. ET was asked to open her mouth and a pink mucosa was seen. Her gumswere also pink upon inspection. Her tongue was observed to be in the middle and so asher pharynx. No inflammation on any part of the tonsils was noted. Mrs. ET haddentures for her upper and lower sets of teeth.

NECK

Mrs. ETs trachea was palpated in the midline of her neck. Likewise, her thyroidgland was noted to be at the middle. No difficulty was noted when Mrs. ET was asked toturn her head. There was no vein engorgement or masses observed.


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CHEST AND LUNGS

Patients breathing pattern was rapid but her chest shape was normal and thelung expansion was symmetrical. Symmetrical vibrations were felt on both lungs uponperforming tactile fremitus. On the other hand, crakles were heard upon auscultation onthe bases of the lungs while dull sounds were noted upon percussion of the organ.

HEART

The pericordial area of the patient was inspected as flat and not bulging. Thrillswere present upon palpation of the apex. When auscultated, S1 and S2 could not bedistinguished. Additionally, S3 and S4 were also heard as well as murmurs.

The patients apical pulse was 89 beats per minute while the radial pulse was 72

beats per minute. A pulse deficit of 17 beats in a minute was noted at the time of assessment. The apical pulse was characterized as weak.

ABDOMEN

U pon inspection, Mrs. ETs abdomen was a bit globular. All of the four quadrantswere auscultated with the following with normoactive bowel sounds of 15 per minute. Itwas noted that there was a dull sound upon percussion. No lump, mass, or anytenderness was found on the patient after palpation.

EXTREMITIES

Mrs. ETs pulse on her extremities was present upon palpation. However, weakpulses were noted on both of her feet. When assessed of capillary refill through her finger and toe nails, it was noted as three seconds. The patients extremity musclestrength was also assessed by allowing her to apply force against resistance applied toher hands and feet. Her strength for both extremities was good as she can withstandthe force being applied to her.

Mrs. ET had edema noted on both of her feet.


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V. GORDONS FUNCTIONAL HEALTH PATTERN

A. HEALTH PERCEPTION - HEALTH MANAGEMENT PATTERN

Generally, patient ET was not having serious problems in her senses becauseshe admitted it as part of being old. She mentioned that she had blurred vision so shehad to use a set of reading eye glasses to be able to visualize and read news papersand bible as well. Sometimes, she had mild problem in hearing.

With her current condition, she felt unsatisfied because of so many changes thathad happened to her since she acquired the heart problem. According to her, she

actually lost weight.She didnt have any vices. She doesn't smoke nor drink alcoholic beverages. She

doesn't use any prohibited and unprescribed drugs.

If there is something wrong with herself, she immediately reports it to her husband. Then, they find a way to lessen her suffering and alleviate the symptoms of her condition.

She said that whenever she is sick, she takes medicine, adequate sleep andenough rest to recover. ET said that she always follows what the doctors and nurses tellher.

Regarding past accidents and hospitalizations, patient ET didnt have any historyof accidents before. She said that this was her second time to be admitted at thehospital. Her first was when she suffered from cardiac disorder and was admitted atPhilippine General Hospital (PGH) last 2007.

According to her, she doesnt have any allergies.


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B. NUTRITION - METABOLISM PATTERN

ET has a good appetite and eats fruits and vegetables regularly but only in smallamount.

Hindi naman ako pihikan sa pagkain, the patient said.

U pon inspection, doesnt have any skin problem but she has edema in her lower right and left extremities. Her wounds usually heal within 2-3 days.

Ayos naman yung paghilom ng sugat ko at sa ngayon wala naman akongsugat, she added.

Patient ET's usual weight was reduced to half since she experienced her currentcondition.

She doesn't have skin problems but she usually tell her husband to rub her stomach and back every night. It seems to be her normal routine every time she wantsto relax and fall asleep.

She has dental problems in frontal part of her teeth. She has dentures. And

sometimes, she also feels nauseated but she is not vomiting.Before she was confined to the hospital she can eat whatever she wants. Since

she is in an unusual condition, she still eats three times a day but in small amounts. 3-4spoons of boiled rice each meal, glass of water per meal and half serving of viand(fish, meat and vegetables).

Nakakatatlo o apat na subo lang ako ng kanin simula noong magkasakit ako,the patient said.

However, she has regained her appetite during her stay at the hospital andfortunately recovered from her condition.

Patient was asked for a 24-hour food recall and the following were mentioned:


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Breakfast Lunch Dinner

y 1 cup of plain lugaw

y 170 mL of water

y 3-4 spoons of boiled rice

y serving of Sinigang tilapiawith string beans andeggplants

y 170 mL of water

y 3 spoons of boiled rice

y serving of friedchicken

y 160 mL of water

Typically, she only drinks about half liter or 500 mL of water per day compared to

her previous intake of at least 6 glasses (1440 mL) of water before.

C. ELIMINATION PATTERN

Before, ET goes to the bathroom for urination every three hours. But at present,she reported that she has increased frequency in urination since her confinement in thehospital.

Parang lagi akong binabalisawsaw, walong beses sa maghapon kung ako'yumihi, she stated. According to her, she sometimes coughs in pain because she hadheart problems. She doesn't pass urine or stool whenever she coughs, sneezes or laughs.

She also mentioned that her bowel movement was regularly 3 times a day, onein each meal. She tries a lot to defecate every each meal. As for the consistency of her stool, she said that, it is slightly soft and normally formed.

When asked, ET said that she doesnt have any problem in controlling with her urination and defecation.


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D. ACTIVITY-EXERCISE PATTERN

As of now, she finds difficulty in completing her desired or required activityeveryday because of her condition. She can still walk around but with limitations and

frequent resting right after an activity.

She mentioned that she doesn't feel weak or fatigued by she easily gets weakevery time she performs her activities. Sometimes she requires assistance from her husband to do her activities. But most of the times she can still do her self careefficiently.

ET narrated that she was a very busy housewife and business woman before.

She and her husband worked together to do all the household chores. Years ago, theysold retail products in different small stores so they didn't have enough time to rest. Sheand her husband usually got very tired after they had delivered all the orders of their costumers. According to her, their daily routines were very stressful and needed somuch effort to be accomplished.

Currently, her only exercise inside the hospital is walking around the hall way.She easily gets tired and her walking is only limited to about three meters in length.

E. SLEEP-REST PATTERN

Patient ET feels rested and has enough energy to do her daily activities. Shedoesn't usually have problem in sleeping, if she feels sleepy, she immediately takes anap and rests in her bed.

Every time she finds it difficult to sleep, she just gets her bible and reads someverses then she prays for her safety and peaceful mind. And after that, according to her,she can now easily get asleep and rested.

U sually, her sleep is not interrupted but now that she is confined in the hospital,she gets awaken most of the time due to vital signs monitoring and medication taking.Sometimes, she also experiences difficulty of breathing and shortness of breath while


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she is sleeping so she can't effectively sleep at night. She said that the reason why sheis experiencing difficulty of breathing is because she has cardiovascular problem.

Every time she dreams, she said that she is always the strong and major

character. She doesn't experience yet to have a nightmare.

F. COGNITIVE - PERCEPTUAL PATTERN

Patient ET is coherent and conscious upon interaction with the student nurses.She responds correctly and attentively to the questions asked to her. She appearsrelaxed and very open to share her thoughts during the interview.

She has no problem in making her decisions whenever she experiences conflictsor problems. Mrs. ET believes that her decisions are guided by God Almighty, so she isvery confident that things would always be fine and things wont go wrong.

She effectively answers the questions asked to her. She also shares her experiences and perceptions on the things that the student nurses want to know abouther.

She doesn't have any problem in her memory. But she has problem in her

movement. Sometimes, she feels body pain and she moves with limitation due to her current condition.

G. ROLES - RELATIONSHIPS PATTERN

ET and her loving husband live together in their house. Her children already havetheir own families. Her husband provides income for their needs.

Before she got sick, she is not just a plain housewife because she still helps her husband in selling retailed products as their source of income. Therefore, upon arrival intheir house, she is already exhausted and tired, but still she always tries to accomplishher responsibilities as the best mother and a good housewife. Sometimes, she finds itvery difficult to shoulder all the tasks and responsibilities in their house. She has noenough time to rest because of so many things to do for her family.


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Her relationship with her relatives is just fine and she has no problem with that.Every time she had her problem, she tried to find some time to discuss it with her husband for them to solve it accordingly.

H. SELF PERCEPTION - SELF CONCEPT PATTERN

Currently, she views her condition as much better than before. She continues torecover from her condition. Mas okay na ang condition ko ngayon kaysa dati, asverbalized by patient ET.

Her perception towards herself changed a lot because of her current condition. According to her, her physique changed and weight is reduced because of her illness.

She usually doesnt get angry whenever she has problem and she always tried tobecome calm to think clearly and decide appropriately.

She didnt experience to lose her hope especially in this kind of situation becauseshe believes that God would help her in all her problems. She also believes that all thethings that are happening to her are all Gods will.

I. COPING STRESS TOLERANCE

ET did not mention any huge crisis in their family except when she wasdiagnosed and suffered from cardiovascular disorder. Although she can cope with thisproblem, she admitted that it was really not that easy.

When asked on her method of resolving conflict with her husband, she said thatshe resolved their problems by talking with her husband and tried to find solutions for their problems.

She is usually calm when she deals with different conflicts and challenges thatcame in her life. And most of the times, she just dont mind those big problems becauseaccording to her, those problems would still have their corresponding solutions.


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J. VALUES BELIEFS PATTERN

ET is a good Born Again Christian who believes in God as her creator and savior.She thinks that religion and her good personal relationship to God is of good help in

solving her problems.

Malaking tulong ang pagiging born again Christian naming mag-asawa, ETstated. Prayer is a powerful weapon in conquering real life battles. At simula noongmaging born again Christian kami malaki na ang pinagbago ng aming buhay, sheadded.

When asked regarding her future plans, she made mention of her children having

their stable job and happy family relationship. She also dreamt of her children to havetheir own family with her grandsons and granddaughters.


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VI. DEFINITION OF COMPLETE MEDICAL DIAGNOSIS

Cardiac Dysrhythmias secondary to Digitalis Toxicity, mitral valve prolapse with

severe Mitral valve regurgitation

The human heart is a hollow muscular organ and is one of the most vital organsin the human body. It is responsible for pumping blood throughout the blood vessels byrepeated, rhythmic contractions. The term cardiac (as in cardiology) means "related tothe heart" and comes from the Greek , kardia, for "heart". The electric energy thatstimulates the heart occurs in the sinoatrial node, which produces a definite potentialand then discharges, sending an impulse across the atria. The Purkinje fibers transmit

the electric charge to the myocardium while the cells of the atrial walls transmit it fromcell to cell, making the atrial syncytium. The heart is an organ but made up of acollection of tissues.

CARDIAC DYSRHYTHMIA

Cardiac dysrhythmia (also known as arrhythmia) is a term for any of a large andheterogeneous group of conditions in which there is abnormal electrical activity in theheart. The heart beat may be too fast or too slow, and may be regular or irregular.

Dysrhythmia is any abnormal cardiac rhythm, including tachyarrhythmia (anincrease in heart rate) and bradyarrhythmia (a decrease in heart rate). Dysrhythmias maybe asymptomatic or symptomatic, causing palpitations, and weakness, loss of consciousness, heart failure, and sudden death. Searching for a reversible cause of thedysrhythmia is the first step in patient care. However, in many cases, antiarrhythmic drugsare necessary to permit stabilization until the underlying condition is normalized. Manypatients require chronic drug therapy for a dysrhythmia due to an underlying diseasecondition that makes them chronically susceptible to cardiac dysrhythmias that areassociated with high morbidity and mortality rates.


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Some arrhythmias are life-threatening medical emergencies that can result incardiac arrest and sudden death. Others cause symptoms such as an abnormalawareness of heart beat (palpitations), and may be merely annoying. These palpitationshave also been known to be caused by atrial/ventricular fibrillation, wire faults, and other technical or mechanical issues in cardiac pacemakers/defibrillators. Still others may notbe associated with any symptoms at all, but may predispose the patient to potentiallylife threatening stroke or embolism.

Some are very minor and can be regarded as normal variants. In fact, mostpeople will on occasion feel their heart skip a beat, or give an occasional extra strongbeat.

It may result from structural or electrical/ conduction system changes in the heart,which may compromise cardiac function and output. Conditions that give rise todysrhythmia include myocardial ischemia, chronic heart failure, hypertension, valvular heart disease, hypoxemia, hypercapnia, thyroid abnormalities, electrolyte disturbances,drug toxicity, excessive caffeine or ethanol ingestion, anxiety, and exercise. Some of these conditions are reversible, and some cause structural changes that are notreversible.

The term cardiac arrhythmia covers a very large number of very differentconditions. The most common symptom of arrhythmia is an abnormal awareness of heartbeat, called palpitations. These may be infrequent, frequent, or continuous. Someof these arrhythmias are harmless (though distracting for patients) but many of thempredispose to adverse outcomes.

Some arrhythmias do not cause symptoms, and are not associated with

increased mortality. However, some asymptomatic arrhythmias are associated withadverse events. Examples include a higher risk of blood clotting within the heart and ahigher risk of insufficient blood being transported to the heart because of weakheartbeat. Other increased risks are of embolisation and stroke, heart failure andsudden cardiac death.


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If an arrhythmia results in a heartbeat that is too fast, too slow or too weak tosupply the body's needs, this manifests as a lower blood pressure and may causelightheadedness or dizziness, or fainting.

Some types of arrhythmia result in cardiac arrest, or sudden death.

Medical assessment of the abnormality using an electrocardiogram is the bestway to diagnose and assess the risk of any given arrhythmia.

Cardiac dysrhythmias are often first detected by simple but nonspecific means:auscultation of the heartbeat with a stethoscope, or feeling for peripheral pulses. Thesecannot usually diagnose specific dysrhythmias, but can give a general indication of the

heart rate and whether it is regular or irregular. Not all the electrical impulses of theheart produce audible or palpable beats; in many cardiac arrhythmias, the premature or abnormal beats do not produce an effective pumping action and are experienced as"skipped" beats.

The simplest specific diagnostic test for assessment of heart rhythm is theelectrocardiogram (abbreviated ECG or EKG). A Holter monitor is an EKG recordedover a 24-hour period, to detect dysrhythmias that may happen briefly and unpredictablythroughout the day.

This can be accomplished in an Electrophysiology study. A minimally invasiveprocedure that uses a catheter to "listen" to the electrical activity from within the heart,additionally if the source of the arrhythmias is found, often the abnormal cells can beablated and the arrhythmia can be permanently corrected.

The method of cardiac rhythm management depends firstly on whether or not theaffected person is stable or unstable. Treatments may include physical maneuvers,medications, electricity conversion, or electro or cryo cautery.

Physical maneuvers: A number of physical acts can increase parasympatheticnervous supply to the heart, resulting in blocking of electrical conduction through the AV


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node. This can slow down or stop a number of arrhythmias that originate above or at the AV node (see main article: supraventricular tachycardias). Parasympathetic nervoussupply to the heart is via the vagus nerve, and these maneuvers are collectively knownas vagal maneuvers.

Antiarrhythmic drugs: There are many classes of antiarrhythmic medications,with different mechanisms of action and many different individual drugs within theseclasses. Although the goal of drug therapy is to prevent arrhythmia, nearly everyantiarrhythmic drug has the potential to act as a pro-arrhythmic, and so must becarefully selected and used under medical supervision.

A number of other drugs can be useful in cardiac arrhythmias. Several groups of drugs slow conduction through the heart, without actually preventing an arrhythmia.These drugs can be used to "rate control" a fast rhythm and make it physically tolerablefor the patient.

Some arrhythmias promote blood clotting within the heart, and increase risk of embolus and stroke. Anticoagulant medications such as warfarin and heparins, andanti-platelet drugs such as aspirin can reduce the risk of clotting.

Dysrhythmias may also be treated electrically, by applying a shock across theheart either externally to the chest wall, or internally to the heart via implantedelectrodes.

Cardioversion is either achieved pharmacologically or via the application of ashock synchronized to the underlying heartbeat. It is used for treatment of supraventricular tachycardias. In elective cardioversion, the recipient is usually sedatedor lightly anesthetized for the procedure.

Defibrillation differs in that the shock is not synchronized. It is needed for thechaotic rhythm of ventricular fibrillation and is also used for pulseless ventricular tachycardia. Often, more electricity is required for defibrillation than for cardioversion. Inmost defibrillation, the recipient has lost consciousness so there is no need for sedation.


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Defibrillation or cardioversion may be accomplished by an implantablecardioverter-defibrillator (ICD).

Electrical treatment of dysrhythmia also includes cardiac pacing. Temporary

pacing may be necessary for reversible causes of very slow heartbeats, or bradycardia,(for example, from drug overdose or myocardial infarction). A permanent pacemaker may be placed in situations where the bradycardia is not expected to recover.

Electrical cautery: Some cardiologists further sub-specialize intoelectrophysiology. In specialized catheter laboratories, they use fine probes insertedthrough the blood vessels to map electrical activity from within the heart. This allowsabnormal areas of conduction to be located very accurately, and subsequentlydestroyed with heat, cold, electrical or laser probes.

This may be completely curative for some forms of arrhythmia, but for others, thesuccess rate remains disappointing. AV nodal reentrant tachycardia is often curable. Atrial fibrillation can also be treated with this technique (e.g. pulmonary vein isolation),but the results are less reliable.

Digoxin toxicity is a poisoning that occurs when excess doses of digoxin (akadigitalis) are consumed acutely or over an extended period of time.

Digoxin toxicity is often divided into acute or chronic. The therapeutic level for digoxin is 0.8-2.0 ng/mL. Low serum potassium increases the risk of digoxin toxicity andcardiac dysrhythmias. The classic arrhythmia is a paroxysmal atrial tachycardia withblock.

Symptoms include fatigue, nausea/vomiting, changes in heart rate and rhythm,loss of appetite (anorexia), diarrhea, visual disturbances (yellow or green halos around

objects), confusion, dizziness, nightmares, agitation, and/or depression, as well as ahigher acute sense of sensual activities.

The primary treatment of digoxin toxicity is digoxin immune Fab. Digoxin shouldnot be given if the apical heart rate is below 60 BPM (beats per minute).


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Other treatments that may be tried to treat life-threatening arrhythmias, untildigoxin Immune Fab is acquired are magnesium, phenytoin, and lidocaine. Atropine isalso used in cases of bradyarrhythmias

DIGITALIS TOXICITY

Digitalis is a medication prescribed to certain heart patients. Digitalis toxicity is acomplication of digitalis therapy, or it may be occur when someone takes more than alarge amount of the drug at one time. (This is called an acute ingestion.)

The most common prescription form of this medication is called digoxin. Digitoxin

is another form of digitalis.Digitalis toxicity can be caused by high levels of digitalis in the body, or a

decreased tolerance to the drug. Patients with decreased tolerance may have "normal"digitalis levels in their blood.

Digitalis toxicity can occur from a single exposure or chronic overmedication, or itmay occur in patients with normal blood levels of digitalis if other risks are present.

People with heart failure who take digoxin are commonly given medicationscalled diuretics, which remove excess fluid from the body. Many diuretics can causepotassium loss. Low levels of potassium in the body increase the risk of digitalis toxicity.Digitalis toxicity may also result in persons who take the drug and who have low levelsof magnesium in the body.

Risks include taking digitalis medications such as digoxin or digitoxin along withmedications that interact with digitalis such as quinidine, verapamil, amiodarone, andothers.

Reduced kidney function will cause digitalis to build up in the body rather than beremoved normally through urine. Therefore, any disorders that disrupt kidneyfunctioning (including dehydration) make digitalis toxicity more likely.


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The symptoms include confusion, irregular pulse, loss of appetite, nausea,vomiting, diarrhea, palpitations, visual changes (unusual), blind spots in vision, blurredvision changes in color perception, halos or rings of light around objects, seeing lights or bright spots

Additional symptoms that may be associated with digitalis toxicity include:decreased consciousness, decreased urine output, difficulty breathing when lying down,excessive nighttime urination and overall swelling

The heart rate may be rapid or slow and may be irregular.

An ECG is done to check for irregular heartbeats. Blood tests will be done to

check: BU

N and creatinine (which help reveal kidney function), Digoxin and digitoxinlevels, Potassium level, and Magnesium level

In an emergency, assist breathing as needed and get professional medical help. Arrhythmias are treated according to which arrhythmia develops.

If toxicity is due to a recent, acute single exposure, treatment may involve: Activated charcoal and tube through the mouth into the stomach to wash out thestomach (gastric lavage)

Digitoxin blood levels may be lowered with repeated doses of charcoal, givenafter gastric lavage.

In severe cases, medications called digoxin-specific antibodies may beprescribed. Hemodialysis may be required to reduce the levels of digitalis in the body.

The outcome varies depending on the extent of toxicity and arrhythmias that

develop.

Possible Complications: Arrhythmias, which may be deadly as well as heartfailure


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prolapse include: Feeling like your heart is racing or is skipping beats, chest pain thatcomes now and then, shortness of breath, dizziness and anxiety or panic.

An echocardiogram is used to determine if there is really a problem in the heart

structures. The echocardiogram provides a picture of the heart that shows the valve asthe blood flows through it.

Most people who have mitral valve prolapse don't need any treatment. Onlyabout 2 of every 100 people who have this condition have complications. The doctor willtell the client if he needs treatment.

Some people who have mitral valve prolapse have to limit participation in

competitive sports. If the mitral valve prolapse causes chest pain or other symptoms,doctor might prescribe medicines such as beta blockers to make your symptoms better.Some people need surgery to fix the valve.

In serious cases of mitral valve prolapse, infection (called bacterial endocarditis)can occur in the valve after surgery or dental work. If a patient has mitral valve prolapse,check with the doctor before dental work (including professional teeth cleaning) or other medical procedures. The doctor may prescribe antibiotics prior to the procedure to

protect against infection.

MITRAL REGURGITATION

Mitral regurgitation is a disorder in which the heart's mitral valve does not closeproperly, causing blood to flow backward (leak) into the upper heart chamber when theleft lower heart chamber contracts. The condition is progressive, which means itgradually gets worse.

Mitral regurgitation is the most common type of heart valve insufficiency. After age 55, some degree of mitral regurgitation is found in almost 20% of men and womenwho have an echocardiogram.


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Blood that flows between different chambers of your heart must flow through avalve. The valve between the two chambers on the left side of your heart is called themitral valve.

Regurgitation refers to leaking from a valve that doesn't close all the way.Diseases that weaken or damage the valve or the heart tissue around the valve causemitral regurgitation.

When the mitral valve doesn't close all the way, blood flows backward into theupper heart chamber (atrium). This leads to a decrease in blood flow to the rest of thebody. As a result, the heart may try to pump harder. This may lead to congestive heartfailure.

Mitral regurgitation may begin suddenly, most often after a heart attack. Whenthe regurgitation does not go away, it becomes chronic (long-term).

Mitral valve prolapse (MVP) is a relatively common cause of chronic mitralregurgitation. However, most patients with MVP do not develop severe mitralregurgitation.

One out of three cases of chronic mitral regurgitation are caused by rheumaticheart disease, a complication of untreated strep throat that is becoming less common.

Congenital (present from birth) mitral regurgitation is most often part of a morecomplex heart defect or syndrome.

Common causes of chronic mitral regurgitation include: Coronary artery diseaseand heart attacks, Endocarditis, Heart tumors, High blood pressure, Marfan syndrome,swelling of the left lower heart chamber, untreated syphilis (rare).

Risk factors include an individual or family history of any of the disordersmentioned above and use of fenfluramine or dexfenfluramine (appetite suppressantsbanned by the FDA) for 4 or more months.


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There are often no symptoms. When symptoms occur, they often developgradually, and may include: Cough, Fatigue, exhaustion, and light-headedness,Palpitations (related to atrial fibrillation), Shortness of breath during activity and whenlying down, andU rination, excessive at night

The doctor may detect a thrill (vibration) over the heart when feeling the chestarea. An extra heart sound (S4 gallop) and a distinctive heart murmur may be heardwhen listening to the chest with a stethoscope. However, some patients may not havethis murmur. If fluid backs up into the lungs, there may be crackles heard in the lungs.

The physical exam may also reveal ankle swelling, enlarged liver, distended neckveins, and other signs consistent with right-sided heart failure.

The following tests may be done: Cardiac color-Doppler study, Cardiaccatheterization, Chest x-ray, CT scan of the chest, ECG, Echocardiogram (anultrasound examination of the heart), Magnetic resonance imaging (MRI), Radionuclidescans, Transesophageal echocardiogram (TEE)

The choice of treatment depends on the symptoms present and the condition andfunction of the heart.

Patients with high blood pressure or a weakened heart muscle may be givenmedications to reduce the strain on the heart and help improve the condition.

Anticoagulant or antiplatelet medications (blood thinners) may be used to preventclots from forming in patients with atrial fibrillation.

Digitalis may be used to strengthen the heartbeat, along with diuretics (water pills) to remove excess fluid in the lungs.

A low-sodium diet may be helpful. Most people have no symptoms; but if aperson develops symptoms, activity may be restricted.

Hospitalization may be required for diagnosis and treatment of severe symptoms.Surgical repair or replacement of the valve is recommended if heart function is poor,


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symptoms are severe, or the condition gets worse. Once the diagnosis of mitralregurgitation is made, you should have regular follow-ups with a specialist to determinewhether you need surgery.

In the past, patients with heart valve problems such as mitral regurgitation weregiven antibiotics before dental work or an invasive procedure, such as colonoscopy. Theantibiotics were given to prevent an infection of the damaged heart valve. However,antibiotics are now used much less often before dental work and other procedures.

The outcome varies based on the underlying conditions. U sually the condition isbenign, so no therapy or restriction is necessary. Symptoms can usually be controlledwith medication. In severe cases, valve repair or valve replacement may be needed.

Complications include: Arrhythmias (abnormal heart rhythms), including atrialfibrillation and lethal arrhythmias, Clots to other areas, Endocarditis (infection of theheart valve), Heart failure, Pulmonary emboli (blood clots in the lungs) and Stroke

Treat strep infections promptly to prevent rheumatic fever. Prompt treatment of disorders that can cause mitral regurgitation reduces your risk.

Any invasive procedure, including dental work and cleaning, can introducebacteria into your bloodstream. The bacteria can infect a damaged mitral valve, causingendocarditis. Always tell your health care provider and dentist if you have a history of heart valve disease or congenital heart disease before treatment.


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VII. ANATOMY AND PHYSIOLOGY AND PATHOPHYSIOLOGY

HEART

The essential function of the heart is to pump blood to various parts of the body.The mammalian heart has four chambers: right and left atria and right and leftventricles. The two atria act as collecting reservoirs for blood returning to the heart whilethe two ventricles act as pumps to eject the blood to the body. As in any pumpingsystem, the heart comes complete with valves to prevent the back flow of blood.Deoxygenated blood returns to the heart via the major veins (superior and inferior venacava), enters the right atrium, passes into the right ventricle, and from there is ejected tothe pulmonary artery on the way to the lungs. Oxygenated blood returning from thelungs enters the left atrium via the pulmonary veins, passes into the left ventricle, and isthen ejected to the aorta.

EXTERIOR OF THE HEART

The heart has four chambers. The right and left atria right and left ventricles.Some of the main blood vesselsarteries and veinsthat make up your bloodcirculatory system are directly connected to the heart


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Right Side of the Heart

After your body's organs and tissues have used the oxygen in your blood, thevena cava carries the oxygen-poor blood back to the right atrium of your heart.The superior vena cava carries oxygen-poor blood from the upper parts of your body,including your head, chest, arms, and neck. The inferior vena cava carries oxygen-poor blood from the lower parts of your body.

The oxygen-poor blood from the vena cava flows into your heart's right atriumand then on to the right ventricle. From the right ventricle, the blood is pumped throughthe pulmonary arteries to your lungs. There, through many small, thin blood vesselscalled capillaries, the blood picks up more oxygen.

The oxygen-rich blood passes from your lungs back to your heart through the

pulmonary veins (in red to the left of the right atrium in the picture).

Left Side of Your Heart

Oxygen-rich blood from your lungs passes through the pulmonary veins (It entersthe left atrium and is pumped into the left ventricle. From the left ventricle, the oxygen-rich blood is pumped to the rest of your body through the aorta.

Like all of your organs, your heart needs blood rich with oxygen. This oxygen issupplied through the coronary arteries as blood is pumped out of your heart's leftventricle.

Your coronary arteries are located on your heart's surface at the beginning of theaorta. Your coronary arteries carry oxygen-rich blood to all parts of your heart.


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INTERIOR OF THE HEART

The SeptumThe right and left sides of your heart are divided by an internal wall of tissue

called the septum. The area of the septum that divides the atria is called the atrial or interatrial septum.

The area of the septum that divides the ventricles (the two lower chambers of your heart) is called the ventricular or interventricular septum.

Heart Chambers

The picture shows the inside of your heart and how it's divided into four chambers. The two upper chambers of your heart are called atria. The atria receive andcollect blood.

The two lower chambers of your heart are called ventricles. The ventricles pumpblood out of your heart into the circulatory system to other parts of your body.


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Heart Valves

Four types of valves regulate blood flow through your heart:y The tricuspid valve regulates blood flow between the right atrium and right

ventricle.

y The pulmonary valve controls blood flow from the right ventricle into thepulmonary arteries, which carry blood to your lungs to pick up oxygen.

y The mitral valve lets oxygen-rich blood from your lungs pass from the left atriuminto the left ventricle.

y The aortic valve opens the way for oxygen-rich blood to pass from the leftventricle into the aorta, your body's largest artery, where it is delivered to the restof your body.

Electrical Activity of the Heart


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When vertebrate muscles are excited, an electrical signal (called an "actionpotential") is produced and spreads to the rest of the muscle cell, causing an increase inthe level of calcium ions inside the cell. The calcium ions bind and interact withmolecules associated with the cell's contractile machinery, the end result being amechanical contraction. Even though the heart is a specialized muscle, thisfundamental principle still applies.

One thing that distinguishes the heart from other muscles is that the heart muscleis a "syncytium," meaning a meshwork of muscle cells interconnected by contiguouscytoplasmic bridges. Thus, an electrical excitation occurring in one cell can spread toneighboring cells. Another defining characteristic is the presence of pacemaker cells.

These are specialized muscle cells that can generate action potentials rhythmically.

Blood Flow

The arrows in the drawing show the direction that blood flows through your heart.The light blue arrows show that blood enters the right atrium of your heart from thesuperior and inferior vena cava.


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From the right atrium, blood is pumped into the right ventricle. From the rightventricle, blood is pumped to your lungs through the pulmonary arteries.

The light red arrows show the oxygen-rich blood coming in from your lungs

through the pulmonary veins into your heart's left atrium. From the left atrium, the bloodis pumped into the left ventricle. The left ventricle pumps the blood to the rest of your body through the aorta.

For the heart to work properly, your blood must flow in only one direction. Your heart's valves make this possible. Both of your heart's ventricles have an "in" (inlet)valve from the atria and an "out" (outlet) valve leading to your arteries.

Healthy valves open and close in very exact coordination with the pumping actionof your heart's atria and ventricles. Each valve has a set of flaps called leaflets or cuspsthat seal or open the valves. This allows pumped blood to pass through the chambersand into your arteries without backing up or flowing backward.


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PATHOPHYSIOLOGY

Inhibition of the sodium-potassiumadenosine triphosphatase

(NA+/K+ ATPase) pump

intracellular calcium (Ca++)

sodium (NA+) intracellular potassium (K+)

contractility

Net Inotropiceffect

Clinical Manifestationsy Irregular pulsey P alpitationsy L ethargyy D izzinessy S hortness of breath

DIGITALIS TOXI C ITY

Precipitating factorsy A gey P ast history of Ac ute Renal Failure

(A RF)y T aking up of Furosemi d e whi c h

lowers potassium levely T aking up of Captopril whi c h further

Predisposing factorsy T aking up of D igitalis

(D igoxin)


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T hose that rea c hthreshol d

S everalac tion

potentials

One a c tion potential

S ustaine d rhythm of

ac tion potentials

Predisposing factorsy D igitalis T oxic ity

Precipitating factorsy A ge (55)y S tress from work

T ransient inwar d c urrent

E nhan c ed or in d uc ed byexc ess D igitalis

A fterpotentials or agter d epolarizations o cc ur


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Sym pto m sy S hortness of breathy Fatiguey L ighthea d ed nessy Coughy H eart palpitationsy S wollen feet or ankles

Clinical m anifestationsy Ed ema on extremitiesy D izzinessy Fatiguey P alpitationsy P aleness of skiny N ec k vein d istentiony Cra c kles on lung soun d sy S hortness of breath

C ARDIA C DYSRHYTH M IA

T reat m enty M ED ICA L:

o P lac ement of an artifi c ial

pace maker (pres c ribe d by

the d oc tor)y P H A R M A :

o P antoprazole(pastmed ic ation)

o A ld ac tone(S pironola c tone

If treated

If not treated

Co m plicationsy heart failurey anginay heart atta c k y strokey sudd en d eath

Preventiony limit c affeine

intakey avoid stressy have plenty of

rest

Co m plicationsy H eart failure (possible)y A trial fibrillation (possible)

GOOD PROGNOSIS

BAD PROGNOSIS

M ITRAL VAL VE

R isk factory A gey Familial

history of heart d iseases

M ITRAL VAL VE

Valve

does notc lose tightly

Bac kwar d flowof the heart


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VIII. LABORATORY AND DIAGNOSTIC STUDIES/ EXAMINATIONS

KIDNEY FUNCTION TEST

DATE LAB. TEST ACTU ALRESU LT

NORMALVALU ES

INTERPRETATIONNU RSING

RESPONSIBILITY

July 21,2010

(BloodU reaNitrogen)

BU N9.3 mmo/L

3.6 7.1mmo/L

High; indicates amoderate-to-severe

degree of renalfailure.

Avoid foods thatare rich in protein

Creatinine 114.2 mEq/L137-145mEq/L

Low; indicates

nothing more thanan efficient andeffective pair of

kidneys;Indicates that thereis a decreased in

muscle mass.

SENSITIVE TEST for a HEART ATTACK


NORMALVALU ES INTERPRETATION

NU RSINGRESPONSIBILITY

July 22,2010

Troponin TTest

negative ----------------------less chances of anacute myocardial

infarction


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HEMATOLOGY

DATE LAB. TEST ACTU AL RESU LT NORMAL VALU ES INTERPRETATIONNU R

RESPON

23, 2010 WBC 6.9 10^9/L 4.3 - 10.8 x 10^9/L Normal

RBC 4.43 x10^12/LMale: 4.7-6.1 x 10^12/L

Female: 4.2 5.4 x10^12/L

normal

HGB 12.9 g/dLMale :14-18 g/dL

Female :12-16 g/dLnormal

HCT 42.5%Male : 42 - 52%

Female : 37 - 47%normal

(MeanCorpuscular

Volume) MCV95.9 fl

Normal Adult Range: 82- 98 fL normal

(MeanCorpuscular Hemoglobin)

MCH

29.1 pg/cellNormal Adult Range:

25.4 - 34.6 pg/cell normal

(MeanCorpuscular Hemoglobin

Concentration)MCHC

30.4 Hb/cellNormal Adult Range: 31

- 36 Hb/cellnormal

(Mean PlateletVolume) MPV

7.9 fL 7.5-11.5 fL normal

RDW 15% 11.5-14.5%High; caused by the

beginning stages of adecrease in vitamin B12

Advise patfoods that folic acids


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or folic acid (a type of vitamin) in the body. Itcan also be caused bythe beginning stages of iron deficiency anemia,

Foods thatiron

PLT 180 150-400 x 10^9/L normal

DIFF. COU NT

Segmenters 58% 54-62% normal

Lymphocytes 29.9% 23-33% normal

Monocytes 6% 3-7% normal

Eosinophils 1.5% 1-3% normal

LIVER FUNCTION TEST


NORMALVALU ES

INTERPRETATIONNU RSING

RESPONSIBILITY

July 24,2010

SGOT 37.9 u/L 0 35 u/LHigh; indicates thereis an inflammation to

the liver

Avoid alcoholicbeverages

Advise patient to beworking closely with

the physician toseek advice for thecondition might not

worse

SGPT 73.4 u/L 3-36 u/LHigh; indicates thereis an inflammation to

the liver


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IX. COURSE IN THE WARD


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X. NURSING CARE PLAN

Day 1

Problem: EASILY GETS TIRED

AssessmentNursing

Diagnosis ObjectiveIntervention

s RationaleEvaluatio

n

Subjective

Cues

y nakaupo nalang palagi.Di akomasyadong

gumagalawkasi madaliakongmapagod,as verbalizedby the pt.

y minsan

nahihirapanakonghumingakahit walangginagawa,as verbalizedby the pt.

y hinahapoako, asverbalized bythe pt.

Objective

y Decreased cardiacoutputrelated toalteredheart

rhythm

After the 8-

hour shift,

the pt. will:

yDemonstratedecreased

episode of dyspnea- RR will

decrease to atleast20cpm

-Will notcomplaindifficultyinbreathing

yDisplay BPstability- BP will

normalize to120/80

Independen

t

y Monitor vital signs

y Positionthe pt. flaton bed

y Promoteadequate

rest bylimitingstimuli tothe ptsactivities

y Avoidactivities,such asisometricexercise,rectal

yMonitoringvital signs isa goodbaselinedata for the

pt.sconditionyLying flatwill allowlessworkload for the heart

whichpromotesbetter circulationyDecreasingstimuliprovides thept.s heartrest whichdecreasesthe workloadof the heartyValsalva

y Observept. for any signsof dyspnea

y Check

vital signsregularly.

Asfrequentas whatthedoctor

orderedy Reassess skinespeciallythe handsif stillclammy.Recheckcapillaryrefill timeif it is still> 3 sec


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Cues

y Laboredbreathing

y Cold clammyskin

y IncreasedRR=31cpm

y LowBP=90/60mmgH

y Pulse weak

and irregular y Decreasedalertness

y Slowcapillary refill(>3sec)

mmHgyMaximizecardiacoutput- Skin will

be warm& dry

- Capillaryrefill willnormalize to < 2

sec

stimulation,vomiting,spasmodiccoughing,which maystimulatevalsalvaresponse

responsecan bedangerousfor pts. withcardiovascular problem.This canincrease theviscosity inthe bloodwhich can

putadditionalstrain to theheart


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Day 2

Problem: DECREASED SENSATION OF THE FEET

AssessmentNursing

Diagnosis Objective

Intervention

sRationale Evaluation

Subjective

Cues

y Namamanhid yung paako, asverbalizedby the pt.

y Namamanas yungparehongpaa ko, asverbalizedby the pt.

Objective

Cuesy (+) edema

on both feetand legs

y Capillary

y Ineffectiveperipheraltissueperfusionrelated todiminishe

d bloodflow

After the

8-hour

shift, the

pt. will:

y Haveincreased

sensationon feet

y Consistenttemperature onboth

handsand feet

y Have atmost 2seconds

y Monitor vitalsigns

y Discouragesitting/standing for long

hours

y Performassistive

range of motionexercises

yMonitoringvital signs is agood baselinedata for thept.s conditionySitting/standing for long

hours willincrease therisk of developingdeep veinthrombosisespecially to

those whohavediminishedperipheralperfusion

y Ask pt.for anyincreaseinsensation

y Palpate

feet andlegs for anychangein thetemperature and

strengthof pulse

y Checkcapillaryrefill


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Subjective

Cues

y Medyonanlalamigyung paako, asverbalizedby the pt.

y Madalaslang akonakaupo o

kayanakahigakasi madaliakonghapuin, asverbalizedby the pt.

ObjectiveCues

y AxillaryTemp =34.4C(belownormal)

y Capillaryrefill > 3sec

y Weakpulses onboth feet

y Hypothermia related toinactivity

After the 8-

hour shift,

the pt. will:

y Displayan axillarytemperaturebetween36 37C

y Havewarmer

skin onbothhandsand feet

y Have atmost 2seconds

capillaryrefill onher fingernails andtoenails

y Monitor vital signs

y Check andmaintain dryclothing

y Cover thept. withblanket andmaintainwarmth

throughoutthe shift

y Performassistiverange of motionexercisesevery shift

yMonitoringvital signs isa goodbaselinedata for thept.sconditionyMaintaining dryclothes willprevent

evaporationof theperspirationon the skinwhichcauses acooling

effect thatcan further decreasethe ptstemperatureyTheblanket willprovide aninsulator that canconservethe ptsbody heat

y Checkthe ptstemperatureevery 15minutesas wellas thepatientsvitalsigns

y Checkcapillaryrefill fromtime totime

y Palpatefeet and

legs for anychangein thetemperature andstrengthof pulse


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y Pale skiny Cooler

hands andfeet

and preventfurther heatlossthroughconvectionyPerformingassistiverange of motionexerciseswill

increasecirculationwhich will insome wayincreaseher bodyscirculation


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XI. DRUG STUDY

SIDE EFFECTS/ADVERSE EFFECTS NURSING CONSIDERAT

y low blood pressurey dizziness.

y Name confusion has occurred betweextreme caution

y Push the drug slowly over a period oit causes arrhymias if pushed too fas

y Check BP before giving the drug to mthe decrease in fluid volume

y Do not give if BP is < 90/60mmHg

Generic NameDose/

FrequencyRoute Classification Indication

Mechanism of

Action Contr

Lasix 40 mg q120 IV Loop Diuretic y Edema associatedwith heart failure,cirrhosis, renaldisease

y Inhibitsreabsorption of sodium andchloride from theproximal anddistal tubules andascending limb of the loop of

Henle, leading toa sodium-richdiuresis

y Cowifursualltarsosev

faicolac

y Dois

Generic NameDose/


Mechanism of

Action Contra

Zocor 20 mg 1tab/OD @

Oral Anti -hyperlipidemic

y To reduce the risk of coronary disease,

y Inhibits HMG CoA

y Conwith


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y headache, nauseay Liver damage

y Ensure that the patient has tried a ch3-6 mos before beginning therapy

y Give in the evening; highest rates ofmidnight and 5 in the morning

yAdvise patient that this drug cannot patient to use barrier contraceptives

y Arrange for regular follow-up duringreducing dose if cholesterol falls bel

hour sleep mortality and CVevents including, CVAand MI and reductionin need for bypasssurgery andangioplasty in patientswith coronary heartdisease andhypercholesterolemia

reductase, theenzyme thatcatalyzes thefirst step in thecholesterolsynthesispathway,resulting in adecrease inserumcholesterol,serum LDLsand either an

increase or nochange inserum HDLs

simbyppreglact

y

Useimp

fun

Generic

Name

Dose/

FrequencyRoute Classification Indication Mechanism of Action

Co

Capoten 25mg tab/TID 8 a.m.1 p.m. & 6p.m.

Oral Anti -hypertensive

y Treatment of hypertensionalone or incombinationwith thiazide-type diuretics

y Blocks ACE fromconverting angiotensin Ito angiotensin II, apowerfulvasoconstrictor, leadingto decreased blood

y

y


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ydizziness, light-headednessy change in the amount of urine

y trouble breathing

yAdminister 1 hr before or 2 hr after y Alert surgeon and mark patient's chataken; the angiotensin II formation srelease during surgery wil be blockewith volume expansion.

y Monitor patient closely for fall in BPvolume (excessive perspiration and excessive hypotension may occur.

y Reduce dosage in patients with imp

y U se cautiously when given with digaction of digoxin which can lead to

pressure, decreasedaldosterone secretion, asmall increase in serumpotassium levels, andsodium and fluid loss;increased prostaglandinsynthesis also may beinvolved in theantihypertensiveaction.

Generic NameDose/


Mechanism of

Action Contr

Spironolactone 25mg 1tab/BID 8

Oral Potassium Sparing Diuretic

y Adjunctive therapy inedema associated

y Competitivelyblocks the

y Cowi


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a.m. & 6 p.m. with heart failure,nephritic syndrome,hepatic cirrhosis whenother therapies areinadequate or inappropriate

y Treatment of hypokalemia or prevention of hypokalemia inpatients who wouldbe at high risk if hypokalemia

occurred; patientswith cardiacarrhythmias

effects of aldosterone inthe renaltubule, causingloss of sodiumand water andretention of potassium

sphyrenanor

SIDE EFFECTS/ADVERSE EFFECTS NURSING CONSID

y Headache, diarrhea, drowsiness, nausea y Give early doses early so that iwith sleep

y Measure and record regular wefluid

y Avoid giving food rich in potasy Arrange for regular evaluation y Monitor I and Oy U sed with other diureticsy Give with meals


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XII. PROGNOSES/ EVALUATION

CRITERIA POO

R

FAIR GOO

D

JUSTIFICATION

Health Perception- HealthManagement

Patient can maintain stablecondition but cannot prevent theoccurrence of illness. She wasadmitted in the hospital onlytwice.

Nutrition/ Metabolism Patient had a mild problem innutrition and metabolism

because of her current condition.She still had a good appetite butnot the same as before she wasadmitted in the hospital. She atefruits and vegetables in very littleamounts.

Activity/ Exercise

She is not doing regular

exercises but now, she is able towalk in the hallway of thehospital. As of now, she can nowmove with strength but still withlimitations because sometimesshe experiences shortness of breath and difficulty of breathing.

Elimination

Patient had no problem inurination and defecation. Thecontrol of frequency was stillnormal and regular.

Sleep/ Rest Patient had a change in her sleeping pattern but she has no


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big problem with it. She slept andrested for about 4-6 hours everyday with some interruptionsbecause of vital signs monitoringand medication taking. She hasno problem in maintaining sleep.

Coping/ Stress

Patient was slightly able to copewith her problems. She handlesher problems by talking about itand giving her full trust to God tohelp her in solving her problems.

Even though she has so manyproblems, she is always calm indealing with them.

Sexuality Patient is not already sexuallyactive because their children arealready old and have their ownfamilies. There is no problem in

sexual aspect of the patient.Self Perception Patient perceived her conditionas not the same with what shewas before. But she hoped thatshe will be able to recover in thiscondition. And currently, her condition progresses so slowlybecause they dont have enoughmoney to buy all thosecardiovascular drugs that her physician prescribed her.

Cognitive Patient was coherent andknowledgeable about what is


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happening around her and her condition. She was also able toidentify important factors thatmade her condition like this.

Roles/ Relationships

Patient had strong bondingrelationship with her husband,children, relatives and her neighbors. Her family was alwaysthere for her condition.

Values/ Beliefs

Patient together with her familyhas strong faith in their beliefs.

They always thank the Lord for giving her this wonderful life andshe is thankful because her condition still improves even soslow. They also consideredreligion as a very good help inher recovery. She still had a good

vision for her children andgrandchildren.*** - Mark of choice

In general the prognosis and evaluation of the patient's condition is fair because of the ratings in the different criteria stated above. The patient is now inthe treatment phase and the medical health team is trying to prevent further complications of her condition. As evaluation, her condition continuouslyimproves in slow rate and compared to her condition (before she was admitted inthe hospital), her condition now is much better. Her problem also decreases asdays go by and the development of better condition of the patient was seenduring the course of interaction and collaborated health care management andindividualized interventions.


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XIII. DISCHARGE PLAN

y MedicationAdvice the patient to take the prescribed drug at the righttime, dosage, frequency, and duration. Complying medicinesaccording on how it is prescribed will aid in faster recoveryand may avoid further possible complications of the disease.

y ExerciseAdvice to have enough and proper rest and exercise to aid ingood blood circulation and increase the daily activity level.Educate and warn the client about the effects of high level of

stress to her condition.y Treatment

Advice not to smoke, not to use illegal drugs or not to abuseprescribed stimulant medications, and to continue not to takecaffeine and alcohol because these may lead to morecomplicated condition.

y Hygiene

Educate the patient regarding the importance of havingproper hygiene and how it will prevent many diseases.Encourage to observe cleanliness in their surroundings for prevention of other infection-related problems that mayworsen her condition.

y Outpatient Orders/Follow upsEncourage the patient to go to the scheduled date of followup check up. Compliance for follow up check up will behelpful in monitoring the condition of the client.Reduce risk factors a number of factors increase your riskof developing heart disease. Reducing or eliminating theserisk factors can be helpful to prevent further complications.


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y DietMineral balance plays an important role in regulatingheartbeat. Diet high in fish oil (omega-3 fatty acids) helpsreduce the likelihood of fatal heart arrhythmia sometimesassociated with heart attack.Stick to herbal brews.Encourage to increase consumption of foods rich in vitaminC to boost the immune systemIn maintenance, patient must be encouraged to consumeenough magnesium in her diet to live long and healthy.


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XIV. BIBLIOGRAPHY

y http :// en.wikipe d ia.org /wiki / M itral_valve_prolapse y http :// www.mayo c lini c .c om / health / mitral-valve-regurgitation /DS00421

y http :// en.wikipe d ia.org /wiki /Car d iac _ d ysrhythmia y http :// eme d ic ine.me d sc ape. c om /artic le/1 54336 -overview y http :// en.wikipe d ia.org /wiki / M itral_valve_prolapse y http :// www.heart-valve-surgery. c om / mitral-valve-regurgitation-symptoms-

leaking.php

cardiac dysrhthmia secondary to digitalis toxicity, mitral valve prolapse with severe mitral...

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