Our Lady of Fatima University

Nursing Care Management

INTRODUCTION Patient JR, a 53 year-old male was admitted due to his chief complaint of chest pain radiating to his left arm. He was then diagnosed with Acute Coronary Syndrome with non-STsegment elevation myocardial infarction. According to rn.com Acute Coronary Syndrome (ACS) is a term that encompasses a spectrum of conditions including unstable angina (UA), the closely related condition non-STsegment elevation myocardial infarction (NSTEMI), and ST segment elevation myocardial infarction (STEMI). In general, ACS is caused by an imbalance between myocardial oxygen supply and demand. Most often, ACS is the result of decreased myocardial perfusion that results from coronary artery narrowing caused by atherosclerotic plaque and thrombi formation involved in coronary heart disease. Initial therapy for JRs condition should focus on stabilizing his condition, relieving ischemic pain, and providing antithrombotic therapy to reduce myocardial damage and prevent further ischemia. In the course of treatment, nurses play a vital role in diagnosis, management, and education of patient. From teaching patient about how to modify his risk factors, administering various medications, and providing pre- and post-care to patient if he will undergo revascularization procedures, nurses are in an important position to improve the outcomes of angina experienced by the patient. .

Our Lady of Fatima University

Nursing Care Management

PATHOPHYSIOLOGY Acute coronary syndrome (ACS) is an emergent situation characterized by an onset of myocardial ischemia that results in myocardial death. (Brunner, 2010) J.R.is a 53 years old male; likes eating foods that are high in cholesterol; and has a family history of CAD and hypertension. These factors (age, gender, diet, family history) greatly contributed to the development of atherosclerosis, the most common cause of ACS. It begins with the Deposit of lipids, calcium, fibrin, and other cellular substances within the lining of the arteries. These initiate a progressive inflammatory response in an effort to heal the endothelium. As an end result of inflammatory process there will be a production of a fibrous atherosclerotic plaque. Plaque can progress to cause coronary stenosis. ACS develops when the vulnerable or high-risk plaque undergoes disruption of the fibrous cap which is the stimulus for thrombogenesis. Thrombus resorption may be followed by collagen accumulation and smooth muscle cell growth. Following disruption of the vulnerable plaque, patients experience angina due to reduced blood flow through the coronary artery. This may be caused by a completely occlusive thrombus or subtotal occlusive thrombus. Patients with anginal pain may present with or without ST-segment elevation on the ECG. (emedicine.medscape.com) rn.com has explained that when patients report anginal chest pain, the goal is to immediately classify them into one of three groups based on their symptoms, ECG findings, and laboratory tests. These determine if the patient is having stable angina, unstable angina, NSTEMI or STEMI. Most patients with ST-segment elevation MI (STEMI) ultimately develop a Q-wave MI. A smaller number will develop a non-Q-wave MI. Patients who do not have ST segment elevation have UA or a non-ST-segment Elevated MI (NSTEMI). The distinction between UA and NSTEMI is the presence or absence of cardiac markers (troponin or CK-MB).

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Nursing Care Management

Most patients with NSTEMI do not evolve a Q wave on the ECG and have sustained a NQMI; only minorities of NSTEMI patients develops a Q wave and are later diagnosed as having Q-wave MI. The spectrum of clinical conditions that range from UA to NQMI and QwMI is referred to as Acute Coronary Syndrome (ACS) (Antman, et al., 2004.) In this case JR developed non-ST segment elevation MI. NSTEMI occurs when myocardial perfusion is disrupted due to persistent thrombotic occlusion or vasospasm. (Douglas M. Char, MD, 2005) Spontaneous thrombolysis, resolution of vasoconstriction or flow from collateral sources limits the resulting ischemic injury. JR then developed complications of ischemia: acute pulmonary congestion probably secondary to left ventricular dysfunction.

Our Lady of Fatima University

Nursing Care Management

HISTORY JR is a 53 years old, male who work as a government employee. He came in due to chest pain. He was admitted on September 18, 2012 at around 2:00 pm as a case of Acute Pulmonary Congestion probably secondary to left ventricular dysfunction and/or Acute Myocardial Infarction, ACS NSTEMI, infarct wall, killip I. He has no known allergies. No history of asthma attacks and diabetes mellitus. No recent surgery. He is an occasional drinker, has a family history of CAD and hypertension, and he usually eats high cholesterol foods. Six days prior to confinement the patient was lifting a heavy object when there was a sudden onset of pursing chest pain radiating to the left arm. There was no dyspnea; no headache. No consultation was done and no medication was taken. On the day of confinement there was a persistence of chest pain, interrupted with work at the hospital.

Our Lady of Fatima University

Nursing Care Management

Nursing Physical Assessment J.R. was coherent, alert and oriented to person, time, and place. The patient temperature was 36. 9 C, pulse rate was 78 bpm, respiration rate was 38 cpm, and a blood pressure of 130/85, apical pulse was 78 bpm; no murmur but there was irregular rhythm, no clubbing of the fingers and no edema. The patient chief complaint was chest pain radiating to his left arm. The patient had a nasal cannula connected to oxygen tank and had a RML IVF of D5W 500cc to run for 24 hour with a side drip of Heparin 5000 unit. The patient skin was soft, non-tender and slightly cold. On the first day, the patient bowel sound was normoactive and stated no bowel movements. The urine output from 2-10 pm was 480 ml. The patient was in a low fat and low salt diet. J.R. appeared pale and weak. The patients height is 53 and he weighs 140 lbs. The patient was placed in a complete bed rest without bathroom privileges even though he was able to performed independent actions; his chest pain was precipitated with light activities.

Our Lady of Fatima University

Nursing Care Management

RELATED TREATMENTS The patient undergone several diagnostic exams: 12 lead ECG ICB, Troponin I, CBC with PO, urinalysis, BUN, creatinine, Na, K, Ca, Mg, PT/PTT every six hours, 2D echo and chest xrays. Medications given were: ASA 80 mg/tab 4 tabs chewed then 1 tab OD for vasodilation and inhibition of platelet aggregation; Clopidogrel 75 mg/tab for inhibition of platelet aggregation; Heparin 3000 IU bolus for inhibition of thrombus and clot formation; Heparin side drip 5000 IU in D5W 100 cc x 12 ugtts/min; Simvastatin 40 mg/tab for inhibition of HMG-CoA reductase; Lactulose 30 cc OD at HS; Metoprolol 50 mg q6 for the first 48 hours upon confinement, for hypertension; Streptokinase, a thrombolytics, 1.5 million units in 100 cc D5W in soluset. According to Brunner (2010) thrombolytics must be administered as early as possible after the onset of symptoms, generally within 3 to 6 hours. On second day, JR still had chest pain but no DOB. Diphenhydramine 50 mg/tab for antihistamine and Captopril 25 mg/tab for hypertension were given. JR had no chest pain until Day 6 and medications were continued. He was also advised to remain in high back rest to reduce myocardial oxygen consumption; should avoid over exertion; and should have had a 24 hour bedside watcher.

Our Lady of Fatima University

Nursing Care Management

NURSING CARE PLAN 1 J.R.s Focus for Nursing diagnosis is Ineffective Tissue Perfusion Secondary to Acute Coronary Syndrome (ACS) as evidenced by chest pain ( Brunners & Suddarths 11th edition). According to ( Ignativiticus 5th edition) ACS is the most prevalent type of cardiovascular disease in adults. It is cause by a ruptured plaque that formed to a thrombus and it will obstruct blood flow in coronary artery leading to coronary artery syndrome. Patient appearance was pale, right hand on his chest and the patient stated that he experienced heavy sensations in the upper chest radiating to left arm and body weakness. Vital sign was taken, blood pressure was 130/85, pulse rate was 88 and respirations was 36, heart rhythm was irregular, Troponin I was obtained with the result of 0.559ng/ml, a 12 lead ECG was done and revealed a myocardium ischemia as evidence by T-wave inversion. The short term goal include immediate and appropriate treatment in angina these includes to reduce chest pain and prevention of complications ( Brunners&Suddarths 11 th edition). Nursing Intervention for the patient include monitor vital signs, hemodynamic, heart sounds, and cardiac rhythm to monitor the condition accurately ( Brunners&Suddarths 11th edition). Instruct the client to stop all activities and position the patient in a sitting position or semi-fowlers position to reduce the oxygen requirement of the ischemic myocardium and decrease chest discomfort and dyspnea ( Brunners&Suddarths 11th edition). Administered Nitrogen sublingual as prescribe and assessed the patient if the chest pain is still present if then repeat administration up to three doses at five minute interval the rationale behind this is nitrogen is a vasoactive agent which help to reduce the myocardial oxygen consumption which decreases ischemia and relieves pain ( Brunners&Suddarths 11th edition). Administer Oxygen therapy at 2 L/min. by nasal cannula to raises the circulating level of oxygen which help to reduce pain associated with low levels of myocardial oxygen ( Ignativiticus 5th edition). Caution client to avoid activities that increases cardiac workload and place the patient in a complete bed rest 7

Our Lady of Fatima University

Nursing Care Management

without bathroom privilege to conserve energy and to decrease oxygen demand ( Ignativiticus 5th edition). Provide stool softeners to prevent straining at stool and provide bedside commode to decrease the cardiac workload (Wilkinsons 2010). Provide information to the patient and primary caregiver about his illness, its treatment, and methods of preventing its progression to reduce anxiety and to promote supportive therapy for the patient ( Brunners&Suddarths 11th edition). After one hour of Nursing Interventions the patient was on a comfortable semifowlers position with no signs of chest pain. Patient stated that pain is relieved promptly. Patient and family members was able to understand and response immediately to any nursing interventions. NURSING CARE PLAN 2 J.R.s Focus Nursing Diagnosis is Impaired Physical Mobility related to possible recurrent chest pain. (Ignativiticus 5th edition). According to Brunners & Suddarths (11th edition) the patient with ACS should place in a complete bed rest without bathroom privilege and should avoid activities that will increase cardiac workload to prevent oxygen demand of ischemic myocardium thus prevent of chest pain this will result of limited activities of the patient. The patient stated that upon his movement he experienced chest pain and discomfort. Patient appearance was pale and weak with limited range of motion, slowed movement and reluctance to attempt movement. The short term goal include promote optimal level of function & prevent complications. ( Nurses Pocket Guide 11TH edition). Nursing Intervention for the patient include assist with the activity and progressive ambulation the rationale behind it is until healing occurs activity is limited and advanced slowly according to individual intolerance ( Nurses Pocket Guide 11TH edition). Encourage and facilitate early ambulation and others ADLs when possible. Assist with each initial charge dangling, 8

Our Lady of Fatima University

Nursing Care Management

sitting in chair, ambulation because the longer the patient remains immobile the greater the level of debilitation that will occur ( Nurses Pocket Guide 11TH edition). Schedule activities with adequate rest periods during the day to reduce fatigue (Nurses Pocket Guide 11TH edition). Encourage participation in self-care occupational activities to enhance self-concept and sense of independence (Nurses Pocket Guide 11TH edition). Provide all personal belonging within reach and provide bedside commode to conserve energy (Wilkinsons 2010). Advised relatives or the family members to stay with the patient to assist the patient if possible (Wilkinsons 2010). Provide a quiet and well ventilated environment for the comfort of the patient (Wilkinsons 2010) and limit visitors if necessary to promote good rest (Wilkinsons 2010). After 6 hour of Nursing Intervention the patient was able to move within range of motion without precipitating of chest pain but still place on a complete bed rest without bathroom privilege.

Our Lady of Fatima University

Nursing Care Management

RECOMMENDATIONS The patient was ordered to go home with advised of his physician to follow up when chest pain is not relieved by medications and home management. According to Brunners & Suddarths lifestyle modifications and adoption of an activity program is a must, these includes smoking cessation, diet control, physical activity and blood pressure and blood glucose control to develop a healthy heart lifestyle. He advised to continue his medications such as aspirin and metropolol. (Ignativiticus 5th edition) has pointed out that nurses has a big role in educating the client about his illness, its treatment, and methods of preventing its progression and helping them to adjust in any changes in their lifestyle. Encourage the patient that always bring medication with him such as isordil when chest pain is present as emergency medication and provide information about this drug include indication, preparation and dosage (Brunners & Suddarths 11th edition).

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Our Lady of Fatima University

Nursing Care Management

REFERENCES http://emedicine.medscape.com http://www.rn.com http://www.sign.ac.uk http://www.cardionursing.com Douglas M. Char, MD (Division of Emergency Medicine, Washington University of Medicine) Brunners and Suddarths Textbook of Medical-Surgical Nursing (12th Edition) Ignativiticus (5th edition) Nurses Pocket Guide (11th edition) Lippincotts Nursing Drug Guideline

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