A. DEMOGRAPHICAL DATA Name: Gender: Age: 80 D. G.

B Female

Religion: Iglesia ni Cristo Occupation: Self - employed Usual Source of Medical Care: Hospital Date of Admission: June 18, 2011 Initial Diagnosis: T/C AMI, DM Type 2

B. SOURCE AND RELIABILITY OF INFORMATION Information that is obtained came from the patient's chart. The patient is currently unconscious and can not talk.

C. REASONS FOR SEEKING CARE OR CHIEF COMPLAINTS 1. Chest Pain 2. Loss of Conscious 3. Difficulty in breathing

D.HISTORY OF PRESENT ILLNESS/ OR PRESENT HEALTH

E. PAST MEDICAL HISTORY OR PAST HEALTH

F. DEVELOPMENTAL HISTORY According to Erik Erickson Developmental Theory the patient was in Integrity vs. Despair Developmental Stage. Some adults may reach this stage and despair at their experiences and perceived failures. They may fear death as they struggle to find a purpose to their lives, wondering "Was the trip worth it?" Alternatively, they may feel they have all the answers (not unlike going back to adolescence) and end with a strong dogmatism that only their view has been correct.

G. REVIEW OF SYSTEM AND PHYSICAL EXAMINATION 1. ROS and PE

June 28, 2011

SYSTEM A. General/ Overall health status

REVIEW OF SYSTEM No verbal cues

PHYSICAL EXAMINATION Unconscious Cyanotic

SIGNIFICANCE

B. Integument (skin, hair, nail)

C. Head

D. Eyes

E. Ears

F. Nose and Sinuses

G. Mouth and Throat

H. Neck

I. Breast and Axillary

J. Respiratory

(+) gasping

K. Cardiovascular

Weak heart rate upon auscultation

L. Gastrointestinal M. Urinary

N. Genitalia O. Musculoskeletal

P. Neurologic

Q. Hematologic

R. Endocrine

2. LABORATORY STUDIES / DIAGNOSTICS

3. OTHER ASSESSMENT TOOLS Date Taken June 18, 2011 Comprehensive Actual Content/ Legend Glasgow Coma Scale or GCS is a neurological scale that aims to give a reliable, objective way of recording the conscious state of a person for initial as well as subsequent assessment. A patient is assessed against the criteria of the scale, and the resulting points give a patient score between 3 (indicating deep unconsciousness) and either 14 (original scale) or 15 (the more widely used modified or revised scale). GCS was initially used to assess level of consciousness after head injury, and the scale is now used by first aid, EMS, and doctors as being applicable to all acute medical and trauma patients. In hospitals it is also used in monitoring chronic patients in intensive care. Best eye response (E) There are 4 grades starting with the most severe: 1. No eye opening Eye opening in response to pain. (Patient responds to pressure on the patients fingernail bed; if this does not elicit a response,supraorbital and sternal pressure or rub may be used.) 3. Eye opening to speech. (Not to be confused with an awaking of a sleeping person; such patients receive a score of 4, not 3.) 4. Eyes opening spontaneously Actual Result Eyes Response Eye opening spontaneously (4)

Verbal Response No verbal response (1)

Motor Response No response (1)

2.

Best verbal response (V) There are 5 grades starting with the most severe:

1. No verbal response 2. Incomprehensible sounds. (Moaning but no words.) 3. Inappropriate words. (Random or exclamatory articulated speech, but no conversational exchange) 4. Confused. (The patient responds to questions coherently but there is some disorientation and confusion.) 5. Oriented. (Patient responds coherently and appropriately to questions such as the patients name and age, where they are and why, the year, month, etc.) Best motor response (M) There are 6 grades starting with the most severe: 1. No motor response 2. Extension to pain (abduction of arm, internal rotation of shoulder, pronation of forearm, extension of wrist, decerebrate response) 3. Abnormal flexion to pain (adduction of arm, internal rotation of shoulder, pronation of forearm, flexion of wrist, decorticate response) 4. Flexion/Withdrawal to pain (flexion of elbow, supination of forearm, flexion of wrist when supra-orbital pressure applied ; pulls part of body away when nailbed pinched) 5. Localizes to pain. (Purposeful movements towards painful stimuli; e.g., hand crosses mid-line and gets above clavicle when supra-orbital pressure applied.) 6. Obeys commands. (The patient does simple things as asked.)

ANATOMY AND PHYSIOLOGY The cardiovascular system can be thought of as the transport system of the body. This system has three main components: the heart, the blood vessel and the blood itself. The heart is the system's pump and the blood vessels are like the delivery routes. Blood can be thought of as a fluid which contains the oxygen and nutrients the body needs and carries the wastes which need to be removed. The following information describes the structure and function of the heart and the cardiovascular system as a whole. Structure and Function of the Heart Function and Location of the Heart

The heart's job is to pump blood around the body. The heart is located in between the two lungs. It lies left of the middle of the chest. Structure of the Heart The heart is a muscle about the size of a fist, and is roughly cone-shaped. It is about 12cm long, 9cm across the broadest point and about 6cm thick. The pericardium is a fibrous covering which wraps around the whole heart. It holds the heart in place but allows it to move as it beats. The wall of the heart itself is made up of a special type of muscle called cardiac muscle. Chambers of the Heart The heart has two sides, the right side and the left side. The heart has four chambers. The left and right side each have two chambers, a top chamber and a bottom chamber. The two top chambers are known as the left and right atria(singular: atrium). The atria receive blood from different sources. The left atrium receives blood from the lungs and the right atrium receives blood from the rest of the body. The bottom two chambers are known as the left and right ventricles. The ventricles pump blood out to different parts of the body. The right ventricle pumps blood to the lungs while the left ventricle pumps out blood to the rest of the body. The ventricles have much thicker walls than the atria which allows them to perform more work by pumping out blood to the whole body. Blood Vessels Blood Vessel is tubes which carry blood. Veins are blood vessels which carry blood from the body back to the heart. Arteries are blood vessels which carry blood from the heart to the body. There are also microscopic blood vessels which connect arteries and veins together called capillaries. There are a few main blood vessels which connect to different chambers of the heart. The aorta is the largest artery in our body. The left ventricle pumps blood into the aorta which then carries it to the rest of the body through smaller arteries. The pulmonary trunk is the large artery which the right ventricle pumps into. It splits into pulmonary arteries which take the blood to the lungs. The pulmonary veins take blood from the lungs to the left atrium. All the other veins in our body drain into the inferior vena cava (IVC) or the superior. These two large veins then take the blood from the rest of the body into the right atrium. Valves Valves are fibrous flaps of tissue found between the heart chambers and in the blood vessels. They are rather like gates which prevent blood from flowing in the wrong direction. They are found in a number of places. Valves between the atria and ventricles are known as the right and left atrioventricular valves, otherwise known as the tricuspid and mitral valves respectively. Valves between the ventricles and the great arteries are known as the semilunar valves. The aortic is found at the base of the aorta, while the pulmonary valve is found the base of the pulmonary trunk. There are also many valves found in veins throughout the body. However, there are no valves found in any of the other arteries besides the aorta and pulmonary trunk. What is the Cardiovascular System The cardiovascular system refers to the heart, blood vessels and the blood. Blood contains oxygen and other nutrients which your body needs to survive. The body takes these essential nutrients from the blood. At the same time, the body dumps waste products like carbon dioxide, back into the blood, so they can be removed. The main function of the cardiovascular system is therefore to maintain blood flow to all parts of the body, to allow it to survive. Veins deliver used blood from the body back to the heart. Blood in the veins is low in oxygen (as it has been taken out by the body) and high in carbon dioxide (as the body has unloaded it back into the blood). All the veins drain into the superior and inferior vena cava which then drain into the right atrium. The right atrium pumps blood into the right ventricle. Then the right ventricle pumps blood to the pulmonary trunk, through the pulmonary arteries and into the lungs. In the lungs the blood picks up oxygen that we breathe in and gets rid of carbon dioxide, which we breathe out. The blood is becomes rich in oxygen which the body can use. From the lungs, blood drains into the left atrium and is then pumped into the left ventricle. The left ventricle then pumps this oxygen-rich blood out into the aorta which then distributes it to the rest of the body through other arteries. The main arteries which branch off the aorta and take blood to specific parts of the body are: Carotid arteries, which take blood to the neck and head Coronary arteries, which provide blood supply to the heart itself Hepatic artery, which takes blood to the liver with branches going to the stomach

 Mesenteric artery, which takes blood to the intestines Renal arteries, which takes blood to the kidneys Femoral arteries, which take blood to the legs The body is then able to use the oxygen in the blood to carry out its normal functions. This blood will again return back to the heart through the veins and the cycle continues.

What is the Cardiac Cycle The cardiac cycle is the sequence of events that occurs in one complete beat of the heart. The pumping phase of the cycle, also known as systole, occurs when heart muscle contracts. The filling phase, which is known as diastole, occurs when heart muscle relaxes. At the beginning of the cardiac cycle, both atria and ventricles are in diastole. During this time, all the chambers of the heart are relaxed and receive blood. The atrioventricular valves are open. Atrial systolefollows this phase. During atrial systole, the left and right atria contract at the same time and push blood into the left and right ventricles, respectively. The next phase is ventricular systole. During ventricular systole, the left and right ventricles contract at the same time and pump blood into the aorta and pulmonary trunk, respectively. In ventricular systole, the atria are relaxed and receive blood. The atrioventricular valves close immediately after ventricular systole begins to stop blood going back into the atria. However, the semilunar valves are open during this phase to allow the blood to flow into the aorta and pulmonary trunk. Following this phase, the ventricles relax that is ventricular diastoleoccurs. The semilunar valves close to stop the blood from flowing back into the ventricles from the aorta and pulmonary trunk. The atria and ventricles once again are in diastole together and the cycle begins again. PATHOPHYSIOLOGY

MEDICAL SURGICAL MANAGEMENT 1. Procedure (Surgery)

Procedure/ Date Tracheostomy / July 5 2011

Indication/ Analysis INDICATION

1. To relieve breathing difficulties by any

blockage in the airway passages.

2. To improve respiratory functions by

reducing the length of the airway, which may be required in special lung conditions like- Bronchopneumonia

3. Respiratory nerve damage temporary or

permanent causing paralysis of chest muscles that assist in breathing. In these situations performing assisted or positive pressure respirations may be required in conditions

4. As a preliminary step in certain surgeries

on the upper airway. ANALYS

Central Venous Pressure / July 5 2011

1. Monitoring of the central venous 2. 3.

4. 5. 6. 7. pressure (CVP) in acutely ill patients to quantify fluid balance Long-term Intravenous antibiotics Long-term Parenteral nutrition especially in chronically ill patients Long-term pain medications Chemotherapy Frequent blood draws Frequent or persistent requirement for intravenous access Need for intravenous therapy when peripheral venous access is impossible

8.

Wound debridement / July 5 2011

An open wound or ulcer can not be properly evaluated until the dead tissue or foreign matter is removed. Wounds that contain necrotic and

ischemic (low oxygen content) tissue take longer to close and heal. This is because necrotic tissue provides an ideal growth medium for bacteria, especially for Bacteroides spp. and Clostridium perfringens that causes the gas gangrene so feared in military medical practice. Though a wound may not necessarily be infected, the bacteria can cause inflammation and strain the body's ability to fight infection. Debridement is also used to treat pockets of pus called abscesses. Abscesses can develop into a general infection that may invade the bloodstream (sepsis) and lead to amputation and even death. Burned tissue or tissue exposed to corrosive substances tends to form a hard black crust, called an eschar, while deeper tissue remains moist and white, yellow and soft, or flimsy and inflamed. Eschars may also require debridement to promote healing.