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Universidad De Manila

College of Nursing

A Case of a Client with

Coronary Artery Disease

A Grand Case Presentation

In Partial Fulfillment of the Requirements in

Related Learning Experience

Submitted by:



The group would like to extend their gratitude to the following persons who
contributed and have been part of this study.

First, to Mrs. Arlene Paduada, RN, clinical instructor in Intensive Care Unit, for
her willingness to share her knowledge about the subject matter as well as her guidance
and support in allowing us to conduct the study to the said client.

Then, to Mr. R, as our subject in this study, his presence gave us the idea of the
topic itself.

Next, to our parents who help us financially and for their loving support to finish
this study.

Subsequently, to the staffs of Ospital ng Maynila Medical Center, the institution

where the client, our subject was confined, for allowing us to access the information of
the said client and to accomplish such study.

Lastly, to God, for giving us the wisdom, strength and guidance that helped us
throughout the study.

1. Background of the Study
Coronary artery disease is atherosclerosis of the coronary arteries, producing
blockages in the vessels which nourish the heart itself. Atherosclerosis occurs when the
arteries become clogged and narrowed, restricting blood flow. Without adequate blood
flow from the coronary arteries, the heart becomes starved of oxygen and vital nutrients
it needs to work properly.
Coronary arteries are blood vessels on the heart. They are smooth and elastic,
allowing blood to flow freely.
Before your teen years, fat can start to deposit in the blood vessel walls. As you
get older, the fat builds up. This causes injury to your blood vessel walls. In an attempt
to heal itself, the fatty tissues release chemicals that promote the process of healing but
make the inner walls of the blood vessel sticky.
Then, other substances, such as inflammatory cells, proteins, and calcium that
travel in your bloodstream start sticking to the inside of the vessel walls. The fat and
other substances combine to form a material called plaque, which can narrow the flow
of blood in the artery (atherosclerosis).
Some plaque deposits are hard on the outside and soft and mushy on the inside.
Some plaque is fragile, cracking or tearing, exposing the soft, fatty inside. When this
happens, platelets (disc-shaped particles in the blood that aid clotting) come to the area,
and blood clots accumulate on the injured vessel wall. This causes the artery to narrow
even more. Sometimes, the blood clot breaks apart by itself, and blood supply is
Over time, the inside of the arteries develop plaques of different sizes.
Eventually, a narrowed coronary artery may develop new blood vessels that go around
the blockage to get blood to the heart. However, during times of increased exertion or
stress, the new arteries may not be able to supply enough oxygen-rich blood to the heart

In other cases, the blood clot may totally block the blood supply to the heart
muscle, causing what is called an acute coronary syndrome. This is actually a name
given to three serious conditions: Unstable angina, Non-ST segment elevation
myocardial infarction (NSTEMI) or non-Q-wave MI, ST segment elevation myocardial
infarction (STEMI) or Q-wave MI.
The most common symptom is of coronary artery disease is angina or simply
chest pain. Angina can be described as a discomfort, heaviness, pressure, aching,
burning, numbness, fullness, squeezing or painful feeling. Other symptoms that can
occur with coronary artery disease include shortness of breath, palpitations,
tachycardia, weakness or dizziness, nausea, sweating.
The study focuses on Mr. R, 71 years old, male client. He was admitted last
August 31, 2011 at 5:50 pm in the Medical-Surgical ward of the Ospital ng Maynila
Medical Center. He was admitted due to complaints of chest pain. Upon admission, his
diagnosis was Coronary Arterial Disease. Moreover, he was diagnosed as having
anemia of chronic disease, pleural effusion secondary to pulmonary tuberculosis, and
psoriasis. All of the said diagnoses will tackle further in this study, most especially
Coronary Artery Disease.
The group had chosen this particular disease condition due to the curiosity and
interest regarding to the current situation of the patient. They do believe that taking this
opportunity would challenge them and they thought that it is a best experience to take
for the group to test how the condition works on client in reality. Through a thorough
and actual observation to the said disease, their knowledge upon the case would make
them further understand and achieved a best type of learning. This is also a good
opportunity to train their skills in doing and giving the actual, direct and potential care
to the patient in order to sharpen their skill as a future nurses.

In line with this, the

readers of this study will also acquire more knowledge and skills that might help them
in their study in the near future.

2. Significance of the Case Study

The case study was done in order to provide knowledge about Coronary Artery
Disease not only to the researcher but also to the readers, researchers and students. This
comprehensive study provides guidance in improving and imparting knowledge such
as disease condition, medical and nursing managements, pharmacological treatments
and formulating nursing care plans.
3. Objective of the Case Study

To gather clients profile from clients chart and relatives which includes the past
and present history of illness, socio-demographic data and other related data that
are needed in the study.

To review the anatomy and physiology as well as the pathophysiology of the disease

To assess the results of the laboratory findings and diagnostic procedures done upon
the need of the client.

To know the different pharmacological and non-pharmacological treatment in

alleviating clients condition.

To identify priority nursing problems which are present to the client during disease

To plan and implement an appropriate nursing interventions to the client.

4. Scope and Limitation of the Study

The case study was conducted in the Intensive Care Unit of Ospital ng Maynila
Medical Center. The nursing students utilized a client that has a current disease related
to Acute Biologic Crisis because this was the assigned disease condition for the group.
The data gathering of the said client was within the clinical duty shift only, and he was
assessed on his admission in the Intensive Care Unit until he was unfortunately died.
The informations needed for working the case study were obtained from clients chart
and relatives. Any information gathered were kept with utmost confidentiality. The

study focused on the main diagnosis of the client, which was Coronary Artery Disease,
other diagnosed diseases in the client was viewed brieftly in the study.


A. Nursing Health History
(1) Personal Data
Patients Name
Date of Birth
Marital Status
Usual Source of Health

Mr. R.
Paco, Manila
71 y/o
November 23, 1939
Sedentary lifestyle
Ospital Ng Maynila
Hospital of Pangasinan

(2) Chief Complaint

Date of Admission
Time of Admission
Admitting Diagnosis

Sumasakit ang dibdib ko, as verbalized by the client.

August 31, 2011
5:50 pm
Intensive Care Unit
Coronary Artery Disease


History of
Present Illness

Two weeks prior to consultation, client experienced difficulty

of breathing and noted to have a chest pain prominent in the
right side.


Past Medical

Five months prior to consultation, client was diagnosed with

psoriasis. He was admitted to San Lazaro Hospital.

B. Physical Assessment
General Survey
General Appearance: The client was received on bed with presence of nasogastric
tube, endotracheal tube and mechanical ventilator. He was weak and stuporous.
Has a Glasgow Coma Scale of 7.
Nutritional State: The client weighs 77 kgs. with a height of 56 feet. He was in
unhealthy appearance. Edema on peripheral extremities noted.
Vital Signs (taken last September 1, 2011)
Vital Signs


Blood Pressure

70/50 mmHg


36.9 C

Pulse Rate

114 beats/min


26 breaths/min

Physical Examination
Type of
Area of






The clients head was proportionate to the body size.
There were no tenderness and wounds in the scalp.
The client was bald.


Inspection &

The client has a blurring vision. No edema or lesions


on eyelids were apparent. Eyelids color was the same

as surrounding skin color. Eyelashes were not present.
Anicteric sclerae, was pale has a palpebral
conjunction. Pupils were round and equal sized, Eyes

were properly aligned. The clients conjunctiva was



The ears of the client and facial skin were the same
color. No inflammation, lesions, or nodules were
apparent. Theres no visible discharge from the
auditory canal though cerumen noted. External
meatus was apparent. No redness or swelling was
noted. The alignments of the pinnas were symmetrical
and they were elastic and recoil when folded.


No masses or tenderness on the auricle was detectable

during manipulation. Mastoid process seen no sign of



The client had an NGT inserted in his right lobe on his

nose. His nose was symmetrical and lesion free, with
no deviation of the septum or discharge. No nasal
flaring was apparent. Nasal mucosa was pinkish red,
with no visible lesions and no purulent drainage



Sinuses were seen no sign of tenderness


The client had dry oral mucosa with symmetric facial

structures. There was presence of endotracheal tube
inserted in his mouth connected to a mechanical

Skin and Nails

Clients skin was pale and scaly while his nails were
dirty and clubbing. His skin texture was cold and


The clients capillary refill is > 3 secs. And has been

noted of having a dry skin. Edema and swelling were
also noted.



There was no presence of vein distention. Skin was

intact and symmetrical.


There was no swelling in the lymph nodes.


There was shallow chest expansion. His chests were

symmetric and aligned.

Thorax &


Dullness was heard upon percussion.



Skin was cold and clammy. No tender spots and

bulges in the chest were detectable.


Crackles were heard on both sides of his lungs.

Wheezing was also noted upon assessment. His
Cardiac rate was 114 beats/minute with regular
rhythm. There were no murmurs heard.


The clients abdomen was symmetric and skin was

same to other body parts.



Flatness was heard upon percussion


Had a board-like abdomen.


Presence of bubbling sound was noted.


Presence of edema was noted. There were no gross


deformities that were apparent. Body parts were

symmetrical and the clients body was aligned.
Swellings were noted. The client werent able to move
his body and had shown muscle weakness.



The client had an edema and swelling were noted


The client has a Foley catheter inserted in his urinary



Inspection &

The patient cant shrug his shoulder. His pupil were



equally round & reactive to light. Eyes moves freely

but slowly. His eyelids does partially closes when we

stroke each cornea with a wisp of cotton. Patient cant

identify familiar odor and he can hear sound. He cant
purse his lips and puff out his cheeks. His tongue
move easily and there were no tremors. His gag reflex
were alaso present. His deep tendon reflex were
dimished. There were also shown weakness in his

Glasgow Coma Scale:

Eye Response (2) patient responds to pain
Verbal Response (2) Patient make incomprehensible
Motor Response (3) the patient has flexion, abnormal,
& decorticate rigidity.

C. Laboratory and Diagnostic Examination

1. Complete Blood Count
Date of Results:

August 30, 2011


Hematology Results











































Based on the obtained values of the laboratory results, the white blood cells count
shows a higher than normal values which indicates that the client had an infection. The
values that were resulted in red blood cells, hemoglobin, and hematocrit fell below the
normal range which indicates that the clients RBC population may have a lower
variation and the client might possibly suffered from anemia. For the platelet count of
the client which was lower than normal values indicates that the client was
experiencing some mild bleeding disorders.

2. Blood Chemistry
Date of Results:

August 31, 2011



Normal Values


4.90 mmol/L

2.9-9.3 mmol/L


88 umol/L

57-113 umol/L

Uric acid

0.25 mmol/L

0.28-0.51 mmol/L


32 IU/L

15-41 IU/L


65 IU/L

17-63 IU/L

Total Protein


65-81 g/L



35-48 g/L


0 g/L

15-35 g/L

A/G Ratio


127 mmol/L

136-144 mmol/L


4.3 mmol/L

3.6-5.1 mmol/L

*BAR-Below Assay Range

This tables illustrates the obtained results of the clients blood chemistry dated on
August 31, 2011. The results indicate that most of the clients blood constituents were
within the normal range, the blood urea nitrogen, creatinine, aspartine serum
transaminase and potassium, specificifically. On the other hand ALT resulted a higher
than noramal values, indicating that the client probably have a liver damage which
could possibly be brought by drugs toxicity from his medications or certainly due to his
disease condition. The uric acid and the sodium result fell to lower than its normal
value because there is a tendency that the kidney of the client was also affected by his
condition, thus lossing its normal function.

3. Blood Crossmatching Results

Date: August 31, 2011

Rh: Positive

The blood crossmatching result shows that the clients type of blood was B
and has a Rh type of Positive which shows that the client has a B antigen on the surface
of his RBCs, and blood serum containing IgM antibodies against the A antigen.
Therefore, the client can receive blood only from individuals of groups B or O (with B
being preferable).

4. Troponin Result


Normal Value

Troponin I (Quanti)

1.07 ng/ml

0-0.034 ng/ml

The troponin result obtained shows a higher than its normal value, which
indicates that the client has a damage or injury to the heart muscle, thus, specifically
proved that he was suffering from a myocardial infarction.


A. Definition and Description of Disease
Coronary Artery Disease
Coronary heart disease (CHD), also called coronary artery disease, is a condition
in which plaque builds up inside the coronary arteries. These arteries supply oxygenrich blood to your heart muscle. Plaque is made up of fat, cholesterol, calcium, and
other substances found in the blood. When plaque builds up in the arteries, the
condition is called atherosclerosis. The buildup of plaque occurs over many years.
Over time, plaque hardens and narrows your coronary arteries. This limits the
flow of oxygen-rich blood to your heart muscle. Eventually, an area of plaque can
rupture (break open). This causes a blood clot to form on the surface of the plaque. If
the clot becomes large enough, it can mostly or completely block blood flow through a
coronary artery.
If the flow of oxygen-rich blood to your heart muscle is reduced or blocked,
angina or a heart attack may occur. Angina is chest pain or discomfort. It may feel like
pressure or squeezing in your chest. The pain also may occur in your shoulders, arms,
neck, jaw, or back. Angina pain may even feel like indigestion. A heart attack occurs if
the flow of oxygen-rich blood to a section of heart muscle suddenly becomes blocked. If
blood flow isnt restored quickly, the section of heart muscle begins to die. Without
quick treatment, a heart attack can lead to serious problems and even death.
Over time, CHD can weaken the heart muscle and lead to heart failure and
arrhythmias. Heart failure is a condition in which your heart can't pump enough blood
to meet your bodys needs. Arrhythmias are problems with the rate or rhythm of the

B. Anatomy and Physiology

o 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.
o 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.
o The heart is the pump responsible for maintaining adequate circulation of
oxygenated blood around the vascular network of the body.
o It is a four-chamber pump, with the right side receiving deoxygenated blood
from the body at low pressure and pumping it to the lungs (the pulmonary
circulation) and the left side receiving oxygenated blood from the lungs and
pumping it at high pressure around the body (the systemic circulation).

Function and Location of the Heart

o 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
o 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
allow them to perform more work by pumping out blood to the whole body.
Blood Vessels
Blood Vessels are 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 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
valve 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.
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
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 drains 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.

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 systole follows 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 diastole occurs. 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.
Components of the Heartbeat
The adult heart beats around 70 to 80 times a minute at rest. When you listen to
your heart with a stethoscope you can hear your heart beat.
The sound is usually described as "lubb-dupp". The "lubb" also known as the first
heart sound, is caused by the closure of the atrioventricular valves. The "dupp"
sound is due to the closure of the semilunar valves when the ventricles relax (at
the beginning of ventricular diastole).

Abnormal heart sounds are known as murmurs. Murmurs may indicate a

problem with the heart valves, but many types of murmur are no cause for

D. Medical Management

Insertion of Foley Catheter

Foley catheter is a thin, sterile tube inserted into your bladder to drain urine. It can be
left in place in the bladder of the client for a period of time. It is held with a balloon at
the end, which is filled with sterile water to hold it in place. The clients urine was
drained into a bag and can then be taken from an outlet device to be drained.
Laboratory tests were also conducted on the clients urine to look for infection, blood,
muscle breakdown, crystals, electrolytes, and kidney function. It was inserted to the
client because he was suffering from urinary incontinence thus assisting the client
during his urination.

Intravenous Therapy

Intravenous therapy or IV therapy is the giving of substances directly into a vein. It was
used to the client in order to correct electrolyte imbalances, to deliver medications and
for blood transfusion or as fluid replacement to correct. The client is hooked with D5W
IV Fluid in companion with some other medications such as dopamine drip.

Oxygen Therapy

It is the administration of oxygen as a medical intervention to the client. Oxygen is

essential for cell metabolism, and in turn, tissue oxygenation is essential for all normal
physiological functions. High blood and tissue levels of oxygen can be helpful or
damaging; depending on circumstances and oxygen therapy should be used to benefit
the patient by increasing the supply of oxygen to the lungs and thereby increasing the

availability of oxygen to the body tissues, especially when the patient is suffering from
hypoxia and/or hypoxemia. It is indicated to used as a medical treatment in both
chronic and acute cases, and can be used in hospital, pre-hospital or entirely out of
hospital, dependant on the needs of the patient and the views of the medical
professional advising, use in chronic conditions. It may also be indicated for any other
patient where their injury or illness has caused hypoxemia, although in this case oxygen
flow should be moderated to achieve target oxygen saturation levels, based on pulse
oximetry and lastly for personal use, high concentration oxygen is used as home
therapy to abort cluster headache attacks, due to its vasoconstrictive effects.


It is the treatment of disease through the administration of drugs. As such, it is

considered part of the larger category of therapy. The client was given drugs that has
an antiplatelet effect such as clopidogrel and asprin, Enoxaparin as anticoagulant,
Simvastatin as anti-hyperlipidemic, Omeprazole which suppresses gastric acid
secretion, Isosorbide Dinitrate as anti-anginal, Albumin Infusion, Lactulose as Laxative,
Morphine for chest pain Diazepam as anxiolytic, Captopril as antihypertensive, and
Hydrocortisone for inflammatory responses.

Endotracheal Intubation

An endotracheal tube is a breathing tube. It is used temporarily for clients breathing

because it keeps the airway open. This curved tube is placed through the patient's nose
or mouth into his trachea (windpipe). Tape or a soft strap holds the tube in place. The
endotracheal tube passes through the patient's vocal cords. This means that the client
would not be able to speak while the tube is on his throat. The patient can mouth
words, write notes or use gestures. While the patient has the endotracheal tube in place
he may not eat or drink because it may cause choking. He will receive fluid and
nutrition through an intravenous (IV) or NGT. In the case of the client, the ET tube was

suctioned from time to time, and also when the clients mouth was already dry, the
nurse wipes it with wet swabs.

Nasogastric Intubation

A nasogastric tube is used for feeding and administering drugs. For drugs and for
minimal quantities of liquid, a syringe is used for injection into the tube. For continuous
feeding, a gravity based system is employed, with the solution placed higher than the
patient's stomach. By inserting a nasogastric tube, the client had gained access to the
stomach and its contents. This will allow gastric immobility, and bowel obstruction to
be treated. In the case of the client, he was not able to ingest food properly so using this
NG tube, adequate nutrition was quite provided and some other oral medications were
also administered through this.


A. Prioritized Nursing Problems

1. Ineffective airway clearance related to presence of fluid in the lungs

2. Imbalanced nutrition less than body requirements related to inability to ingest

food as manifested by the presence of nasogastric tube

3. Grieving related to anticipatory loss of significant other