A Case Study on Emphysema

A Partial Requirement in NCM 103

Submitted by: Majkel Benche Cust di

!ebruary "#$ "01%

vi. Introduction
A. Background of the study
&he case study that is t be 'resented (eatures a 'atient )h has em'hysema* +m'hysema is a chr nic bstructi,e 'ulm nary disease -C.P/0* 1t is (ten caused by e2' sure t t 2ic chemicals$ includin3 l n34term e2' sure t t bacc sm ke r ci3arette sm kin3* &he lun3s bec me dama3ed because ( reacti ns t irritants enterin3 the air)ays and al,e li* Ci3arette sm kin3 is the maj r cause ( em'hysema$ acc untin3 ( r m re than 50 'ercent ( all cases* +m'hysema ccurs m st (ten in 'e 'le lder than a3e %0 )h ha,e sm ked ( r many years* 6 n34term e2' sure t sec ndhand sm ke may als 'lay a r le* Sm kin3 stresses the natural anti 2idant de(ense system ( the lun3$ all )in3 (ree radicals t dama3e tissue d )n t the cellular le,el* 7hen ci3arette sm ke is inhaled$ 50 t 80 'er cent remains in the lun3s and causes irritati n$ increased mucus 'r ducti n and dama3e t the dee' 'arts ( the lun3s* +,entually mucus and tar cl 3 u' the air tubes$ causin3 chr nic br nchitis and em'hysema* Am n3 ther causes ( em'hysema are industrial ' llutants$ aer s l s'rays$ n n4t bacc sm ke$ internal4c mbusti n en3ine e2haust$ and 'hysi l 3ical atr 'hy ass ciated )ith ld a3e -senile em'hysema0* 1t )as ,erbali9ed by the )i(e ( the 'atient that he used t ) rk at the (arm in M r n3* this c uld be ne (act r that caused the 'atient:s disease* +m'hysema is characteri9ed by l ss ( elasticity -increased 'ulm nary c m'liance0 ( the lun3 tissue caused by destructi n ( structures (eedin3 the al,e li$ )in3 t the acti n ( al'ha 1 antitry'sin de(iciency* &his causes the small air)ays t c lla'se durin3 ( rced e2halati n$ as al,e lar c lla'sibility has decreased* As a result$ air(l ) is im'eded and air bec mes tra''ed in the lun3s$ in the same )ay as ther bstructi,e lun3 diseases* Sym't ms include sh rtness ( breath n e2erti n$ and an e2'anded chest* ; )e,er$ the c nstricti n ( air 'assa3es isn<t al)ays immediately deadly$ and treatment is a,ailable* +m'hysema is (ten the result ( sm ke that has tri33ered the immune system t 'r duce m re harm(ul en9ymes* Alth u3h these harm(ul en9ymes are n rmally 're,ented (r m causin3 any si3ni(icant dama3e by a 'r tecti,e 'r tein$ sm kin3 reduces the 'r tein:s 'r tecti,e e((ect* +,en i( s me ne has 'lenty ( the 'r tein in their system$ sm kin3 3enerates certain substances that kee' the 'r tecti,e 'r tein (r m d in3 its j b* 7e as nurses are in, l,ed in learnin3 )hat ty'e ( nursin3 inter,enti ns )e are t a''ly t this ty'e ( 'atient* Bey nd understandin3 the rele,ant health issue$ this case study )ill als e2'l re ther (act rs that can enhance ur kn )led3e in the (ield ( ur nursin3 'ractice* &his is als the 'rimary reas n )hy )e ch se this case study because )e kn ) that it is hi3hly bene(icial aside (r m it bein3 c nsidered distincti,e r unique* 1ncluded )ith the case study are the discussi ns ( the anat mical 'arts$ thr u3h 'hysical assessment ( the 'atient$ lab rat ry results and their c rres' ndin3 (indin3s$ a rea''lied (rame) rk the ry by !l rence Ni3htin3ale* Added t this )e als ha,e a c rres' ndin3 'lan ( r "

the 'atients dischar3e arran3ement and (inally a discussi n ( the 'atient:s daily acti,ities and nursin3 care 'lans* B.

Objectives
Genera objectives

A(ter e2' sure in the medical )ard ( =ueen Mary ; s'ital the 'r m ti n ( health and the 're,enti n ( illness sh uld ha,e been a''lied thr u3h the use ( e((ecti,e nursin3 care* 7ellness sh uld be met thr u3h the im'lementati ns that ha,e been d ne )ith re3ards t the a''licati n ( the nursin3 'r cess* &hat is a(ter de,el 'in3 and im'lementin3 an inter,enti n$ and m nit rin3 the im'act ( that inter,enti n t the 'atient* &his is t kn ) )hether the treatments 3i,en t him )ere e((ecti,e r n t* Specific Objectives .ur bjecti,e is t de,el ' ur skills in identi(yin3 and assessin3 the health 'r blems$ h ) t utili9e and render quality health ser,ice in the care ( an indi,idual )h has em'hysema* .ther bjecti,es ) uld include the establishment ( ra'' rt ( r the 'atient t (ully c 'erate )ith his treatment and s as t assess him )ith his health related 'r blem*

I.

!ursing Assessment
A. "ersona #ata

!ame$ Mr* 6P Address$ >* R bles Mayban3kal Street$ M r n3$ Ri9al Age$ ?1 years ld Birth date$ March 30$ 18%5 %e igion$ R man Cath lic Civi Status$ Married !ationa ity$ !ili'in Occupation$ ! rmer !armer Admitted on$ @une "1$ "008 &ime$ 8:10 '*m* Admitting #iagnosis$ C.P/ in e2acerbati n$ Plural +((usi n$ Pneum nia$ tAc +lectr lyte imbalance o Chief Comp aint$ /*.*B* -/i((iculty ( Breathin30 o o o o o o o o o o o

B. 'istory of "ast i ness

Patient has under3 ne$ th racentesis last @une 1B at =ueen Mary ;el' ( Christians h s'ital 'ri r t that admissi n he )as dia3n se )ith 'lural e((usi n$ th racentesis )as 'er( rm and a(ter B days ( admissi n he )as dischar3e h me*

C. 'istory of "resent I ness

A(ter the 'atient )as dischar3e h me ar und 5:B0'm -@une 1B$ "0080 a(ter 3 days at h me he e2'erienced /.B and he )as rush t the h s'ital acc m'anied by his )i(e and c usins* 4C.P/ 4=uesti nable Pneum nia 4+lectr lyte 1mbalance

#. (ami y 'istory
Acc rdin3 t 'atients )i(e they can n t recall any illness in the (amily ( his husband e2ce't (r m asthma*

E. "atient)s Concept of 'ea th I ness and 'ospita i*ation

;e didn:t e2'ect that this ) uld ha''en t him$ d ct rs d esn:t ha,e any idea ( the s urce ( his illness but the 'atient says$ that it mi3ht be (r m the ) rk$ he th u3ht that it ) uld just be a sim'le c u3h due t tirin3 day but it lasted ( r ab ut a m nth and he needs t be admitted and under3 ne s me 'r cedures*

(. "hysica E+amination,Assessment
Area 1* ;air !orma (inding 4 black$ e,enly distributed and c ,ers the )h le scal'$ thick$ shiny$ (ree (r m s'lit ends 4 )hite$ clean$ (ree (r m masses$ lum's$ scars$ dandru(( and lesi ns 4 .bl n3 r ,al* Symmetrical* !acial e2'ressi n that is de'endent n the m d r true Actua (inding I. 'ead 4 black sli3htly 3rayish $ thick* Ana ysis 4A3in3

"* Scal'

4 )ith ut dandru((

4 n rmal

3* !ace

4 7ith )rinkles$ symmetrical* 7ith e2'ressi n ( 'ain and an2iety

4 'atient is still ) rried ab ut his c nditi n and a''earance %

%* +yes

B* N se

?* 6i's

#* &eeth and >ums

(eelin3s$ sm th and (ree (r m )rinkles$ n in, luntary muscles in, l,ed 4 'arallel and e,enly 'laced$ symmetrical$ n n4'r trudin3$ b th eyes are black and clear 4 midline$ symmetrical and 'atent clear 'inkish )ith (e) cilia -40 c n3esti n 4 'inkish$ symmetrical$ ti' mar3in )ell de(ine$ sm th and m ist 4 3" 'ermanent teeth$ )ell ali3ned$ (ree (r m carries r (ilin3* 4N h arseness and )ell C m dulated* Can able t say t) ) rds )ith meanin3

4 symmetrical$ black in c l r and can still read )ith ut 3lasses 4 symmetrical )ith N>&

4 n rmal

4 'atient has under3 ne sur3ery

4 crack and dry li's

4 )ith ut dentures$ 3ums are n rmal in c l r Can n t s'eak$ makes s me m derate n ise$ can c mmunicate )ith si3n lan3ua3e r by )ritin3*

4 'atient )asn:t able t eat and drink that much due t his trache t my 4 'atient )as instructed t 3ar3le bactid l &rache st my can bl ck the , cal c rds that:s )hy 'atient )asn:t able t make any s unds

5* S'eech

8* +ars

4Parallel$ symmetrical$ 'r ' rti nal t the si9e ( the head$ bean sha'ed$ heli2 is in line )ith the uter canthus ( the eye$ skin is the same c l r as the surr undin3 area$ clean$ (irm cartila3e* +ar canals are 'inkish )ith scant am unt ( cerumen and a (e) cilia* Able t hear )his'er s' ken " (eet a)ay* 4N halit sis$ ( ul d r$ (ruity and s)eet* 4N in(lammati n$ n di((iculty in s)all )in3 and n 'r ducti,e c u3h*

4N rmal !indin3s e2ce't$ +nable t hear )his'er s' ken " (eet a)ay*

4A3in3

10* Breath

4 7ith minimal halit sis 4 N in(lammati n$ Presences ( c u3h )ith 3reenish yell ) 'hle3m and e2'eriencin3 di((iculty in s)all )in3 4 Presences ( 'al'able lum's$ sensati n ( 'ain )hen tryin3 t s'eak*

4 ;alit sis may be due t ' r dental hy3iene 4e2cessi,e mucus 'r ducti n in his l )er lun3 due t im'aired de(ense mechanisms caused by 'r l n3ed years ( sm kin3* 4 6ym'h n des are 'resent a(ter sur3ery$ 'atient:s (eels 'ain in the neck due t b dy )eakness in the area ( trache st my*

11* &hr at

1"* Neck

4 Pr ' rti nal t the si9e ( b dy and head$ symmetrical and strai3ht* N. 'al'able lum's$ masses$ r areas ( tenderness

II. &hora+

1* Breathin3

4 N rmal breath s unds are br nch ,esicular$ a medium 'itched s und r medium intensity$ heard ' syeri rly bet)een the sca'ulae* &he s und ha,e bl )in3 quality )ith the ins'irat ry 'hase equal t the e2'irat ry 'hase and Desicular s unds )hich heard ,er the lun3 'eri'hery* 1t created by air m ,in3 thr u3h the small air)ays* &hey are s (t$ bree9y and l ) 'itched and the ins'irat ry 'hase is ab ut three times l n3er than the e2'irat ry 'hase* Res'irati n rate ran3es (r m 1? C "0 in n rmal adult* 4 (lat chest$ tender: br )nish in c l r*

4 Abn rmal Res'irati n %0b'm$ di((iculty in breathin3* +2'eriencin3 c u3h a(ter nebuli9ati n*

4 +2cessi,e 'hle3m 'r ducti n bl cks his th ra2 and this may cause di((iculty in breathin3*

"* chest

4 a tube is inserted in the (i(th interc stals s'ace$ mid4a2illary line* 4 Enblemished skin$ uni( rm c l r$ symmetric m ,ement cause by res'irati n $ s (t$ n tenderness$ n lum's r masses$

4 t rem ,e (luid (r m the intrath racic s'ace 4 n rmal

3* Abd minal +2am

4 C l r is uni( rm$ symmetrical m ,ement caused by res'irati n* S (t abd men$ n tenderness$ n lum's$ r masses$ n r3an me3aly

III. -imbs #

1* +2tremeties

4 n areas ( tenderness$ muscle a''ear )ith 3 d muscle t ne

4 )ith 1D catheter n his ri3ht arm and a red s' ts in the site ( the 1D catheter* 4 'ale nail beds and 'eri'heral last ( r %sec nds 4&here are n dischar3es r any bleedin3* 4 ;e can ans)erAres' nd t us a little bit sl )ly*

4 red s' ts may cause itchiness in the site ( 1D and als this may cause in(ecti n r 'hlebitis* 4' r circulati n

"* Nails

4 trans'arent$ sm th and c ,er )ith 'ink nail beds and translucent 4N dischar3es r bleedin3$ n di((iculty in urinatin3* 4 Can be able t res' nds (r m any questi ns and can still be (amiliar t his en,ir nment

I.. Genita ia

4Patients urinate n the bed 'an

.. /enta State

4 Sli3htly an2i us ab ut his c nditi n$ and tries t think ab ut )hat )hen )r n3 be( re he e2'erience his illness* 4 Patient has a draina3e tube at his chest and under3 ne trache st my$ 'atients e2'eriencin3 b dy )eakness can n t m ,e 'r 'erly

.I. 'ygiene and comfort

4 !ull bath and able t 'ractice sim'le hy3iene and care ( r himsel(*

4 Patients de'ends n si3ni(icant thers in eatin3$ takin3 a bath -&SB0 and ther ch res that in, l,es )ide m ,ement*

II.

A!A&O/0

&he Res'irat ry System

"arts of the %espiratory System

Structurally$ the res'irat ry system c nsists ( t) 'arts:

1* E''er Res'irat ry &ract "* 6 )er Res'irat ry &ract !uncti nally$ the res'irat ry system c nsists ( t) 'arts: 1* &he c nductin3 ' rti n "* &he res'irat ry ' rti n %espiratory &ract &he res'irat ry tract is the 'ath ( air (r m the n se t the lun3s* 1t is di,ided int t) secti ns: E''er Res'irat ry &ract 6 )er Res'irat ry &ract 1pper respiratory tract 1* N se "* Pharyn2 -thr at0 3* Ass ciated structures -o2er %espiratory &ract 1* 6aryn2 -, ice b 20 "* &rachea -)ind'i'e0 3* Br nchi %* 6un3s 8

III. -aboratory E+amination

/icrobio ogy
S'ecimen: Pleural !luid Result: N Path 3enic .r3anism is lated a(ter 3 days .( intebati n* /r* N el C* Sant s M/ !PSP

#ate$ 3456476

Chemistry &est
Na 1%"*? -13#41%Bmm l0 M3 *80 -*??4*8Bmm lA60 BEN ?*B -3*"4#*1mm lA60 Creatinine 83 -#14133mm lA60 S>P&-A6&0 %B -134?1mm lA60 S>.& 18 -1%4B0mm lA60 F 3*?" -3*B4B*1mm lA60 & tal C;.N ?" -?345">A60 Albumin 31 -3B4B0 >A60 >l bulin 31 AA> Rati 1*0

#ate$ 3488476

'istopatho ogy
4Ne3ati,e ( r Mali3nancy$ Pleural !luid $Cyt l 3y

#ate$ 3488476

4>r ssAMicr sc 'ic descri'ti ns submitted ( r cyt l 3y is a 16 G %0ml dirty yell ) (luid* 4Micr sh ) reacti,e mes thelial cells$ lym'h cytes$ ccasi nal ' lys* N mali3nant cell seen* Mennen A* Als l M*/* Path l 3ist 10

'emato ogy
;3b 4 1B# ;emat crit 4 0*%5 7BC 4 1B*5 Se3menters 4 0*80 6ym'h cyctes 4 0*0# M n cytes 4 0*03 -1"041B03A60 -0*3#40*%#0 -B*0410*0210A60 -0*%"40*#B0 -0*"040*B10 -0*0"40*080

#ate$ 3489476

1nter'retati n: P lycythemia )ith in(ecti n related t 'leural e((usi n

"rotime
C ntr l H 10*" sec* Pt H #*5 sec* 1DR H 0*50 Iacti,ity H 131I

#ate$ 3489476

Sero ogy : Immuno ogy

&est: Pr state s'eci(ic anti3en S'ecimen: Serum Result: 1*30 m3Aml N rmal Dalues: 6ess than %*0m3Aml Pls* N te: C lerate clinically N el C* Sant s M/ !PSP

#ate$ 3489476

ECG
Rhythm: Sinus =RS a2is #0 Rate: Auricular 1"0Amin* Dentricular: 1"0Amin* PR inter,al 0*1? sec* =RS inter,al 0*10 sec*

#ate$ 3483476

11

=& inter,al 0*3? sec* 1nter'retati n: Sinus tachycardia 6e(t atrial enlar3ement$ 'ersistent (e,er$ di((use n ns'eci(ic &4 )a,e chan3es*

1rina ysis
C l r: Jell ) &rans'arency: &urbid Reacti n: B*0 S'eci(ic >ra,ity: 1*01B Su3ar: ne3ati,e Pr tein: ' siti,e Puss: %*BAh'( RBC: !e) +'ithelial: !e) Erates: !e) Mucus threads: !e) /r* Mennen Als l M/

#ate$ 7348;476

'istopatho ogy
S'ecimen: D cal c rd masses

#ate$ 3486476

Path l 3ic /2 4Squam us 'a'ill mas sh )in3 chr nic n n4s'eci(ic in(lammati n$ Ri3ht and 6e(t , cal c rds* >r ssAmicr descri'ti n 4S'ecimen c nsist ( 3rayish )hite tissue (ra3ments measurin3 as labeled A* 120*?cm and B* 1*120*Bcm +ntire s'ecimen submitted* Micr secreti ns A and B discl sed tissues lined by thickened strati(ied squam us e'ithelium set in a (ibr ,ascular str ma )ith C ci ( chr nic in(lammati n* &here is n e,idence ( mali3nancy*

ECG
=RS C #B Rhythm: Sinus Rate Auricular: 110Amin* Dentricular: 110Amin* PR 1nter,al: 0*1?Asec* =RS: 0*08Asec* =& int* 0*3?Asec*

#ate$ 3497476

1"

1nter'retati n: Sinus tachycardia* 1nc m'lete Ri3ht bundle branch bl ck And 'ersistent (e,er* /r* Ma* 1melda 6* Balajadia Cardi l 3ist

Chest A" Sitting

#ate$ 3497476

4! ll )4u' Chest !ilm ?430408 )hen c m'ared t 're,i us (ilm dated ?41#408 sh )ed increase in 're,i usly n ted P+ in b th hemith races su33est clinical cerrelati n and ( ll )4u'* /r* Ru(ely S* 6ar n M/ !RAMS

Sonographic
Chest Eltras und

#ate$ <45476

4Pleural +((usi n is 'resent in b th Ri3ht and 6e(t hemith races )A estimated , lume ( 1$15" ml G B18 ml res'ecti,ely* N N l culati n r cen lidati n seen* Ma* Clarita /* +s'an l M/$ !PCR Radi l 3ist

'emato ogy
;3b 4 1"5 ;emat crit 4 0*38 7BC 4 11*B Se3menters 4 0*81 6ym'h cytes 4 0*0? M n cytes 4 0*03 -1"041B0 3mA60 -0*3#40*%#0 -B*0410*0210A60 -*%"4*#B0 -*"04*B10 -*0"4*080

#ate$ <49476

1nter'retati n: Pri r t his last hemat l 3y result the 'atient has in(ecti n related t 'resence ( )ater in his lun3s-Pleural e((usi n0* /r* Anne Paulette C* San Ant ni M/

'emato ogy
;3b 4 1"5 ;emat crit 4 0*38 7BC 4 11*B Se3menters 4 0*81 6ym'h cytes 4 0*0? -1"041B0 3mA60 -0*3#40*%#0 -B*0410*0210A60 -*%"4*#B0 -*"04*B10

#ate$ <4=476

13

M n cytes 4 0*03

-*0"4*080

1nter'retati n: Pri r t his last hemat l 3y result the 'atient has in(ecti n related t 'resence ( )ater in his lun3s-Pleural e((usi n0* /r* Anne Paulette C* San Ant ni M/

Chest Ap Sitting

#ate$ <4=476

4! ll )4u' chest (ilm )hen c m'ared )A the ne d ne n @une 30$ "008 sh ) decrease in the am unt ( 'leural e((usi n$ bilaterally* &here is a ri3htsided chest tube in 'lace )A its ti' at the le,el ( the 5th ' steri r rib* &rache st my tube is a3ain seen in 'lace* &here is minimal subcutane us in the ri3ht chest )all*

Chest Ap Sitting

#ate$ <4<476

4! ll )4u' chest (ilm #4#408 )hen c m'ared t 're,i us (ilm dated #4%408 sh )s res luti ns ( 're,i usly n ted ri3ht sided 'leural e((usi n* ; )e,er$ n si3ni(icant inter,al chan3e in 're,i usly n ted le(t sided 'leural e((usi n ther (indin3 remain unchan3ed* Su33est clinical c rrelati n G ( ll )4u'*

ECG
Rhythm: Sinus =RS A2is: 55 Rate: Auricular 110Amin* Dentricular 110Amin PR inter,al: 0*1? sec* =RS inter,al: 0*10 sec* =& inter,al: 0*3" secK 1nter'retati n: Sinus &achycardia

#ate$ <4<476

1%

I.. #%1G S&1#0

!A/E O( #%1GS Atr ,ent Kantich liner3ic$ br nch dilat r K1 neb L "cc NSS =1/ AC&IO! Chemically related t atr 'ine$ it anta3 ni9es the e((ect ( acetylch line* 1t causes a l cal and site s'eci(ic br nch dilatati n by 're,entin3 the increase in intracellular cyclic 3uan sine m n 'h s'hate )Ac is 'r duce by the interacti n ( acetylch line )ith the muscarinic rece't rs ( the br nchial sm th muscles* Pharmac kenetics Abs r'ti n: Minimal /istributi n: n ne Metab lism: li,er -small Am unt ( abs r'ti n0 +2creti n: kidneys abs rbed am unt ;al( li(e: "hrs* Pharm c dynamics 1nhalati n .nset: B41B mins* Peak: 14"hrs* /urati n: 34?hrs* I!#ICA&IO! Acute e2acerbati ns ( C.P/* Esed in juncti n )ith B4 adrener3ic stimulant ( r acute asthmatic attacks* !SG.CO!SI#E%A&IO! &each 'atient andA r (amily: Kthat the dru3 may induce ,isual disturbances$ slee'iness$ r di99iness$ and t use care )hen 'er( rmin3 tasks that require mental alertness* Kt increase (luid intake$ as dru3 causes dry m uth$ thr at irritati n$ and a bad taste ( the m uth*

1B

!A/E O( #%1GS AC&IO! >luc c rtic id )A the hi3h t 'ical anti in(lammat ry ' tency* 1t has a str n3 !li2 tide a((inity ( r and a3 nist acti,ity at human Kanti in(lammat ry 3l c c rtic id rece't rs* K1A" neb L 1cc NSS Pharmac kenetics q1" Abs r'ti n: limited$ -bi a,ailability M"I0 distributi n: minutes traces metab lism: li,er e2creti n li,er hal(li(e: 5 hrs Pharmac dynamics .nset unkn )n 'eak: 14" hrs durati n: unkn )n*

I!#ICA&IO! Pr 'hylactic mana3ement in mild$ m derate and se,ere asthma*

!SG.CO!SI#E%A&IO! KM nit r ( r ' ssible dru3 induced ad,erse reacti ns: /ryness ( m uth$ and thr atN h arsenessN 'arad 2ical br nch s'asm* K assess ( r 'ulm nary and cardiac status* Kassess the 't* and (amilies kn )led3e n dru3s thera'y*

!A/E O( #%1GS

AC&IO! 1mmediately and c m'letely Prednis ne c n,erted t acti,e 'rednis l ne in the li,er* &he anti4 Kadren c rtic ster ids$ in(lammat ry e((ects synthetic* may be due t K10 m3 1 tab &1/ inhibiti n ( 'r sta3landin synthesis* Pharmac kinetics: Abs r'ti n: )ell /istributi n: )ide Metab lism: li,er

I!#ICA&IO! Aller3ic and in(lammati n c nditi ns$ in br nchial asthma

!SG.CO!SI#E%A&IO! K btain baseline )t* bl d 'ressure and electr lyte le,el and m nit r 'eri dically durin3 thera'y* Kassess ( r OkP de'leti n* !ati3ue$ nausea$ , mitin3$ de'ressi n$ ' lyuria$ )eakness$ edema$ hy'ertensi n* Km nit r ( r ' ssible induce reacti ns: CNS: ins mnia CD: heart (ailure r ;PN* >1: 'e'tic ulcerati ns muscul skeletal: muscle )eakness*

1?

+2creti n: kidney ;al( li(e: 1543?hrs

!A/E O( #%1GS Nitr 3lycerine Kc r nary ,as dilat r KBm3 ./

AC&IO! /ecreases 're4l ad and a(ter4l ad )Ac thus decreases le(t ,entricular end diast lic 'ressure and systemic ,ascular resistant: dilates c r nary arteries and im'r ,e bl d (l ) thr u3h c r nary ,asculature$ dilates arterial$ ,en us beds systemically* Pharmac kinetics Abs r'ti n: )ell abs rbed -P. buccal and S60 /istributi n: unkn )n Metab lism: li,er e2tensi,ely +2creti n: kidney ;al( li(e: 14%mins* Pharmac dynamics .nset: 30 mins* Peak: unkn )n /urati n: "41" hrs1

I!#ICA&IO! &reatment ( acute an3ina*

!SG.CO!SI#E%A&IO! &each 'atient andA r (amily: Kt a''ly nly as directed Kt remember t rem ,e ld 'ad Kt r tate sites ( a''licati n Kn t t disturb r 'en 'atch K+,aluate thera'eutics e((ecti,eness cardiac status and ad,erse res' nse: e*3* hy' tensi n$ arrhythmias$ >1 disturbance*

1#

!A/E O( #%1GS AC&IO! N r,asc K KBm3 1tab q% until (ebrile 1nhibits in(lu2 ( calcium i n acr ss cell membranes t 'r duce rela2ati n ( c r nary ,ascular sm th muscle dilatati n ( c r nary artery$ decrease 'eri'heral ,ascular resistance ( sm th muscle decrease bA' and increases my cardial ." deli,ery in 'atient:s )A ,as s'atic an3ina* 'harmac kinetics Abs r'ti n: )ell abs rbed u' t 80I /istributi n: 8BI b und in 'lasma 'r tein cr sses 'lacenta Metab lism: e2tensi,ely in li,er +2creti n: kidneys ;al( li(e: 304B0hrs* increases in elderly he'atic disease* 'harmac dynamics .nset: unkn )n Peak: ?410hrs /urati n: "% hrs

I!#ICA&IO! &reatment: hy'ertensi n$ chr nic stable an3inaN ,as s'astic an3ina*

!SG.CO!SI#E%A&IO! Kassess ( r cardi res'irart ry status: an3ina 'ain$ BAP$ 'ulse$ res'irati n$ +C>* Kassess hydrati n and (luid , lume status$ in'ut and ut'ut rati $ e2tended neck ,ein$ lun3 crackles$ adequate 'ulses and skin tur3 r*

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