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A. General Objective After the discussion of this case presentation, the students will be able to deal and care for a patients with Aortic Aneurysm integrally by applying their knowledge, skills, and positive attitudes based on what they have learned out of the discussion.
B. Specific Objectives At the end of the case presentation, it is expected that the students will be able to: Skills 1. Deal patient with thoracic aortic aneurysm. 2. Provide proper care and intervention with limitation to stressful activities. 3. Conduct physical assessment and organize data efficiently. 4. Perform nursing procedures effectively and correctly to attain optimum level of wellness. Knowledge 1. Define Thoracic Aortic Aneurysm. 2. Have an overview about the diseases, including its causes and preventive measures. 3. Determine the signs and symptoms. 4. Review the anatomy and physiology of the organ affected. 5. Understand the pathophysiology of the disease. 6. Identify and enumerate the management needed depending on the severity and possible rupture of the aneurysm. 7. Formulate nursing care plans that will aid in the improvement of patient s condition. Attitudes 1. Develop a positive attitude in caring the patient with thoracic aortic aneurysm throughout the nursing Process. 2. To be able to establish rapport with the patient and folks. 3. To be able to develop respect and trust to the folks as well as in other health care team member in caring of clients with Thoracic Aortic Aneurysm.
INTRODUCTION
A. Definition
An Aneurysm is a localized dilation or out pouching of
vessel wall or cardiac chamber. The Law of Laplace can provide an understanding of the hemodynamic of an aneurysm. Presumably, in myocardial infarction, a ventricular wall aneurysm forms when intraventricular tension stretches the non contracting infracted muscle. The stretching produces
infarct expansion, a weak and thin layer of necrotic muscle, and fibrous tissue that bulges with each systole. Aneurysm forms in the arteries when there is disruption of the wall of the vessel associated with changes in collagen and elastin that make the vessel more vulnerable to intravascular pressures. The aorta is particularly susceptible to aneurysm formation because of the constant stress on the vessel wall and the absence of penetrating vasa vasorum in the media layer. Three fourths of all aneurysms occur in the abdominal aorta. Atherosclerosis is the most common cause of arterial aneurysms because plaque formation erodes the vessel wall and contributes to inflammation and release of proteinases that can further weaken the vessel. Hypertension also contributes to aneurysm formation by increasing wall stress. Dissection of the arterial walls occurs when there is a tear in the intima and blood enters the wall of the artery. Dissection can involve any part of the aorta and can disrupt flow through arterial branches, thus creating a surgical emergency.
B. Statistics International:
The following statistics relate to the prevalence of Aortic aneurysm: 5 to 7% of people over 60 have thoracic aortic aneurysms in the US
The term 'prevalence' of Aortic aneurysm usually refers to the estimated population of people who are managing Aortic aneurysm at any given time. The term 'incidence' of Aortic aneurysm refers to the annual diagnosis rate, or the number of new cases of Aortic aneurysm diagnosed each year.
b. Capillaries which enable the actual exchange of water and chemicals between the blood and the tissues c. Veins which carry blood from the capillaries back toward the heart
The arteries and veins have different structures, veins having two layers and arteries having three:
a.
Tunica intima It is the thinnest layer: a single layer of simple squamous endothelial cells glued by a polysaccharide intercellular matrix, surrounded by a thin layer of
subendothelial connective tissue interlaced with a number of circularly arranged elastic bands called the internal elastic lamina. Also the inner layer of the vessel.
b.
Tunica media It is the thickest layer: circularly arranged elastic fiber, connective tissue, polysaccharide substances, the second and third layer are separated by another thick elastic band called external elastic lamina. The tunica media may (especially in arteries) be rich in vascular smooth muscle, which controls the caliber of the vessel. Also the middle layer of the vessel.
c.
Tunica adventitia It is entirely made of connective tissue. It also contains nerves that supply the vessel. Also the outer layer of the vessel.
Besides circulating blood, the blood vessels provide two important means of measuring vital health statistics: pulse and blood pressure. We measure heart rate, or pulse, by touching an artery. The rhythmic contraction of the artery keeps pace with the beat of the heart. Since an artery is near the surface of the skin, while the heart is deeply protected, we can easily touch the artery and get an accurate measure of the heart's pulse. When we measure blood pressure, we use the blood flowing through the arteries because it has a higher pressure than the blood in the veins
If you took all of the blood vessels out of an average child, and laid them out in one line, the line would be over 60,000 miles long! An adult's vessels would be closer to 100,000 miles long!
The aorta is the largest artery in the body, originating from the left ventricle of the heart and extending down to the abdomen, where it branches off into two smaller arteries, the common iliac. The aorta distributes oxygenated blood to all parts of the body through the systemic circulation.
The aorta gives off branches that go to the head and neck, the arms, the major organs in the chest and abdomen, and the legs. It serves to supply them all with oxygenated blood. The aorta is the central conduit from the heart to the body. The aorta is usually divided into five segments/sections:
a.
Ascending aorta - It is the section between the heart and the arch of aorta
b.
Arch of aorta - It is the peak part that looks somewhat like an inverted "U"
c.
Descending aorta - It is the section from the arch of aorta to the point where it divides into the common iliac arteries. Thoracic aorta It is the half of the descending aorta above the diaphragm
Abdominal aorta It is the half of the descending aorta below the diaphragm. The abdominal aorta is the largest artery in the abdominal cavity. As part of the aorta, it is a direct continuation of the descending aorta in the thorax.
A. Definition
An Aneurysm is a localized sac or dilation of an artery formed at a weak point in the vessel wall.
Types of Aortic Aneurysm: 1. Thoracic aortic aneurysm It is an aortic aneurysm that is present primarily in the thorax. 2. Abdominal Aortic Aneurysm It is a localized dilatation of the abdominal aorta exceeding the normal diameter by more than 50 percent, and is the most common form of aortic aneurysm. 3. Cerebral / Intracranial Aneurysm It is a dilation of the walls of a cerebral artery that develops as a result of weakness in the arterial wall.
Sites of Thoracic Aortic Aneurysm: 1. Aortic root 2. Ascending Thoracic Aorta 3. Arc aorta 4. Descending Thoracic Aorta
Characteristics of Aneurysm: 1. False Aneurysm It is actually a pulsating hematoma. The clot and connective tissue are outside the arterial wall. 2. True Aneurysm One, two, or all three layers of the artery may be involved.
3. Fusiform Aneurysm Symmetric, spindle shaped expansion of entire circumference of involved vessel.
5. Dissecting Aneurysm This is usually a hematoma that splits the layers of the arterial wall.
B. Risk factors
Gender Age Occurs frequently between ages of 40 70 years. Men are more affected than women.
Congenital Primary connective tissue disorders including Marfan s syndrome and Ehlers Danlos syndrome. Infectious Bacterial, fungal, spirochetal infection.
Inflammatory (non infectious) Associated with arteritis; Takayasu s disease, systemic Lupus Erythematosus.
Cigarette Smoking The primary cause of atherosclerosis. Atherosclerosis is the most common cause of arterial aneurysms because plaque formation erodes the vessel wall and contributes to inflammation and release of proteinases that can further weaken the vessel. Hypertension. Contributes to aneurysm formation by increasing wall stress.
C. Signs/Symptoms Symptoms are variable and depend on how rapidly the aneurysm dilates and how the pulsating mass affects surrounding intrathoracic structures. Yet, some do not produce symptoms.
From the Textbook Constant chest pain associated with a harsh breathing which may occur only in supine position. Dyspnea, cough (paroxysmal and brassy), or stridor
Rationale It results from the disruption of normal circulation in the thoracic region.
Hoarseness, weak voice or aphonia Dysphagia
It is the result of pressure of aneurysm sac against trachea, a main bronchus, or the lung itself. Resulting from the pressure against the laryngeal nerve. Due to impingement on the esophagus by the aneurysm.
When large veins in the chest are compressed by the aneurysm, the superficial veins of the chest, neck, or arms become dilated. A result of pressure against the cervical sympathetic chain.
Unequal pupils
D. Diagnostic Findings
Most thoracic aortic aneurysms are detected by tests performed for other reasons, it may include: Chest x-ray It is a projection radiograph of the chest used to diagnose conditions affecting the chest, its contents, and nearby structures and can show presence of any masses in the thorax. Echocardiogram
It is important for the evaluation of the aortic valve and also can be used to evaluate the size of the ascending aorta. Chest CT scan
This can show the size of the aorta and the exact location of the aneurysm. Aortogram
It is a special set of x-ray images made when dye is injected into the aorta that can identify the aneurysm and any branches of the aorta that may be involved.
E. Prevention
To prevent atherosclerosis: Control your blood pressure and blood lipid levels. Do not smoke. Exercise regularly.
F. Medical management
Medical or surgical management depends on the type of aneurysm. For a ruptured aneurysm, prognosis is poor and surgery is performed immediately. When surgery is delayed, medical measures include: Strict control of blood pressure and reduction in pulsatile flow. Correcting risk factors. Systolic pressure maintained at 100 to 120 mm Hg with antihypertensive drugs, such as: Nitroprusside (Nipride) Hydralazine (Apresoline)
Pulsatile flow reduced by medications that reduce cardiac contractility, such as: Propranolol
G. Surgical Management
Removal of the aneurysm and restoration of vascular continuity with a graft is the goal of surgery and treatment of choice for aortic aneurysm. It is recommended if the aneurysm is larger than 5.5 cm (2 inches) in diameter or those that are enlarging. Intensive monitoring in the critical care unit is required. The surgical procedure includes: Thoracic Endovascular Grafting / stenting The endovascular grafts or stents are inserted into the t horacic aorta via various vascular access routes, including the femoral or iliac artery. This is a tiny metal or plastic tube that is used to hold an artery open and can be placed into the body without cutting the chest. Resection and Bypass Graft It involves removing theaneurysmal portion of the aorta and replacing it with an a rtificial Dacron tube. If the aortic valve is damaged it also need to be replaced or repaired. Replacement options include mechanical and tissue valves.
Pre operative assessment: Assessment is guided by the fact that the aneurysm may rupture Signs include persistent or intermittent back or abdominal pain that may be localized in the middle or lower abdomen or lower back. Establish functional capacity of all organ systems, recognizing possible cerebral, cardiovascular, pulmonary, and renal impairment due to atherosclerosis. Implement medical therapies to stabilize patient.
Post operative assessment Intensely monitor the pulmonary, cardiovascular, renal and neurologic systems. Monitor for complications: arterial occlusion, hemorrhage, infection, ischemic bowel, renal failure and impotence. Prescribe an exercise schedule after the recovery phase. Discouraged prolonged sitting
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H. Rupture of Aneurysm
Rupture or dissection of these aneurysms produces dramatic symptoms. A ripping sensation within the chest accompanied by severe pain in the back between the shoulder blades is the most typical complaint during thoracic aortic dissection or rupture. Dizziness, difficulty walking and speaking can all accompany this acute event.
Patients with known aortic aneurysms experiencing such symptoms need to contact their physician or surgeon immediately and go to the nearest emergency room.
I. Nursing considerations
Smoking cessation Avoid carrying heavy objects to prevent pressure on the vessel wall. Strict compliance to antihypertensive medications to keep your blood pressure under control. Limit stressful physical activities Get regular exercise. Reduce cholesterol and fat in your diet.
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Congestive heart failure (CHF) is a condition in which the heart's function as a pump is inadequate to supply sufficient blood flow to meet the needs of the body. The most common causes of congestive heart failure are: Coronary artery disease Hypertension DM Obesity Longstanding alcohol abuse Disorders of the heart valves Unknown (idiopathic) causes, such as after recovery from myocarditis
Signs & Symptoms Right Sided Heart Failure Peripheral edema, Anasarca Nocturia Paroxysmal nocturnal dyspnea Ascites Fatigue Hepatomegaly Coagulopathy Cool extremities at rest. Confusion Left Sided Heart Failure Pulmonary congestion Dyspnea (SOB) Orthopnea Exercise intolerance Wheezing Dizziness
Diagnostic Examination Electrocardiogram (ECG) Is used to determine changes or variation in electrical activity of the heart.
Chest X-ray To detect previous heart attacks, arrhythmia, heart enlargement, and fluid in and around the lungs. Echocardiogram In which ultrasound is used to image the heart muscle, valve structures, and blood flow patterns. The echocardiogram is very helpful in diagnosing heart muscle weakness.
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B-type natriuretic peptid level This level can vary with age and gender but is typically elevated from heart failure and can aid in the diagnosis, and can be useful in following the response to treatment of congestive heart failure Coronary angiography It is a procedure that uses a special dye or contrast material and x-rays to see how blood flows through your heart.
Prevention Do not smoke. Do not drink alcohol. Reduce salt intake. Exercise as recommended by your health care provider.
Treatment Coronary artery bypass graft surgery Is a surgical procedure in which one or more blocked coronary arteries are bypassed by a blood vessel graft to restore normal blood flow to the hear. Angioplasty Is a term describing a procedure used to widen vessels narrowed by stenoses or occlusion.
Single or dual chamber pacemaker To help with slow heart rates or certain other heart signaling problems.
Biventricular pacemaker To help the left and right side of your heart contract at the same time.
Intra-aortic balloon pump (IABP) A temporary device placed into the aorta
Left ventricular assist device (LVAD) Which takes over the role of the heart by pumping blood from the heart into the aorta; it's most often used by those who are waiting for a heart transplant.
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Pharmacologic Treatment ACE inhibitors Such as captopril, enalapril, lisinopril, and ramipril to open up blood vessels and decrease the work load of the heart Diuretics Including hydrochlorothiazide, chlorthalidone, chlorothiazide,furosemide, torsemide, bumeta nide, and spironolactone to help rid your body of fluid and salt (sodium) Digitalis glycosides To increase the ability of the heart muscle to contract properly and help treat some heart rhythm disturbances. Angiotensin receptor blockers (ARBs) Such as losartan and candesartan to reduce the workload of the heart; this class of drug is especially important for those who cannot tolerate ACE inhibitors Beta-blockers Such as such as carvedilol and metoprolol, which are particularly useful for those with a history of coronary artery disease.
Nursing Management Take the medications as directed. Carry a list of medications with you wherever you go. Limit salt intake. Smoking Cessation Stay active. For example, walk or ride a stationary bicycle. Your doctor can provide a safe and effective exercise plan based on the degree of heart failure and how well you do on tests that check the strength and function of your heart. DO NOT exercise on days that the weight has gone up from fluid retention or if not feeling well. Lose weight if overweight. Provide enough rest, including after exercise, eating, or other activities. This allows the heart to rest as well. Keep your feet elevated to decrease swelling.
Here are some tips to lower your salt and sodium intake: Look for foods that are labeled low-sodium, sodium-free, no salt added, or unsalted.
Check the total sodium content on food labels. Be especially careful of canned, packaged, and frozen foods. A nutritionist can teach you how to understand these labels.
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Don t cook with salt or add salt to what you are eating. Try pepper, garlic, lemon, or other spices for flavor instead. Be careful of packaged spice blends as these often contain salt or salt products (like monosodium glutamate, MSG). Avoid foods that are naturally high in sodium, like anchovies, meats (particularly cured meats, bacon, hot dogs, sausage, bologna, ham, and salami), nuts, olives, pickles, sauerkraut, soy and Worcestershire sauces, tomato and other vegetable juices, and cheese. Take care when eating out. Stick to steamed, grilled, baked, boiled, and broiled foods with no added salt, sauce, or cheese. Use oil and vinegar, rather than bottled dressings, on salads. Eat fresh fruit or sorbet when having dessert.
Prognosis With the availability of newer drugs to potentially favorably affect the progression of disease, the prognosis in congestive heart failure is generally more favorable than that observed just 10 years ago. In some cases, especially when the heart muscle dysfunction has recently developed, a significant spontaneous improvement is not uncommonly observed, even to the point where heart function becomes normal
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Myocardial infarction, commonly known as a heart attack, is the irreversible necrosis of heart muscle secondary to prolonged ischemia.
Etiology Atherosclerosis Age Sex Family history of premature coronary heart disease Male-pattern baldness Dyslipidemia Smoking or other tobacco use Diabetes mellitus Hypertension Hypercholesterolemia and hypertriglyceridemia, including inherited lipoprotein disorders Obesity Sedentary lifestyle and/or lack of exercise Psychosocial stress Poor oral hygiene Type A personality
Signs & Symptoms Pain, fullness, and/or squeezing sensation of the chest Jaw pain, toothache, headache Nausea, vomiting, and/or general epigastric discomfort Sweating Heartburn and/or indigestion Arm pain Upper back pain General malaise Shortness of breath
Diagnostic Studies Electrocardiogram(ECG) Is a recording of the electrical activity of the heart. Abnormalities in the electrical activity usually occur with heart attacks and can identify the areas of heart muscle that are deprived of oxygen and/or areas of muscle that have died.
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Blood tests Cardiac enzymes are proteins that are released into the blood by dying heart muscles. These cardiac enzymes are creatine phosphokinase (CPK) and troponin I, and their levels can be measured in blood. A series of blood tests for the enzymes performed over a 24-hour period are useful not only in confirming the diagnosis of heart attack, but the changes in their levels over time also correlates with the amount of heart muscle that has died.
Treatment Thrombolytic / fibrinolytic therapy Has been shown to reduce death from heart attacks similarly in men and women; however, the complication of strokes from the thrombolytic therapy may be slightly higher in women than in men. Percutaneous transluminal coronary angioplasty ( PTCA) Or coronary stenting for acute heart attack The use of a balloon-tipped catheter to enlarge a narrowed artery. Coronary Artery Bypass Graft (CABG) A surgery creates new routes around narrowed and blocked arteries, allowing sufficient blood flow to deliver oxygen and nutrients to the heart muscle.
Nursing Management Patients with active symptoms of ACS should be instructed to call emergency services and should be brought in by emergency medical services personnel, not by themselves, family, or friends. Patients should be instructed to come to the emergency department immediately if the suspected ACS symptoms last longer than 20 minutes at rest or are associated with near syncope or hemodynamic instability. If nitroglycerin is prescribed to a patient with suspected ACS, the patient should be instructed to take a dose if symptoms arise. If no relief is experienced 5 minutes after the first dose, the patient should contact emergency services. Educate post myocardial infarction patients about the role of a low-cholesterol and low-salt diet. Educate patients about the American Heart Association (AHA) dietary guidelines, including a lowfat, low-cholesterol diet. A dietitian should see and evaluate all patients post myocardial infarction prior to their discharge. Emphasize exercise training because current evidence demonstrates that cardiac rehabilitation post myocardial infarction results in lower rates of recurrent cardiovascular events.
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Following myocardial infarction, educate all patients regarding the critical role of smoking in the development of coronary artery disease. Smoking cessation classes should be offered to help patients avoid smoking after their myocardial infarction Prognosis Acute myocardial infarction is associated with a 30% mortality rate; half of the deaths occur prior to arrival at the hospital. An additional 5-10% of survivors die within the first year after their myocardial infarction. Approximately half of all patients with a myocardial infarction are rehospitalized within 1 year.
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Athersclerotic cardiovascular disease is most commonly known as coronary heart disease. This condition involves the hardening of the heart arteries. Athersclerotic cardiovascular disease is attributed to the builds up of fat deposits, which essentially clog up the heart's arteries.
Treatment Dietary sodium restriction Regular moderate exercise Smoking cessation Weight reduction
Pharmacological Treatment ACE inhibitors Such as captopril, enalapril, lisinopril, and ramipril to open up blood vessels and decrease the work load of the heart Digitalis glycosides To increase the ability of the heart muscle to contract properly and help treat some heart rhythm disturbances. Angiotensin receptor blockers (ARBs) Such as losartan and candesartan to reduce the workload of the heart; this class of drug is especially important for those who cannot tolerate ACE inhibitors Beta-blockers Such as such as carvedilol and metoprolol, which are particularly useful for those with a history of coronary artery disease.
Nursing Management Maintain the healthiest lifestyle possible. This means eating a healthy and nutritious diet. Getting a good amount of physical activity in your daily schedule Sodium restriction and low-fat diet Encourage to stop smoking
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VITAL IBFORMATION
Name Sex Age Address Civil Status Religion Occupation Educational Attainment Date & Time Admitted
J.B Male 60 years old North Natividad, Pilar, Capiz Married Roman Catholic Fisherman Elementary Graduate June 29, 2011 4:20 pm
St. Catherine Laboure SOB T/C CAP MR, T/C aortic aneurysm, CHF 2 AMI, HACVD, S/P AMI
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CLINICAL ASSESSMENT
A. Nursing History
For almost nine (9) years, Mr. J.B is very compliant to all of his medications as maintenance and regular check up to Dr. B. However, a month ago, Mr. J.B was not able to meet the recommended
medications for his maintenance due to lack of knowledge. He thought that he is fine since his blood pressure was always ranging to 130 / 80 to 140 / 90. He also stopped seeing his doctor for regular check up because of the long distance travel and has the belief of the routine medical advice. Pareho malang gyapon ang ginahimo kag ginareseta sa akon as verbalized. Moreover, three weeks prior to his admission, Mr. J.B. experienced sudden onset of shortness of breath especially if placed on supine position associated with harsh breathing. Also, he experienced occasional nape pain and full to heavy chest pain as described. These complaints continued until his admission to St. Anthony College Hospital. On the day prior to Mr. J.B s admission, June 29, 2011 at around 4:20 pm, he sought consultation with his attending physician, and was advised for intensive care unit admission. During this time, Mr. J.B needs an intensive care for he is suspected to have an aneurysm which is a medical emergency case.
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C. Family Genogram
F.B
R.B
G.B
B.B
R.B
J.B
H.B
C.B
D.B
N.B
LEGEND:
Patient
J.B
Male
R.B
Diabetes Mellitus II
Female
Hypertension
F.B
Death
R.B
Aging
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PATTERNS OF FUNCTIONING
Nutritional History a. Drinking Patterns HOME Mr. J.B is fond of drinking water. He drinks water before and after meals, as well as when there is a feeling of dry mouth and thirst. Mr. J.B is not fond of drinking neither soft drinks nor coffee and a beverage at all. He can consume not less than 8 glasses of water a day. HOSPITAL His fluid intake was limited for he cannot tolerate large amount of fluids. He only consumes 350cc of water per shift during our care.
b. Eating Pattern HOME Mr. J.B had a very good appetite. He can tolerate large amount of food; is able to consume his meal and have extra rice every meal. Since Mr. J.B lives in Pilar, there viand most of the time is sea foods which is rich in sodium. Yet, he also likes to eat vegetables. His wife prepares vegetables 3 or 4 times a week and sometimes fruits. HOSPITAL Mr. J.B loses his desire for foods. He had a poor appetite and can only consume 1/3 of the meal served. Mr. J.B cannot tolerate large amount of foods. The meals being served to him was full diet and low in cholesterol.
c. Breathing Patterns HOME Mr. J.B experienced an episode of shortness of breath associated with harsh breathing when in supine position before he was admitted. HOSPITAL Mr. JB had oxygen of 1 L breaths per minute via nasal cannula. Sometimes, he complained of shortness of breath with a respiratory rate ranging from 22 24 breaths per minute.
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d. Circulation Temperature Pulse rate Respiration rate Blood pressure Apical rate 36C 88 bpm 24 bpm 160/100 mmHg 90 bpm IVF Left carpal vein Side Drip # 2 PNSS 1L x KVO AC Drip: 500 ml D5 water + 2 Apresoline + 2 Catapres @ 15 gtts / min (Maintain systolic blood pressure of 140 to 150, titrate 5 ugtts / min and stop side drip for Bp of 140).
Daily Activity Patterns: a. Rest and Sleeping Patterns HOME Mr. J. B usually sleeps at night after watching television news with long intervals. He slept at about 8 - 9 in the evening and wake up at 5 6 in the morning to have walking at the seashore. He also slept at noon time to rest in his small hut. HOSPITAL Mr. J.B has a difficulty in sleeping at night; he claimed that he can only slept at night in a short interval due to dizziness and coming in and out of nurses in the room. He slept at 10 - 11 pm and woke up at 6 in the morning.
b. Personal Hygiene HOME At home, Mr. J. B takes a bath every day and does his oral hygiene once a day by himself. HOSPITAL In hospital, Mr. J. B takes a bath occasionally and does his oral hygiene once a day after dinner with assistance from the student nurse assigned or the folks. Sponge bath is also rendered by his wife every day or when he did not take a bath.
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c. Elimination Patterns Bowel Movement FREQUENCY Home Hospital PROBLEMS / DIFFICULTIES Home Hospital
None
Urinates whenever feels the urge with a urine output approximately 620 cc during our 8 hour care.
None
None
A. Educational Background - Mr. J.B is an elementary graduate at Dulangan Elementary School. B. Occupational Background - Mr. J.B is a fisherman. C. Religious practices - Mr. J.B does not attend regular masses every Sunday except during Holy days of obligations. Yet, he said that he is praying before sleeping and before eating his meals. D. Economic status - They belong in the middle class of economic level in this society.
SOCIO-CULTURAL HEALTH A. Cultural Health Mr. J.B participates when they have their fiesta in their barrio. They also prepare foods for their visitors. He did not consider superstitious beliefs. Rather, he believes that everything happens in God s will.
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B. Recreational Pattern Mr. J.B loves to have walking every morning and during sunset in the seashore. For him, breathing fresh air is the best way that he could relax himself. Other than that, he is also fond of watching news in ABS-CBN and stay in his nipa hut to have rest. He also listens to the music or news in Bombo station through his favourite radio.
C. Environmental Pattern Their house is located in between of the road and coastal area. It is also at the front of basketball court and chapel. As what we have observed, the environment there is conducive to make Mr. J.B feel relax.
D. Interaction Pattern Through the help of his grandchildren, Mr. J.B forgot that he has health problem. When they are all in, they tend to have conversation with each other and have humours. Kasadya gid kong makita ko sila tanan , as what Mr. J.B told us. According to him, his family is his strengths and being with them, is the most treasure he had.
E. Coping Pattern Mr. J.B had no idea about his aneurysm; all he knew was that he is only suffering from a high blood pressure associated with a cardiac problems. From that information he had, he tried to maintain and lower down his blood pressure through a long period of rest, a strict compliance to all the medications, and avoiding stressful stimuli like noises. They have a strong bond in their family. All of her children as well as his wife participate in the plan of care for him. Actually, they monitor the blood pressure of Mr. J.B, taking good care of his feelings and asking him not to perform those activities that need effort. They also accompanied Mr. J.B when he likes to walk in the seashore. Because of his situation, they decided to keep the real status of Mr. J.B s condition.
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CLINICAL INSPECTION
Vital Signs
Upon Admission Temperature 36.1C Respiratory rate 25 bpm Apical pulse 105 bpm Radial pulse 100 bpm Blood pressure 220/140 & 230/150 mmHg
During our Care September 16, 2010 Time Temperature (C) Respiratory rate (bpm) (bpm) 7:00 8:00 9:00 10:00 11:00 12:00 1:00 2:00 36.1 22 86 82 36 24 90 88 160/100 150/100 160/100 160/100 150/100 140/100 140/100 140/100 (bpm) (mmHg) Apical pulse Radial pulse Blood pressure
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PHYSICAL ASSESSMENT
General Appearance Mr J.B is awake and consciously lying on bed at a high fowler s position which appears weak,
fatigue, with shortness of breath, and pale but still oriented and in an appropriate mood; with an ongoing IVF of #2 PNSS 1 L x KVO infusing well on the right carpal vein at the level of 500 cc, a secured AC drip of 500 ml D5 water + 2 Appresoline + 2 Catapres @ 15 ugtts / min; this is to maintain systolic blood pressure of 140 to 150 mmHg and to be titrated at 5 ugtts / min, and O2 inhalation of 1 LPM via nasal cannula. He is coherent, physically and mentally conscious wherein responsiveness to any stimuli is observed, and with non edematous lower & upper extremities are not noted.
Cephalocaudal
Body Parts Method of Assessment Skin Inspection Poor skin turgor Due to physiologic changes of aging; limited physical activity and range of motion. Findings Interpretation
Skin is warm and dry, (-) pallor, (-) cyanosis. Skin is intact and wrinkled Fair complexion. Skin is soft and no scar, bruise or petechiae noted.
Normal
Head
Inspection
Normocephalic, , hair is evenly distributed, black in color, straight, smooth and short Symmetrical feature of the face. Normal
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Facial grimace
(+) chest pain when in supine position; It results from the disruption of normal circulation in the thoracic region.
Nails
Inspection
(-) of clubbing with an angle of about 160 degrees. Eyes Inspection Pupil size R = 2mm L = 1.5 Sluggish pupil reaction Reddish sclera & conjunctiva Moderately reactive to light and accommodation.
Normal
(-) Tenderness and lumps Color same as facial skin Auricle is aligned with the outer cantus of the eye Responsive to moderate voices
Normal
Normal
Nose
Inspection
Symmetric with the nasal septum at the center O2 @ 1 liter per minute
Normal
Neck
Inspection
Normal
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Inspection
It is the result of pressure of aneurysm sac against trachea, a main bronchus, or the lung itself.
Auscultation
(-) adventitious breath sounds Abdomen Inspection Abdominal wall is uniform in color and round.
Normal
Normal
Auscultation
Palpation
Normal
Extremities
Inspection
Normal It results from the disruption of normal circulation in the thoracic region.
Bp = 160/100 mmHg
Due to atherosclerosis and continues decreased in the passage way of blood as a result of
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HR = 90 bpm PR = 88 bpm Genitourinary Inspection Voids freely in the comfort room with no complaints of pain and difficulties. The urine output during our care is 620 cc. Urine is clear and aromatic Musculuskeletal Inspection Able to ambulate with assistance Limited physical activity
Normal
Normal
Due to his condition. This is to provide rest and prevent stressors that could cause an increase in blood pressure result to rupture of aneurysm.
A. General Appraisal
i.
Speech
iii. Hearing He can hear moderate sound and interpret auditory stimuli appropriately.
iv. Emotional status He is slightly worried about his condition. He all knows that he had only hypertension and he worries about it when his blood pressure is above normal. His medical condition was decided by Mr. J.B s family to keep it from him. This is the reason why he did not know about the extent of thoracic aortic aneurysm and the effects of it in his lifestyle. v. Mental status
He is conscious, alert, coherent, and able to comprehend instructions and commands. He is also oriented to person, time, place and events occurring in the environment and sometimes he asks about his condition.
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Date: June 29, 2011 Chest X Ray View: Anterior Posterior Impression: Cardiomegaly. Mild Pulmonary congestion. Bibasal Pneumonia. Left hilar mass vs. Aortic Aneurysm. Atheromatous aorta. Hyperthrophic Degenerative Osteoarthropathy, thoracic spine.
Fluid Serum Test Result Normal Values Sodium Calcium Magnesium Creatinine 143 mmol/L 2.39 mmol/L .9 mmol/L 126.8 umol/L 136 145 2.12 2.52 .74 - .99 53 115 Normal Normal Normal Reduced blood flow to the kidney due to disturbed arterial circulation. Potassium 3.5 mmol/L 3.5 5.1 Normal Significance
Hematology Test Result Normal Values Hematocrit Hemoglobin Red Blood Cell White Blood Cell Segmenters .70 50 60 % As a compensatory mechanism of the body to .46 vol. fr. 151 gms/L 5.36 x 10 ^ 12/L 10.9 x 10^ 9/L 0.42 0.52 120 160 4.6 6.2 4.5 11 Normal Normal Normal Normal Significance
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fight against the invasion of pathogens. Eosinophils Lymphocytes Monocytes Platelet .02 .25 .03 294 x 10 ^ 9 / L 1 4% 25 30 % 2 5% 150 350 Normal Normal Normal Normal
CT Scan Request: Chest (Plain) Interpretation: Pneumonitis, both lungs, not ruled. Aortic arc aneurismal dilatation. Atherosclerotic aorta. Cardiomegaly. Bilateral minimal Infero Posterior pleural thickening. Thoracic hyperthrophic degenerative osteoarthropathy.
Date: June 30, 2011 Serum Test Test Result Normal Values Glucose 9.12 mmol / L 4.4 6.1 Due to decrease utilization of insulin from the pancreas, specifically the beta cells of the Islet of Langerhands. Significance
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PATHOPHYSIOLOGY
Degenerative Changes
DM
Cigarette smoking
Atherosclerosis
Plaque Formation
Arterial Spasm
Prolonged high blood pressure Creatinine of Vastarel MR 35 mg 1 tab BID Losartan 50 mg 1 tab O.D AC drip of 500 ml D5 water + 2 catapres + 2 Appresoline @ 15 gtts / min Imdur 30 mg 1 tab OD Dilzem 60 mg 1 tab TID 126.8 umol/L Chest pain SOB
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MEDICAL MANAGEMENT
A. Drug Study
Generic Name Brand Name Drug class Dosage Indications Contraindications Adverse reaction Mechanism of Action Nursing Responsibilities Trimetazidine Vastarel MR Beta blocker 35 mg 1 tab BID Hypertension Hypersensitivity to the drug and any of its constituents. Nausea and vomiting It is known to depress renin secretion. Should be taken with food. Swallow whole, do not crush Monitor heart rate prior to administration
Generic Name Brand Name Drug class Dosage Indications Contraindications Adverse reaction
Isosorbide Mononitrate Imdur Nitrate 30 mg 1 tab OD Angina pectoris Hypersensitivity to nitrate, MI with low left ventricular filling pressure. Headache, dizziness, nausea and vomiting, flushing, weakness, orthostatic hypotension.
Mechanism of Action
May reduce cardiac oxygen demand by decreasing left ventricular end diastolic pressure (preload) and, to lesser extent, systemic vascular resistance (after load). Thus, increases blood flow through collateral coronary vessel.
Nursing Responsibilities
Monitor blood pressure, heart rate and rhythm, and intensity and duration of drug response. Do not give the drug during an 8 to 12 hour period daily. Give drug on empty stomach, either 30 minutes before or 1 to 2 hours after meals, and have him swallow tablets whole. Advise him to take drug regularly , as prescribed, and to keep it accessible at all times.
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Generic Name Brand Name Drug class Dosage Indications Contraindications Adverse reaction
Losartan potassium Cozaar ACE Inhibitor 50 mg 1 tab OD Hypertension Hypersensitivity Dizziness, syncope, headache, insomnia, hypotension, diarrhea, abdominal pain, nausea, cough, back pain, hyperkalemia.
Mechanism of Action
It selectively blocks the binding of angiotensin II to specific tissue receptors found in the vascular smooth muscle and adrenal gland; this action blocks the vasoconstriction effect of the rennin angiotensin system as well as the
release of aldosterone leading to decreased Bp. Nursing Responsibilities Administer without regard to meals. Monitor his blood pressure regularly and thereafter therapy to monitor drug s effectiveness. Regularly monitor creatinine and BUN to monitor kidney function. Give once daily dose in the morning to prevent insomnia. Tell patient to avoid sodium substitutes because they may contain potassium, which can cause hyperkalemia in patients taking drug.
Generic Name Brand Name Drug class Dosage Indications Contraindications Adverse reaction
Diltiazem Hydrochloride Dilzem Calcium Channel Blocker 60 mg 1 tab 1 tab TID Angina pectoris Allergy to diltiazem, heart block, cardiogenic shock, sick sinus syndrome. Lightheadedness, dizziness, headache, peripheral edema, arrhythmia, bradycardia, nausea, flushing.
Mechanism of Action
It inhibits calcium ion influx across cardiac and smooth muscle cells, decreasing myocardial contractility and oxygen demand; also dilates coronary arteries and arterioles.
Nursing Responsibilities
Monitor blood pressure when therapy starts and when dosage changes. Monitor ECG and heart rate, and rhythm regularly. Give the tablet before meals and at bedtime. Assist with ambulation during start of therapy because dizziness may occur. Immediate report if he experiences chest pain, shortness of breath,
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dizziness, palpitations, or swelling of the limbs. Minimize exposure to direct sunlight and to take precautions when in sun because of drug induced photosensitivity.
Moxifloxacin Hydrochloride Avelox Fluoroquinolone 400 mg 1 tab TID Infection (pneumonitis, both lungs) Hypersensitivity to the drug, any of its components, or other fluoroquinolones. Use cautiously in patients with known or suspected CNS disorders and in patient with risk factors that may predispose them to seizures or lower the seizure threshold.
Adverse reaction
Vertigo, allergic, dyspnea, tachycardia, hypertension, peripheral edema, somnolence, tremor, anxiety, insomnia, headache, dizziness, paresthesia.
Mechanism of Action
Inhibits the enzymes needed for bacterial DNA replication, transcription, repair, and recombination.
Nursing Responsibilities
Obtain specimen for culture and sensitivity test before first dose. Monitor him for hypersensitivity reactions and symptoms of CNS toxicity, including seizures, prolonged QT interval, phototoxicity and tendon rupture. Give with or without food. Give at the same time each day to provide consistent absorption.
Side Drips Medication: Generic Name Brand Name Drug class Dosage Indications Contraindications Adverse reaction Hydralazine Hydrochloride Appresoline Vasodilator 500 D5 water + 2 Appresoline + 2 Catapres @ 15 gtts / min Hypertension Hypersensitivity to drugs and its components, Coronary artery disease. Headache, palpitations, tachycardia, anorexia, nausea, vomiting, diarrhea, orthostatic hypotension, anorexia, dizziness, arrhythmia, rash. Mechanism of Action Acts directly on vascular smooth muscle to cause vasodilation, primarily arteriolar, decreasing peripheral resistance; maintains or increases renal and cerebral blood flow. Nursing Responsibilities Instruct patient that he may experience dizziness and weakness as
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adverse affects of this drug. Lie down for a while if dizziness occurs. Assist when changing patient s position. Monitor patient s blood pressure before therapy and regularly thereafter. Monitor CBC during therapy. Tell patient to limit sodium intake.
Generic Name Brand Name Drug class Dosage Indications Contraindications Adverse reaction
Clonidine Hydrochloride Catapres Centrally Acting Sympatholytic 500 D5 water + 2 Appresoline + 2 Catapres @ 15 gtts / min Hypertension Hypersensitivity to drugs and its components. Anxiety, dizziness, drowsiness, fatigue, headache, somnolence, bradycardia, hypotension, orthostatic hypotension, constipation, dry mouth, vomiting, pruritis and dermatitis.
Mechanism of Action
It inhibits central vasomotor centers, decreasing sympathetic outflow to heart, kidneys, and peripheral vasculature, resulting in decreased peripheral vasculature resistance, decreased systolic and diastolic blood pressure, and decreased heart rate.
Nursing Responsibilities
Monitor blood pressure before therapy and thereafter therapy. Drug may be given to lower blood pressure rapidly in some in some hypertensive emergency situations. Monitor him closely, especially during the few days of therapy. Respiratory depression or deep sedation may occur. Caution him that drug can cause drowsiness, but that he will develop tolerance to these adverse effects.
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B. Medi Map
Risk factors:
Pathophysiology: Atherosclerosis is the most common cause of arterial aneurysm because plaque formation erodes the vessel wall and contributes to inflammation and release of proteinases that can further weaken the vessel. Hypertension also contributes to aneurysm formation by increasing wall stress. Thus, aneurysms form in arteries when there is disruption of the wall of the vessel associated with changes in clollagen and elastin that make the vessel more vulnerable to intravascular pressures.
Laboratory and Diagnostic Test Chest X ray Troponin I Determination Hematology Chest CT Scan Capillary blood Glucose Serum K, Na, Ca, Mg Creatinine Clearance
Signs & symptoms: Chest pain when in supine position Shortness of breath Occasional cough Unequal pupils
Medical Management
Nursing interventions: Smoking cessation Avoid carrying heavy objects to prevent pressure on the vessel wall.
Drugs; Vastarel MR 35 mg 1 tab BID Imdur 30 mg 1 tab OD Losartan (Cozaar) 50 mg 1 tab OD Dilzem 60 mg 1 tab TID Avelox 400 mg 1 tab OD IV Therapy Bottle #2 PNSS 1 L x KVO AC Drip: 500 ml D5 water + 2 Appresoline + 2 Catapres @ 15 gtts / min (Maintain systolic blood pressure of 140 to 150, titrate 5 ugtts / min and stop side drip for Bp of 140) O2 Therapy: O2 @ 1 Lpm via nasal cannula
Prevention: Control your blood pressure and blood lipid levels. Do not smoke. Exercise regularly.
Strict compliance to antihypertensive medications to keep your blood pressure under control. Limit stressful physical activities Get regular exercise. Reduce cholesterol and fat in your diet.
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NURSING MANAGEMENT
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2. Ineffective cardiac tissue perfusion r/t diminished arterial circulation to the cardiac muscle. 1. Decreased cardiac output r/t disturbed arterial circulation 2 to obstruction in the aortic
3. Ineffective renal tissue perfusion r/t t diminished arterial circulation to the kidney.
4. Chronic pain r/t the disruption of normal circulation in the thoracic region.
9. Risk for deficient fluid volume: hemorrhage r/t potential abnormal blood loss secondary to possible
7. Sleep deprivation r/t coming in and out of staff nurses in the room.
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1. Decreased cardiac output r/t disturbed arterial circulation 2 to obstruction in the aortic arc. Objectives: BP = 160 / 100 mmHg RR = 24 bpm Shortness of breath (+) Weakness (+) Fatigue Facial grimace Capillary refill of 4 seconds Creatinine clearance result: Creatinine = 126.8 umol/L Chest X ray result: Left hilar mass vs Aortic Aneurysm. Atheromatous aorta. Cardiomegaly Chest CT Scan (Plain) Aortic arc aneurismal dilatation. Atherosclerotic aorta Cardiomegaly. Vastarel MR 35 mg 1 tab BID Losartan 50 mg 1 tab. AC drip of 500 ml D5 water + 2 catapres + 2 Appresoline @ 15 gtts / min given by NOD. O2 inhalation of 1 Liter per minute.
2. Ineffective cardiac tissue perfusion r/t diminished arterial circulation to the cardiac muscle. Subjective: Masakit akon dughan kung gahigda ko as verbalized. Objectives: BP = 160/100 mmHg RR = 24 bpm (+) Weakness (+) Fatigue (+) Shortness of breath Chest pain when in supine position Capillary refill of 4 seconds Chest X ray result: Left hilar mass vs Aortic Aneurysm. Atheromatous aorta. Cardiomegaly Chest CT Scan (Plain) Aortic arc aneurismal dilatation. Atherosclerotic aorta. Cardiomegaly. Vastarel MR 35 mg 1 tab BID Losartan 50 mg 1 tab. AC drip of 500 ml D5 water + 2 catapres + 2 Appresoline @ 15 gtts / min given by NOD. O2 inhalation of 1 Liter per minute.
3. Ineffective renal tissue perfusion r/t diminished arterial circulation to the kidney. Objectives: BP = 160/100 mmHg (+) Weakness (+) Fatigue Capillary refill of 4 seconds Creatinine clearance result: Creatinine = 126.8 umol/L Chest X ray result: Left hilar mass vs Aortic Aneurysm. Atheromatous aorta. Cardiomegaly Chest CT Scan (Plain) Aortic arc aneurismal dilatation. Atherosclerotic aorta. Cardiomegaly. Vastarel MR 35 mg 1 tab BID Losartan 50 mg 1 tab. AC drip of 500 ml D5 water + 2 catapres + 2 Appresoline @ 15 gtts / min given by NOD. O2 inhalation of 1 Liter per minute.
4. Chronic pain r/t the disruption of normal circulation in the thoracic region. Subjective: Masakit akon dughan , as verbalized. Objectives: BP = 160 / 100 mmHg With shortness of breath (+) Weakness (+) Fatigue (+) Chest pain with a pain scale of 5 to 6. (+) Facial grimace (+) Anorexia Chest X ray result: Left hilar mass vs Aortic Aneurysm. Chest CT Scan (Plain) Aortic arc aneurismal dilatation. Dilzem 60 mg 1 tab. Imdur 30 mg 1 tab Oxygen inhalation at 1 Liter per minute.
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6. Activity intolerance r/t limited physical activity 2 to possible rupture of aneurysm. Subjective: Daw nahapo ko kung sagad
7. Sleep deprivation r/t coming in and out of staff nurses in the room. Subjective: Wala ako nakatulog mayad kay sagad binalik balik sang nurse, as verbalized. Objective: (+) Weakness (+) Fatigue (+) Facial grimace (+) Anorexia Slowed reaction
9. Risk for deficient fluid volume: hemorrhage r/t potential abnormal blood loss secondary to possible rupture of aneurysm. Objectives: BP = 160 / 100 mmHg Shortness of breath Facial grimace (+) Weakness (+) Fatigue Capillary refill of 4 seconds Chest X ray result: Left hilar mass vs Aortic Aneurysm. Chest CT Scan (Plain) Aortic arc aneurismal dilatation. Vastarel MR 35 mg 1 tab BID Losartan 50 mg 1 tab. AC drip of 500 ml D5 water + 2 catapres + 2 Appresoline @ 15 gtts / min given by NOD. O2 inhalation of 1 Liter per minute.
ko lakat, as verbalized.
Objectives: (+) Weakness (+) Nonproductive, intense cough Bp = 160 / 100 mmHg With shortness of breath (+) weakness Hematology result: Segmenters = 70 % high Chest X ray: Bibasal Pneumonia Avelox 400 mg 1 tab. (+) fatigue (+) facial grimace Chest X ray result: Left hilar mass vs Aortic Aneurysm. Chest CT Scan (Plain) Aortic arc aneurismal dilatation.
8. Deficient knowledge r/t lack of information about current medical condition Subjective: Wala pa siya namon ginsugiran sang iya condition. as verbalized by the folks. Objectives: Has no idea about his aortic aneurysm
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min given by NOD. Chest CT Scan (Plain) Aortic arc aneurismal dilatation. Atherosclerotic aorta Cardiomegaly. Provided O2 inhalation of 1 Liter per minute.
Independent: Monitored vital signs; including blood pressure, heart rate, and respiratory rate. To monitor patient from any changes in his status. Elevated VS may indicate poor circulation and oxygenation.
Rest helps lower arterial pressure and reduces the workload of the myocardium by diminishing the requirements for cardiac output.
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Prevents compression in the thoracic region by the aneurysm. Thus, prevents further disturbances in the circulation.
Encouraged to immediately report ripping sensation within the chest accompanied by severe pain in the back between the shoulders.
Encouraged to keep in bed rest and avoid if not possible, limit physical activity.
Stress could bring tension; and blood pressure may increase due to tension. Thus, adding pressure to the affected vessel.
Encouraged not to elevate the legs above the level of the heart.
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Skin pallor and cold temperature of the skin signals poor circulation in the periphery.
Decreased cardiac output results in decreased perfusion of the kidney, with a resulting decrease in urine output.
Diagnosis Ineffective cardiac tissue perfusion r/t diminished arterial circulation to the cardiac muscle.
Planning To provide adequate cardiac perfusion as evidenced by the absence of shortness of breath, a decrease in episodes of
Rationale
Evaluation
Goal met. Adequate cardiac tissue perfusion was provided as evidence by respiratory rate of 22 breaths per minute with no complaints
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RR = 24 bpm (+) Weakness (+) Fatigue (+) Shortness of breath Chest pain when in supine position Capillary refill of 4 seconds
It selectively blocks the binding of angiotensin II to specific tissue receptors found in the vascular smooth muscle and adrenal gland; this action blocks the vasoconstriction effect of the rennin angiotensin system as well as the release of
of shortness of breath and blood pressure ranging from 140 / 100 to 160 / 100 millimeter of mercury after 8 hour of care.
Chest X ray result: Left hilar mass vs Aortic Aneurysm. Atheromatous aorta. Cardiomegaly AC drip = 500 ml D5 water + 2 catapres + 2 Appresoline @ 15 gtts / min given by Chest CT Scan (Plain) Aortic arc aneurismal dilatation. Atherosclerotic aorta. Cardiomegaly. Provided O2 inhalation of 1 Liter per minute. NOD.
To provide a systemic effect of antihypertensive and directly lowers down the blood pressure.
To supply supplemental oxygen needed by the cardiac muscle for metabolic demand.
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Independent: Monitored vital signs; including blood pressure, heart rate, and respiratory rate.
To monitor patient from any changes in his status. Elevated VS may indicate poor circulation and oxygenation.
Prevents compression in the thoracic region by the aneurysm. Thus, provides perfusion to the cardiac muscle and relieves chest pain.
Encouraged to immediately report ripping sensation within the chest accompanied by severe pain in the back between the shoulders.
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Encouraged to keep in bed rest and avoid if not possible, limit physical activity.
Stress could bring tension; and blood pressure may increase due to tension. Thus, adding pressure to the affected vessel.
Assessment Objectives: BP = 160/100 mmHg (+) Weakness (+) Fatigue Capillary refill of 4 seconds
Diagnosis Ineffective renal tissue perfusion r/t diminished arterial circulation to the kidney.
Planning To provide adequate renal perfusion as evidence by blood pressure of 140 / 80 to 150 / 100 mmHg within 8 hours of care.
Rationale
Evaluation
evidenced by blood pressure ranging from 140 / 100 to 160 / 100 millimeter of mercury.
found in the vascular smooth muscle and adrenal gland; this action blocks the vasoconstriction
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Chest X ray result: Left hilar mass vs Aortic Aneurysm. Atheromatous aorta. Cardiomegaly
effect of the rennin angiotensin system as well as the release of aldosterone leading to decreased Bp.
Chest CT Scan (Plain) Aortic arc aneurismal dilatation. Atherosclerotic aorta. Cardiomegaly.
To provide a systemic effect of antihypertensive and directly lowers down the blood pressure.
Independent: Monitored vital signs; including blood pressure, heart rate, and respiratory rate. To monitor patient from any changes in his status. Elevated VS may indicate poor circulation and oxygenation.
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Diagnosis Chronic pain r/t the disruption of normal circulation in the thoracic region.
Planning To alleviate level of pain as evidence by a decreases in pain scale from 5 - 6 to a pain scale of 2 - 3 after 4 hours of nursing intervention.
Rationale
Evaluation
It inhibits calcium ion influx across cardiac and smooth muscle cells, decreasing myocardial contractility and oxygen demand; also dilates coronary arteries and arterioles.
Goal met. The level of pain was alleviated as evidenced by pain scale of 2.
Objectives: BP = 160 / 100 mmHg With shortness of breath (+) Weakness (+) Fatigue (+) Chest pain with a pain scale of 5 to 6. (+) Facial grimace
May reduce cardiac oxygen demand by decreasing left ventricular end diastolic pressure (preload) and, to
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(+) Anorexia
To provide supplemental oxygen needed by the cardiac muscle. Lack of oxygen in the myocardial tissue can cause chest pain.
Independent: Encouraged to perform relaxation technique like deep breathing exercise. To assist in muscle and generalized relaxation.
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To monitor and evaluate client s pain status. VS is elevated when suffering from pain
This position makes him feel comfortable and helps in reducing pressure in the thoracic region which alleviates chest pain.
Assessment Objectives: BP = 160 / 100 mmHg Shortness of breath (+) Fatigue (+) Weakness (+) Nonproductive, intense cough
Rationale
Evaluation
Inhibits the enzymes needed for bacterial DNA replication, transcription, repair, and recombination.
Goal met. Mr. J.B shows improvement in his condition as evidenced by (-) cough, (-) weakness and
including temperature.
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high
procedures.
Diagnosis Activity intolerance r/t limited physical activity 2 to possible rupture of aneurysm.
Rationale
Evaluation
Goal met. Mr. J.B improved his activity tolerance as evidenced by ability to perform activity like sitting on chair, walking around the room and going to the
Objectives: Bp = 160 / 100 mmHg With shortness of breath (+) weakness (+) fatigue (+) facial grimace Instructed to stop activity immediately if experiencing chest tightness, unusual fatigue, dizziness and discomfort.
These are common symptoms of angina and are cause by a temporary insufficiency of coronary blood supply.
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Monitored vital signs; including blood pressure, heart rate and respiratory rate.
Rest helps lower arterial pressure and reduces the workload of myocardium.
Assessment Subjective: Wala ako nakatulog mayad kay sagad binalik balik sang nurse, as verbalized.
Diagnosis Sleep deprivation r/t coming in and out of staff nurses in the room.
Intervention Independent: Promoted adequate physical exercise activity as tolerated during day.
Rationale
Evaluation
It enhances expenditure of energy and release of tension so that client feels ready for sleep.
Goal met. Mr. J.B demonstrated an improvement in sleep/rest pattern as evidenced by a sleep with a long interval.
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Objective: (+) Weakness (+) Fatigue (+) Facial grimace (+) Anorexia Slowed reaction
Minimized coming in and out of the room by doing things at the same time as possible.
Assessment Subjective: Wala pa siya namon ginsugiran sang iya condition. as verbalized by the folks.
Diagnosis Deficient knowledge r/t lack of information about current medical condition.
Planning To provide understanding about his current condition and health maintenance without mentioning aortic aneurysm within the shift.
Rationale
Evaluation
Goal met. Mr. J.B was able to understand his condition as evidenced by realization that his blood pressure had
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increased continuously due to decreased compliance in medication and regular check up, kinahanglan ko nagid emonitor akon
Informed to watch for ripping sensation within the chest accompanied by severe pain in the back between the shoulder blades; and immediately bring him to the nearest hospital as possible.
To provide awareness that this symptom is an emergency situation. Thus, prompt action or intervention is necessary.
Discussed the importance of strict compliance to medication & regular check up.
drugs and antiangina is necessary to maintain blood pressure between its normal range and relieves chest pain.
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Emphasized the significance of controlling blood pressure without mentioning anything about his aortic aneurysm.
This may enhance the knowledge of the patient regarding the potential health problems that may occur due to a high blood pressure; and could motivate him to strictly comply to its treatment.
Assessment Objectives: BP = 160 / 100 mmHg Shortness of breath Facial grimace (+) Weakness (+) Fatigue Capillary refill of 4 seconds
Diagnosis Risk for deficient fluid volume: hemorrhage r/t potential abnormal blood loss secondary to possible rupture of aneurysm.
Planning To prevent the risk for deficient fluid volume within 8 hour shift.
Rationale
Evaluation
Goal met. The risk for deficient fluid volume was prevented as
It selectively blocks the binding of angiotensin II to specific tissue receptors found in the vascular smooth muscle and
evidenced by the absence of hemorrhage or abnormal blood loss due to rupture of the aneurysm.
adrenal gland; this action blocks the vasoconstriction effect of the rennin
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angiotensin system as well Chest CT Scan (Plain) Aortic arc aneurismal dilatation. as the release of aldosterone leading to decreased Bp.
To provide a systemic effect of antihypertensive and directly lowers down the blood pressure.
Independent: Monitored intake and output. A urine output of < 30 cc per hour is insufficient for normal kidney function and indicates hypovolemia or onset of renal damage.
To check for signs of hypovolemia; including low Bp and increased heart rate respiratory rate.
Encouraged to limit
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tension. These can contribute to an increase in Bp that adds pressure into the aneurysm.
Informed to watch for ripping sensation within the chest accompanied by severe pain in the back between the shoulder blades; and immediately notify staff nurses or physician if it is being felt.
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DISCHARGE PLANNING
edications
Encourage the patient to have a strict compliance with regards to the medication to attain therapeutic effects. Explain to the patient the use and side effects of the medications so that he will be aware of its effects. Give adequate instructions to the significant others about the importance of the following medications and dietary regimens so that the patient s condition can remain stable as soon as possible. 1. Hyzaar 100mg / 25 mg 1 tab at 6 am 2. Dilzem 60 mg 1 tab 3x a day 3. Vastarel MR 25 mg b.i.d p.c 4. Imdur 30 mg o.d 1 tab at 8 am 5. Avelox 400mg 1 tab p.c lunch 6. Neoform 1 tab o.d p.c breakfast 7. Lilac 30 cc HS if no BM. 8. Iterax tab HS 9. Lipitor 40 mg tab HS
xercise
Educate the patient about bed exercises such as leg exercise, since patient have limitations on his physical activity because of possible rupture of aneurysm. Instruct not to carry heavy objects. Teach how to perform range-of-motion exercises as tolerated to prevent muscle shortening and any factors that may contribute to limitation of motion. It also maintains or increases proper joint movement and flexibility. Encourage to have a regular exercise.
reatment
Aware the patient to avoid over work for the following days and must have adequate bed rest to regain energy or strength. By means of anticipating the needs on the course of healing and curing process, train the patient to focused to himself by not always depending on the interventions that are not highly needed just to ease or prevent any health problem regarding his condition.
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Encourage to comply on further treatment for the proper maintenance and gain of optimal health by means of anticipating the needs on the course of optimum wellness.
ome teaching
To promote adherence to the therapeutic programs. Teach the following:
Environmental sanitation is needed to provide a therapeutic way of curing himself. Teach the patient and family how to measure blood pressure. Encourage the folks to regularly monitor his blood pressure. Instruct not to carry objects or avoid stressful activities. Limit physical activities. Inform to watch for ripping sensation within the chest accompanied by severe pain in the back between the shoulder blades; and immediately bring him to the nearest hospital as possible. Discus the importance of strict compliance to medication & regular check up.
ut-patient
Remind the patient that he must come back to the hospital one week after, for the follow-up check-up to confirm if the patient s condition is really restored. Also to know if there are complications sited during the check up to know if patients condition have worsen or not. Advise patient and the family to report to the physician if any recurrence or severity of symptoms, any adverse effects to the medication, and any development of complications. Advise patient to comply with the medication strictly as well as to regular check up. Teach the patient about the importance of continuing medications that is prescribed by the physician.
iet
Advise to eat nutritious food would somehow help the patient on regaining some strengths or energy to his body, such as green leafy vegetables Inform the client and the client s relatives on the specific types of food that may help speed
up the recovery from the condition; including low salt, low cholesterol and low fat.
pirituality
Encourage the patient to read the Bible and pray to God always, ask for guidance and pray for the healing and restoration of health. Ask the patient to reflect on the Bible Scripture, For I will restore health to you and heal you on your wounds. says the Lord. (Jeremiah 30:17). Always seek spiritual advice and go on Sunday masses.
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PROGNOSIS
Two weeks after our clinical care to Mr. J.B, July 17, 2011, during our after care visit at North Natividad, Pilar, Capiz; he was able to comply all his medications on time which includes: Hyzaar 100mg / 25 mg 1 tab at 6 am Dilzem 60 mg 1 tab 3x a day Vastarel MR 25 mg b.i.d p.c Imdur 30 mg o.d 1 tab at 8 am Avelox 400mg 1 tab p.c lunch Neoform 1 tab o.d p.c breakfast Lilac 30 cc HS if no BM. Iterax tab HS Lipitor 40 mg tab HS And last July 28, 2011 he went to his attending physician together with his wife and undergone different laboratories related to his condition.
As we have our follow-up care, we observed that Mr. J.B was capable of performing activities of daily living by himself. He is also walking in the seashore every morning and before the sun sets as one of his recreational activities. This habit of Mr. J.B becomes a routine activity of him, wherein it makes him feel unwind and calm.
His family also helps him by monitoring his blood pressure regularly. The seafoods and sodium rich foods that is being prepared every meal was also lessen and sometimes, he was discouraged to eat those mentioned foods and to carry heavy objects or exert much effort and pressure in every activities.
Moreover, Mr. J.B complained episodes of full to heavy chest pain in a tolerable level. There is no episodes of shortness of breath and slept in a high back rest position as described. According to his wife, is blood pressure ranges from 160 / 100 to 140 / 90 millimeter of mercury. Mr. J.B s latest vital signs were: Blood pressure of 150 / 100 millimeter of mercury Heart rate of 89 beats per minute Respiratory rate of 21 breaths per minute; and Pulse rate of 84 beats per minute.
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JOURNEY
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ACKNOWLEDGEMENT
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REFERENCE
http://www.nlm.nih.gov/medlineplus/ency/article/001119.htm Brunner & Suddarths Textbook of Medical Surgical Nursing, eleventh edition http://en.wikipedia.org/wiki/Thoracic_aortic_aneurysm http://www.slrctsurgery.com/Thoracic%20aortic%20aneurysms.htm http://www.mayoclinic.com/health/aortic-aneurysm/DS00017/DSECTION=lifestyle-and-homeremedies http://www.wrongdiagnosis.com/a/aortic_aneurysm/prevalence.htm http:/www.mims.com
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