PHILIPPINES COLLEGES of HEALTH & SCIENCES

AFPMC V. Luna General Hospital

Medical Intensive Care Unit (MICU)
NMC 204 (2 008 - 2009)

CASE STUDY: MYOCARDIAL INFARCTION

GROUP D1

BELTRAN, JHON MARC

MARIANO, RYAN
TADIFA, JOLEEN

MR. EPHRAIM MIRAFUENTES

Clinical Instructor
 I. Introduction

An intensive care unit (ICU), also sometimes known as a critical care unit or an
intensive therapy department is a special ward found inside most hospitals. It
provides intensive care (treatment and monitoring) for people who are in a critically
ill or unstable condition. Patients in ICUs need constant medical support to keep
their body functions going. They may not be able to breathe on their own, and
may have multiple organ failure, so medical equipment takes the place of these
functions while they recover.There are several circumstances in which a person may
be admitted to intensive care, for example, following surgery, or after an accident or
severe illness. ICU beds are a very expensive and limited resource because they
provide specialized monitoring equipment, a high degree of medical expertise and
constant access to highly trained nurses (usually one nurse for each bed). Being in an
ICU can be a daunting experience both for the patient and his or her friends and
family. The healthcare professionals in ICUs understand this and are there to help and
support both patients and their families during their time in intensive care.
 Myocardial infarction (MI) is the irreversible necrosis of heart muscle
secondary to prolonged ischemia. This usually results from an imbalance of
oxygen supply and demand. The appearance of cardiac enzymes in the
circulation generally indicates myocardial necrosis. MI is considered, more
appropriately, part of a spectrum referred to an acute coronary syndromes
(ACSs), which also includes unstable angina and non–ST-elevation MI
(NSTEMI). Patients with ischemic discomfort may or may not have ST-
segment elevation. Most of those with ST-segment elevation will develop Q
waves. Those without ST elevations will ultimately be diagnosed with
unstable angina or NSTEMI based on the presence of cardiac enzymes. MI
may lead to impairment of systolic function or diastolic function and to
increased predisposition to arrhythmias and other long-term complications.
b. General Objective
1. Describe Critical Care as a collaborative, holistic
approach that includes the patient, family and significant
others

2. Established priority critical measures instituted for

any patient with a critical conditions.

3. Differentiate, describe, and specify critical care

measures and management for admission due to
coronary artery disease (Myocardial infarction).

4. Use of multidisciplinary Team to find simple solution.

5. Have knowledge on safe drug administration

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

6. Evaluate the patient’s condition and provide nursing

care according to the identified needs, report unusual
manifestation/ findings and complication.
c. Importance of the study
1.  Explain cardiac physiology in relation to cardiac
anatomy and the conduction system of the
heart. Describe the essential components of heart
anatomy and physiology to include path of blood flow,
the role of arteries, veins, and capillaries.
2. Incorporate assessment of functional health patterns
and risk factors into the health history and physical
assessment of the patient with coronary artery
disease.
3. Outline and define the physiologic/Pathophysiology
sequence of events that lead to an acute myocardial
infarction (AMI).
4.  List the critical parameters of assessment and
treatment emergency responders must perform when
first attending to a patient with an acute myocardial
infarction.
5. Describe the information each of the following tests
provide an critical care with physician or cardiac
specialist when presented with a patient with a
suspected AMI.
6. Define the following as to their prevention or
treatment of an MI.
7.  Describe the key roles the following health
II. Data
Base
a. Client’s Profile

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

Address: # 405TNR, FTI Compound, Western Bicutan, Taguig City
Birthday: October 2, 1937 Birthplace: Bohol
Religion: 7 Day Adventist Status: Married
TH

Race: Filipino Reg. #: 901668

Admitted to E.R.: March 4, 2009, assisted by Maj. Benejane.

Chief Complaint: Right side body weakness

Diagnosis: Nosocomial Pneumonia; CAD, ACS, NSTMI, Killip II, HCVD, FC II,
Intracerebral he, (L) Basal Ganglia with intraventricular extension

Transferred to M.I.C.U.: March 7, 2009

Room #: 5 Rank: C/V/T
b. History

1. History of Present Illness

The patient was not able to get up at early morning, as they notice. Then
after two hours he had vomited episodely and cramping, so, their relatives
rush up at Fort Santiago General Hospital. Then, they transferred at AFPMC
V.Luna, around 10:00 AM.
2. Past Medical History
He have a high blood pressure, not complaining for almost 10 years, he
only taking the drugs that given to him since the last consultation.
3. Family Medical History
He had history of hypertension and diabetes mellitus on paternal side.
4. Social History
According to his wife, he used to smoke 8-10 sticks per day but he
occasionally drinks any liquor. He sleeps 5-6 hours a day, irregular
habit time of sleep.
5. 11 Functi onal Heal th
Patter n (Gor do ns) in
NAND A
1. Health perception-Health Management Pattern
The patient was never ask a consultation at the Physician as
long as he can stand alone and can walk. Until he woke up
with vulnerable condition, the reason to seek a health
management.
2. Nutritional-Metabolic Pattern
He doesn’t care, too much, what should be the food to be
intake, and what not should be, too. He always telling his
wife “ano na lang ang kakainin ko?!”. And now he is feeding
thru NGT with low salt, low cholesterol and 1,800kCal.
3. Elimination Pattern
He used to commode at least once a day before he admit
MICU, according to his wife. The physician ordered a
Lactulose 30 cc to help him in bowel movement.
4. Activity-Exercise Pattern
The patient working as a carpenter, before his condition
getting bad. At the MICU, helping the patient turning side-
to-side every two hours, as ordered by the physician, and do
the passive R.O.M.
5. Sleep-Rest Pattern
According to his wife, he sleep for almost 5-6 hour with
 6. Cognitive-Perceptual Pattern
He perform self-care within the level of ability to do the ADL and other activity.
Since he got an Intracerebral hemorrhage, he had disturbed perceptual abilities
due to his illness.
7. Self-Perception/self-concept Pattern
He took a healthy body for granted, a kind of denial of the eventuality of aging
and illness. Due to the threats to self-concepts about the self these condition may
pose.
8. Role-Relationship Pattern
He was hard worker and good father to his family. Because of his condition, he is
now lying at room # 5, MICU. His family involved in decision making processes
directed at appropriate solution for the situation crisis
9. Sexuality-reproductive Pattern
He had children by their own. Since, he got CAD, less frequency and satisfaction
of their sexual activity.
10. Coping-Stress Tolerance Pattern.
When the patient felt stress, he used to smoke. Although he know there is other way to
move the stress away.
11. Value-belief Pattern
They do visit their church together with their family aside from his son, working on
weekends. All we know, Adventist should not eat pork, but he still doing it.
Physical Assessment
1. Physical Assessment (head-to-toe)
General Survey:
Vital Signs BP – 110/80 RR - 40
Temp. 37.4˚C PR – 101 bpm
Unconscious patient lying on bed, with the position of
semi-fowlers
Integument
Cold skin, from the body to lower extremity.
The head, right and left arm are enough heat skin.
Nails, delayed refill capillary
Moist skin on his face and neck
Head and neck
Skull and face, shape symmetry
Neck, no presence of contusions.
Eyes, yellow conjunctiva, unequal pupil 2-3 mm pupil on
left
and 3-4 pupil on right
Ears, lesion on auricle of the Left ear
Nose, nasal flaring, placing an NGT (French 18) on his
Left.
Mouth, placing an Endotracheal tube with 7.0, plastering
on his right lips; dry lips, yellowish teeth
Chest
RR- 40 auscultated chest with crackles sounds
Extra sounds on Heart sounds
Abdomen, no contour, no lesions
Apical pulse rate: 101 bpm
Extremity
Left arm infused IV Fluid
Right arm, no muscle tone, no strength muscle, +1 edema scale
Left and Right leg, are pale, cold & dry skin, delayed capillary refill
Genito Elimination
Urine, yellow-orange, 200 cc at 4 hours.
Bowel, no bowel movements
Neurological
Glasgow Coma Scale: total score of 6
Eye: 2, he slightly his upper eyelid on pain
Motor: 3, flexes abnormally
Verbal: 1, no response
Level of conciousness: comatose
 2. Diagnostic procedure done, and
possible to be done to the
patient
Persistent chest pain, ST- segment changes on
the electrocardiogram (ECG), and elevated levels
of total creatinine kinase (CK) and the CK-MB
isoenzyme over a 72 hour usually confirm an MI.
Cardiac troponins are useful in differentiating an
MI from skeletal muscle injury, or when CK-MB
measurements are low and a small MI has
actually occurred. Auscultation may reveal
diminished heart sounds, gallops, and, in
papillary dysfunction, the apical systolic murmur
of mitral valve area. When signs and symptoms
are equivocal, assume that the patient has had
an MI until tests rule it out. Diagnostic test results
 Serial 12-lead ECG: ECG abnormalities may be absent or
inconclusive during first few hours following an MI. When present,
characteristics abnormalities include serial ST-segment depression
in subendocardial MI and ST-segment elevation in a transmural MI.
 Coronary Angiography: visualization reveals which vessels have
been affected and the extent of damage.
 Serial serum enzyme levels: CK levels are elevated ; specifically,
CK-MB or troponin levels.
 Myoglobin: because myoglobin always rises within 3-6 hours after
an MI, lack of an increase within 6 hours indicates that an MI
hasn’t occurred.
 Echocardiography: may show ventricular-wall motion
abnormalities in patients with a transmural MI.
 Nuclear ventriculography (multigated acquisition scan or
radionuclide ventriculography) scanning: Nuclear scanning can
identify acutely damaged muscle by picking up radioactive
nucleotide, which appears as a “hot spot” on the film. It’s useful in
localizing a recent MI.
 Chest X-ray: venous congestion, cardiomegaly, and kerley’s B
lines
 Cardiac catheterization: show decrease cardiac output, increase in
Pulmonary arterial pressure, pulmonary artery wedge pressure
and central venous pressure.
Anatomy

1. Right Coronary
2. Left Anterior Descending
3. Left Circumflex
4. Superior Vena Cava
5. Inferior Vena Cava
6. Aorta
7. Pulmonary Artery
8. Pulmonary Vein
9. Right Atrium
10. Right Ventricle
11. Left Atrium
12. Left Ventricle
13. Papillary Muscles
14. Chordae Tendineae
15. Tricuspid Valve
16. Mitral Valve
 Coronary Arteries. Because the heart is composed primarily of
cardiac muscle tissue that continuously contracts and relaxes, it
must have a constant supply of oxygen and nutrients. The
coronary arteries are the network of blood vessels that carry
oxygen- and nutrient-rich blood to the cardiac muscle tissue. The
blood leaving the left ventricle exits through the aorta, the body’s
main artery. Two coronary arteries, referred to as the "left" and
"right" coronary arteries, emerge from the beginning of the aorta,
near the top of the heart. The initial segment of the left coronary
artery is called the left main coronary. This blood vessel is
approximately the width of a soda straw and is less than an inch
long. It branches into two slightly smaller arteries: the left
anterior descending coronary artery and the left circumflex
coronary artery. The left anterior descending coronary artery is
embedded in the surface of the front side of the heart. The left
circumflex coronary artery circles around the left side of the heart
and is embedded in the surface of the back of the heart. Just like
branches on a tree, the coronary arteries branch into
progressively smaller vessels. The larger vessels travel along the
surface of the heart; however, the smaller branches penetrate the
heart muscle. The smallest branches, called capillaries, are so
narrow that the red blood cells must travel in single file. In the
capillaries, the red blood cells provide oxygen and nutrients to the
cardiac muscle tissue and bond with carbon dioxide and other
metabolic waste products, taking them away from the heart for
disposal through the lungs, kidneys and liver. When cholesterol
plaque accumulates to the point of blocking the flow of blood
through a coronary artery, the cardiac muscle tissue fed by the
coronary artery beyond the point of the blockage is deprived of
oxygen and nutrients. This area of cardiac muscle tissue ceases to
function properly. The condition when a coronary artery becomes
blocked causing damage to the cardiac muscle tissue it serves is
 Aorta. The aorta is the largest single blood vessel in the body. It is approximately the diameter
of your thumb. This vessel carries oxygen-rich blood from the left ventricle to the various
parts of the body.
 Pulmonary Artery. The pulmonary artery is the vessel transporting de-oxygenated blood from
the right ventricle to the lungs. A common misconception is that all arteries carry oxygen-rich
blood. It is more appropriate to classify arteries as vessels carrying blood away from the heart.
 Pulmonary Vein. The pulmonary vein is the vessel transporting oxygen-rich blood from the
lungs to the left atrium. A common misconception is that all veins carry de-oxygenated blood.
It is more appropriate to classify veins as vessels carrying blood to the heart.
 Right Atrium. The right atrium receives de-oxygenated blood from the body through the
superior vena cava (head and upper body) and inferior vena cava (legs and lower torso). The
sinoatrial node sends an impulse that causes the cardiac muscle tissue of the atrium to contract
in a coordinated, wave-like manner. The tricuspid valve, which separates the right atrium from
the right ventricle, opens to allow the de-oxygenated blood collected in the right atrium to
flow into the right ventricle.
 Right Ventricle. The right ventricle receives de-oxygenated blood as the right atrium contracts.
The pulmonary valve leading into the pulmonary artery is closed, allowing the ventricle to fill
with blood. Once the ventricles are full, they contract. As the right ventricle contracts, the
tricuspid valve closes and the pulmonary valve opens. The closure of the tricuspid valve
prevents blood from backing into the right atrium and the opening of the pulmonary valve
allows the blood to flow into the pulmonary artery toward the lungs.
 Left Atrium. The left atrium receives oxygenated blood from the lungs through the pulmonary
vein. As the contraction triggered by the sinoatrial node progresses through the atria, the
blood passes through the mitral valve into the left ventricle.
 Left Ventricle. The left ventricle receives oxygenated blood as the left atrium contracts. The
blood passes through the mitral valve into the left ventricle. The aortic valve leading into the
aorta is closed, allowing the ventricle to fill with blood. Once the ventricles are full, they
contract. As the left ventricle contracts, the mitral valve closes and the aortic valve opens. The
closure of the mitral valve prevents blood from backing into the left atrium and the opening of
the aortic valve allows the blood to flow into the aorta and flow throughout the body.
 Papillary Muscles. The papillary muscles attach to the lower portion of the interior
wall of the ventricles. They connect to the chordae tendineae, which attach to the
tricuspid valve in the right ventricle and the mitral valve in the left ventricle. The
contraction of the papillary muscles opens these valves. When the papillary
muscles relax, the valves close.
 Chordae Tendineae. The chordae tendineae are tendons linking the papillary
muscles to the tricuspid valve in the right ventricle and the mitral valve in the left
ventricle. As the papillary muscles contract and relax, the chordae tendineae
transmit the resulting increase and decrease in tension to the respective valves,
causing them to open and close. The chordae tendineae are string-like in
appearance and are sometimes referred to as "heart strings."
 Tricuspid Valve. The tricuspid valve separates the right atrium from the right
ventricle. It opens to allow the de-oxygenated blood collected in the right atrium to
flow into the right ventricle. It closes as the right ventricle contracts, preventing
blood from returning to the right atrium; thereby, forcing it to exit through the
pulmonary valve into the pulmonary artery.
 Mitral Value. The mitral valve separates the left atrium from the left ventricle. It
opens to allow the oxygenated blood collected in the left atrium to flow into the
left ventricle. It closes as the left ventricle contracts, preventing blood from
returning to the left atrium; thereby, forcing it to exit through the aortic valve into
the aorta.
 Pulmonary Valve. The pulmonary valve separates the right ventricle from the
pulmonary artery. As the ventricles contract, it opens to allow the de-oxygenated
blood collected in the right ventricle to flow to the lungs. It closes as the ventricles
relax, preventing blood from returning to the heart.
 Aortic Valve. The aortic valve separates the left ventricle from the aorta. As the
ventricles contract, it opens to allow the oxygenated blood collected in the left
ventricle to flow throughout the body. It closes as the ventricles relax, preventing
blood from returning to the heart.
PHYSIOLOGY
 The heart is the muscular organ of the
circulatory system that constantly pumps blood
throughout the body. Approximately the size of
a clenched fist, the heart is composed of
cardiac muscle tissue that is very strong and
able to contract and relax rhythmically
throughout a person's lifetime. The heart has
four separate compartments or chambers. The
upper chamber on each side of the heart, which
is called an atrium, receives and collects the
blood coming to the heart. The atrium then
delivers blood to the powerful lower chamber,
called a ventricle, which pumps blood away
from the heart through powerful, rhythmic
contractions.
 The human heart is actually two pumps in one.
The right side receives oxygen-poor blood from
the various regions of the body and delivers it to
the lungs. In the lungs, oxygen is absorbed in
the blood. The left side of the heart receives the
oxygen-rich blood from the lungs and delivers it
to the rest of the body.
 Systole. The contraction of the cardiac muscle
tissue in the ventricles is called systole. When
the ventricles contract, they force the blood
from their chambers into the arteries leaving
the heart. The left ventricle empties into the
aorta and the right ventricle into the pulmonary
artery. The increased pressure due to the
contraction of the ventricles is called systolic
pressure.
 1. Sinoatrial node (SA
 The Sinoatrial Node (often node)
called the SA node or sinus 2. Atrioventricular node
node) serves as the natural (AV node)
pacemaker for the heart.
Nestled in the upper area of the 3. Common AV Bundle
right atrium, it sends the 4. Right & Left Bundle
electrical impulse that triggers Branches
each heartbeat. The impulse
spreads through the atria,
prompting the cardiac muscle
tissue to contract in a
coordinated wave-like manner.
 The impulse that originates
from the sinoatrial node strikes
the Atrioventricular node (or AV
node) which is situated in the
lower portion of the right
atrium. The atrioventricular
node in turn sends an impulse
through the nerve network to
the ventricles, initiating the
same wave-like contraction of
the ventricles.
 The electrical network serving
the ventricles leaves the
atrioventricular node through
the Right and Left Bundle
Branches. These nerve fibers
send impulses that cause the
cardiac muscle tissue to
contract.
A. Laboratory Result
and significant
HEM AT OLO GY
Significances:
 Hematology:
Hgb: still at normal ranges.
Hct: acute massive blood loss
RBC: decreasing due to side effects of the drugs.
WBC: Increasing due to immunocompromised, immune
responses.
Platelet: increasing the fibrin that attract the platelet to
increased
Blood indices:
MCHC: decreased in severe hypochromic anemia.
 Coagulation:
Bleeding time: defective in platelet function
INR: prolonged in deficiency of fibrinogen; used to
standardized the prothrombin time and anti- coagulation
therapy.
 Serum enzyme levels:
Na+ : decreased; myxedema
K+ : decreased; GI losses, Vitamin D Deficiency
Cl+ : decreased; pneumonia, febrile condition.
Creatinine: decreased; check the status of the kidney
Troponin: negative; if increased the patient may experience
myocardial infarction.
IV. Pathophysiology
& Schematic Diagram
In an MI, an area of the myocardium is permanently destroyed; a condition in which the
blood supply to the heart muscle is partially or completely blocked. The heart muscle
needs a constant supply of oxygen-rich blood. The coronary arteries, which branch off the
aorta just after it leaves the heart, deliver this blood. MI is usually caused by the reduced
blood flow in a coronary artery of an atherosclerotic plaque and subsequent occlusion of
the artery by a thrombus. Coronary artery disease can block blood flow, causing chest
pain. In unstable angina and acute MI are considered to be the same process but different
appoints along a continuum. specifically coronary atherosclerosis (literally “hardening of
the arteries,” which involves fatty deposits in the artery walls and may progress to
narrowing and even blockage of blood flow in the artery., As an atheroma grows, it may
bulge into the artery, narrowing the interior (lumen) of the artery and partially blocking
blood flow. With time, calcium accumulates in the atheroma. As an atheroma blocks more
and more of a coronary artery, An atheroma, even one that is not blocking very much
blood flow, may rupture suddenly. The rupture of an atheroma often triggers the formation
of a blood clot (thrombus), the supply of oxygen-rich blood to the heart muscle
(myocardium) can become inadequate. The blood supply is more likely to be inadequate
during exertion, when the heart muscle requires more blood. An inadequate blood supply
to the heart muscle (from any cause) is called myocardial ischemia. If the heart does not
receive enough blood, it can no longer contract and pump blood normally. Other causes of
MI include vasospasm, (sudden constriction or narrowing) of a coronary artery, decreased
oxygen supply (e.g. from acute blood loss, anemia, or low blood pressure), and increased
demand for oxygen (e.g. rapid heart rate, thyrotoxicosis, or ingestion of cocaine). In each
case, a profound imbalance exists between myocardial oxygen supply and demand. The
area of infarction develops over minutes to hours. As the cells are deprived of oxygen,
ischemia develop, cellular injury occurs,, and the lack of oxygen results in infarction, or
the death of cells. The area of the heart muscle supplied by the blocked artery dies.
 Aging
#1

Smoking

Genetic
Predisposition
DRUG
STUDY
NURSING
CARE
MNGT.
 a. Pr obl em Li st

 secretion blocking the airway of

intubation tube for his oxygenation
 adventitious sounds (crackles) on his
chest
 shortness ob breath, increasing the
Respiratory rate and pulse rate
 cool and pale skin, moisten skin on
upper part of the body
 physical immobilization
3 ACTUAL PROBLEM
 ASSESSMENT NURSING PLAN OF CARE INTERVENTION RATIONALE EVALUATION
DIAGNOSI
S
Subjective: Ineffective The patient will initially assess, assist in After rendering of
“hindi normal cardiac alleviate document, and determining nursing
yung vital tissue and report to the cause and intervention, the
physician the effect of the
signs niya” as perfusion appears chest
patient had
following: the
verbalized by related to comfortabl discomfort appears
patient’s
the relative of reduced e and is and provide a comfortable and is
description of
the patient. coronary free of pain chest baseline data free from pain.
Objective: blood flow. and other discomfort, the
for Blood pressure is
Auscultated heart sign and characteristic 110/80.
effect of it on s findings of
have extra symptoms: cardiovascular Temperature of
ischemic pain
sound respiratory perfusion 37.1˚C. But the RR
and
shortness of breath rate, change in blood 40 and PR 101
symptoms.
cool & pale skin cardiac bpm are still
pressure and
rate, and heart sounds, An ECG compensating to
blood changes in LOC, during maintain cardiac
pressure decrease in symptoms output. The goal is
return to urine output may be partially met.
prediscomf useful in the
and to the skin
diagnosis of
ort level. temperature, an extension
nad other of MI.
symptoms such .
as nausea,
increase
sweating, or
complaints of
unusual fatigue.
obtain a 12 –lead ECG
recording the
symptomatic
event, as
prescribed by
physician, to
determine
extension of
infarction.
ASSESSMENT NURSING PLAN OF INTERVENTION RATIONALE EVALUATION
DIAGNO CARE
SIS
administer oxygen at the Oxygen therapy After rendering of nursing
level of prescribed. increases the intervention, the
oxygen supply
to the patient had appears
myocardium comfortable and is
if actual free from pain.
oxygen Blood pressure is
saturation is 110/80.
less than
administer medication normal. Temperature of
therapy as medication therapy 37.1˚C. But the RR
prescribed, and is the first line 40 and PR 101 bpm
evaluate the of defense in are still
patient’s response preserving compensating to
continuously. myocardial
tissue. The
maintain cardiac
side effects of output. The goal is
the partially met.
medications
can be
hazardous and
the patient’s
status must be
assessed.
physicals rest
ensure physical rest; use reduces
the bedside myocardial
commode with oxygen
assistance; backrest consumption.
elevated to Stress
promote comfort; response, this
diet as tolerated; results, this
arms supported result,
during upper increase
extremity activity; myocardial
use of stool oxygen
softener to consumption.
straining stool.
Provide a restful
environment.
 ASSESSMENT NURSING PLAN OF INTERVENTION RATIONALE EVALUATION
DIAGNO CARE
SES

adventitious breath Ineffective After of nursing assess, document & can be used as a After of nursing
sounds airway intervention report to the guide for intervention the
changes in respiratory physician on activity
clearance the patient abnormal breath prescription patient will clear
rate and rhythm related to will clear the airway patency.
sound and a basis
copious the airway maintain the patency of for patient
tracheobro patency. oxygenation health
nchial therapy management.
Monitor Arterial Blood to provide an
secretions. Gases Analysis oxygen
suction tracheobronchial needed by the
secretion physiologic
established the turning need of the
patient as and body.
“tapping back” , as to indicate the
prescribed by the effectiveness
physician. of
oxygenation
therapy and
changes that
need to
improve gas
exchange.
retention of
secretions
lead to
decrease of
oxygen
supply
help to loosen the
secretions.
 ASSESSMENT NURSING PLAN OF CARE INTERVENTION RATIONALE EVALUATION
DIAGNOSE
S
Objective: risk for excess fluid After of 8 hours of >AUSCULTATE BREATH > MAY INDICATE After of 8 hours of nursing
>Decreasing urinary volume, nursing SOUNDS FOR PULMONAR intervention the
decreased intervention PRESENCE OF Y EDEMA patient had monitor
output
organ the patient CRACKLES. SECONDARY fluid status and reduce
>abnormal breath TO CARDIAC
perfusion will monitor occurrence of fluid
sounds, crackles DECOMPENS
fluid status excess. the goal is met.
>dyspnea ATION.
and reduce > Measure I&O, noting
occurrence of > DECREASED
decrease in output,
CARDIAC
fluid excess. concentrated
OUTPUT
appearance. Calculate
RESULTS IN
fluid balance.
IMPAIRED
KIDNEY
PERFUSION,
SODIUM/WA
TER
RETENTION,
AND
REDUCED
URINE
OUTPUT.
>assess for edema and > Sudden changes in
weigh daily. weight reflect
alterations in
fluid balance.\
>Sodium enhances
>Provide low-sodium fluid retention
diet/beverages. and should
therefore be
restricted
during active
MI phase
and/or if heart
failure is
present.
 ASSESSMENT NURSING PLAN OF INTERVENTION RATIONALE EVALUATION
DIAGNO CARE
SES

Objectives: impaired skin After rendering of assess, document the for guiding data. After rendering of nursing
physical integrity nursing skin patient. to avoid possible care intervention
immobilization related to intervention ask the physician if the that can the patient will not
prolonged bed prolonged the patient patient will trigger to his be able to get a bed
pressure allowed to turn the disease.
bed will not be sore.
patient on side-to to avoid possible
pressure. able to get a side and the time complication
bed sore. interval. on skin.
do the skin care
POTENTIAL PROBLEM
 POTENTIAL CONSIDERATIONS following discharge from care setting
(dependent on patient’s age, physical condition/presence of complications,
personal resources, and life responsibilities)

 Activity intolerance —imbalance between myocardial

oxygen supply/demand.
 Grieving, anticipatory—perceived loss of general well-
being, required changes in lifestyle, confronting
mortality.
 Decisional Conflict (treatment)—multiple/divergent
sources of information, perceived threat to value system,
support system deficit.
 Family Processes, interrupted—situational transition and
crisis.
 Home Management, impaired—altered ability to perform
tasks, inadequate support systems, reluctance to request
assistance.
 c. Discharge Planning use METHODS
Medications
Promotes adherence measures by thoroughly explaining
the prescribed medication regimen and other treatment
measures.
Warn the patients together with relatives about adverse
reaction to drugs, and advise them to watch the sign and
symptoms of toxic (nausea, anorexia, vomiting, and yellow
vision)
Exercises
Organize patient care and activities to maximize periods
of uninterrupted rest.
Assist with range-of-motion exercise. And turn him, every
two hours, as ordered by physician.
Don’t stress yourself, too much exercise. Enough, walk
for 15 minutes.
Treatment
Antiembolism stockings help prevent venostasis and
thromboplebitis.
Encourage participation in a cardiac rehabilitation
program.
 • Healt h t eac hi ng
 Wat ch f or si gn and sym pt om s of fl ui d ret ent ion (cr ack les, co ug h,
tac hyp nea, and ed em a), whi ch may ind icat e i mpend ing HF. Ca ref ul ly
moni tor dai ly w ei ght , int ak e and out put, resp irat ion, se rum enzy me lev el
and b loo d pressur e.
• Oxy genat ion a nd OPD fol low up
 Oxy gen ad mini st rat ion at a m odest fl ow r at e for 3-6 hours .
• Diet of the pat ient
 Revi ew diet ary r est ri cti on wi th the p atient . A lo w sod ium, l ow f at , or
low cho lest er ol diet and caf fei ne-f ree ma y b e or der ed , provide a l is t of
foo d that h e shoul d avoid . Provi de a clear liqui d diet unt il nausea
sub si des. As k diet itian t o sp eak to the pat ient ’s f am ily.
• Sp iri tual a nd sex ual teac hing
 Counse l p at ient to resume sexu al act ivi ty prog ressively .
 Enc our ag es the fam ily t o see k out r el ig iou s act ivit ies, pert ai ni ng to
sp iri tual issues.
Thank you…

..have a great day ahead…

VII. Referrences

Medical-Surgical Nursing, 11th edition,

Brunner & Suddarth’s (Smeltzer, Bare, Hinkle,
Cheever)
Handbook of Diseases, 3rd edition, Sarah Y. Yuan
Nursing Drug Handbook 2008, 28th edition,
Wolter Kluwer/Lippincott William & Williams
http://www.cardioconsult.com
http://www.aacn.org
VIII. Evaluation
Beltran, Jhon Marc
Mr. Ephraim Mirafuentes & Staff Nurse (MICU): Highly competitive
critical care nurse, that know how to assess, monitor and treat a critically
ill patient, the better that patient’s chances are for early intervention. All
of them excellence in the work environment. Their team using a method of
habitual concentration our staff nurses could develop qualities of
excellence for an improved outlook toward themselves, their work
environment, and their profession. This improved outlook would lead to
improved morale followed by an increase in retention within the unit, as
well as progress in meeting our other goals. We recognized that our
patient care, the attitudes of our nurses and staff, the helpfulness of peers,
and even the cleanliness of the unit were based on tradition. During
orientation, we learned what was expected of them in their individual
units, and they continued this process by orienting others to the same
routines. As we recognized, we needed to improve ourselves in reality, in
the world of Intensive care unit. Because we must aware that our work was
in critical situation.
As we are the nursing student that would be excited to us learn more to do
some activities in the role as they accept, in their life, around the Intensive
care unit.

We learned some nursing skills that we can used in critical situation.

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

Medical Intensive Care Unit provides comprehensive and

continuous care for patients who suffer from a serious illness
or medical problem as well as social and psychological
support for patients and their families. Their team includes
board-certified, critical care physicians , highly trained
nurses and other specialists who are specifically trained in
critical care and provide round-the-clock care.
We learned some nursing skills using their equipment in an
intensive care unit (ICU) includes mechanical ventilation to
assist breathing through an endotracheal tube or a
tracheotomy; intravenous lines for drug infusions fluids,
nasogastric tubes, suction pumps, drains and catheters; and
a wide array of drugs including their medication
management.
Tadifa, Joleen
In MICU, patients are given 24-hour assessments by the healthcare team. Preparatory
orders for the ICU generally vary from patient to patient since treatment is
individualized. The initial workup should be coordinated by the attending ICU staff
(intensiv and ICU nurse specialist), pharmacists (for medications and IV fluid therapy),
and respiratory therapists for stabilization, improvement, or continuation of
cardiopulmonary care. Well-coordinated care includes prompt consultation with other
specialists soon after the patient is admitted to the ICU. The patient is connected to
monitors that record his or her vital signs (pulse, blood pressure, and breathing rate).
Orders for medications, laboratory tests, or other procedures are instituted upon
arrival. The staff are highly skilled for critically ill patients. Using their advanced patient
monitoring technology and sophisticated medical equipment, as providing continuous,
comprehensive care for patients with serious conditions. providing expert healthcare
and to treating patients with the compassion and respect they deserve.
Patients requiring intensive care usually require support for airway or respiratory
compromise (such as ventilator support), potentially lethal cardiac dysrhythmias.
Critical care nurse are giving their intensive care to the patient, support for the above
are usually admitted for intensive/invasive monitoring. Ideally, intensive care is usually
only offered to those whose condition is potentially reversible and who have a good
chance of surviving with intensive care support. Since the critically ill are so close to
dying, the outcome of this intervention is difficult to predict.