A Grand Case Presentation

Presented to the Faculty of St. Lukes College of Nursing

In Partial Fulfillment of the Requirements

In Related Learning Experience for the

Degree of Bachelor of Science in Nursing

Submitted to:

Submitted by:
Steffi Shanice M. Muriel

March 2017

Introduction
 Coronary artery disease, in which atherosclerotic plaque builds up inside
the coronary arteries and restricts the flow of blood (and therefore the deliv- ery
of oxygen) to the heart, continues to be the number-one killer of Americans.
One woman or man experiences a coronary artery dis- ease event about every
25 seconds, despite the time and resources spent educating clinicians and the
public on its risk factors, symptoms, and treatment. Coronary artery disease can
lead to acute coronary syndrome (ACS), which describes any condition
characterized by signs and symptoms of sudden myocardial ischemiaa sudden
reduction in blood flow to the heart. The term ACS was adopted because it
was believed to more clearly reflect the disease progression associated with
myocardial ischemia. Unstable angina and myocardial infarc- tion (MI) both
come under the ACS umbrella

The signs and symptoms of ACS constitute a con- tinuum of intensity from
unstable angina to nonST- segment elevation MI (NSTEMI) to ST-segment elevation
MI (STEMI). Unstable angina and NSTEMI normally result from a partially or
intermittently occluded coronary artery, whereas STEMI results from a fully
occluded coronary artery. The degree to which a coronary artery is occluded
typically correlates with presenting symptoms and with variations in cardiac
markers and electrocar- diographic findings. Angina, or chest pain, continues to
be recognized as the classic symptom of ACS. In unstable angina, chest pain
normally occurs either at rest or with exertion and results in limited activity.
Chest pain associated with NSTEMI is nor- mally longer in duration and more
severe than chest pain associated with unstable angina. In both condi-tions, the
frequency and intensity of pain can increase if not resolved with rest,
nitroglycerin, or both and may last longer than 15 minutes. Pain may occur with or
without radiation to the arm, neck, back, or epigastric area. In addition to
angina, patients with ACS also present with shortness of breath, diaphoresis,
nausea, and lightheadedness. Changes in vital signs, such as tachycardia, tachyp-
nea, hypertension, or hypotension, and decreased oxygen saturation (SaO2) or
cardiac rhythm abnor- malities may also be present
Patients Profile

A Demographic Data

Name: E. A. I

Address: Quezon City

Age: 60 years old

Gender: Male

Civil Status: Married

Nationality: Filipino

Religion: Roman Catholic

Admitting Diagnosis: Acute coronary syndrome -- STEMI

Date and time of Admission: March 3, 2017 10:30 AM

B. Chief Complaint
The patient came in due to chest pain
`C. History of the Present Illness
Patient is a 62 year old male with a known case of CAD last 1990 with
maintenance cardio medications. The patient experienced chest pain and
heaviness on exertion thus consulted with his AMD and then advised for
coronary angiography yet was not able to undergo procedure. Few hours PTA
the patient had sudden chest pain and dyspnea then was brought to UERM
and was intubated due to desaturation and decrease in sensorium then was
transferred to SLMC.
D. History of the Past Illness
(+) Acute Myocardial Infarction (2009)
(+) PTB (2012-2013)
(+) Hypertension and Diabetes Mellitus
F. Allergies
The patient has no known allergies
Pathophysiology

Modifiable Factors Non Modifiable Factors

Lack of physical activity Age: 62 years old

Diet: high in fat Gender: Male

Diabetes Mellitus II

Hypertension

Acute Myocardial Infarction

(2009)

ATHEROSCLEROSI

Disrupted atherosclerotic
plaque

Stimulates platelet
aggregation and

Blood flow is obstructed and

Coronary blood supply less than

demand

Decreased Increased
oxygen CO levels

Ischemia of tissue in the region supplied by

the artery

Impaired myocardial
perfusion
Anaerobic Lactic acid
Glycolysis

Myocardial cell death Chest Pain

 Decreased
Altered contractility Myocardial
repolarization of irritability
the myocardium
Increased Dysrythm
Elevated ST Myocardial oxygen
segment requirements

Decreased left
ventricular

Decreased
cardiac
output

Decreased renal
perfusion

Compensatory
RAAS

ADH

Increased
myocardial
preload and
workload

fatigue Dyspnea Chest pain Shortness weakness

of breath

Course in the ward

March 6, 2017
 Laboratory results for NA, K, BUN and crea was repeated
Albumin was 2.3 (3.4-5) thus Albumin correction was done
Human Albumin 20% (50mL) was administered for 2 hours
Patient was for clean catch urine exam
For 12L ECG
For Na, K, ICA, Mg, TSH stat
To follow Precedex 400mcg in 100cc NSS
Hold Coralan
Kcl 4mEqs + 250mL NSS was started

March 7, 2017
Patient was maintained in AC mode
Schedule for CABG was verified to CVOR
Hold Kcl syrup
For procalcitonin
For ETA GS/CS
IABP was removed
Clexane was resumed
Enteral feeding was revised to Pure Novasource 1300kcal 2:1 @27cc/hr

MEDICATIONS

INDICATION/ SIDE / ADVERSE NSG.

DRUG
CONTRAINDICATION EFFECTS CONSIDERATION
Generic: Indication: Administer at
Atorvastatin Secondary prevention of CNS: dizziness,
bedtime and limit
cardiovascular disease headache,
grapefruit
Brand: (decrease risk of MI, insomnia,
consumption of the
Lipitor stroke, revascularization weakness
patient
procedures, angina, and EENT: rhinitis
CV: chest pain,
Classification hospitalizations for CHF)
peripheral edema
: in patients with
Resp: bronchitis Monitor lipids, liver
Anti- clinically evident CHD. GI: abdominal
hyperlipidemic function, and
cramps, creatine kinase
Contraindication: constipation,
Dosage: Patients hypersensitive levels, and assess
diarrhea for myopathy
80mg NGT OD to atorvastatin and GU: erectile
active liver disease or dysfunction
unexplained persistent
in aspartate
aminotransferase (AST)
or alanine
aminotransferase (ALT)

INDICATION/ SIDE / ADVERSE NSG.

DRUG
CONTRAINDICATION EFFECTS CONSIDERATION
Generic: -Give before meals.
Lansoprazole Indication: CNS: dizziness,
Reduction of risk of GI headache, -To give drug via NG
Brand: bleeding in critically ill drowsiness, tube, mix granules in
Hiza patients and condition fatigue, weakness acidic juice because
where inhibition of CV: chest pain enteric coating
gastric acid secretion GI: abdominal dissolves in alkaline
Classification
may be beneficial pain, acid pH.
:
regurgitation,
Proton pump
constipation, -Monitor patient for
inhibitor
diarrhea, bone fracture, it can
Contraindication: flatulence, increase risk for
Dosage: -Hypersensitivity to nausea, vomiting osteoporosis-related
30mg NGT OD omeprazole Derm: itching, fractures.
-Metabolic alkalosis rash
-Hypocalcemia
Miscellaneous:
allergic reaction
DRUG INDICATION/ SIDE / ADVERSE NSG.
CONTRAINDICATI EFFECTS CONSIDERATION
 ON

Generic: Indication: CNS: dizziness, -Assess for signs of

Enoxaparin Treatment of acute headache, bleeding and
ST- segment- insomnia hemorrhage (bleeding
Brand: elevation MI and CV: edema gums, nosebleed, black
Clexane prevention of venous GI: vomiting, tarry stools, hematuria).
thromboembolism. constipation, Notify physician if such
Classification (VTE) nausea, reversible manifestations occur.
: increase in liver
Anti-coagulant Contraindication: enzymes -Administer the drug in
GU: urinary
-Hypersensitivity to a slow manner
retention
Dosage: specific agents or subcutaneously.
Derm:
0.6mL SQ Q12 pork products
ecchymosis,
-Hypersensitivity to -Alternate injection site
pruritus, rash,
enoxaparin sodium to avoid hypertrophy
-Active bleeding urticaria
-History of heparin- Hematology:
induced bleeding, anemia,
thrombocytopenia thrombocytopenia
Local: erythema
at injection site,
irritation, pain,
hematoma

SIDE /
INDICATION/CONT NSG.
DRUG ADVERSE
RAINDICATION CONSIDERATION
EFFECTS
Generic: Indication: GI: Nausea, -Monitor effectiveness
Acetylcysteine Treatment of stomatitis of therapy and advent
respiratory affections Hypersensitivity of adverse/allergic
Brand: characterized by thick : Urticaria effects.
Fluimucil viscous Respiratory:
hypersecretions Bronchospasm, -Bronchial tapping
Classification especially
: Contraindication: in patients with
Mucolytic -Hypersensitivity to asthma
acetylcysteine Other:
Dosage: Rhinorrhea
1200mg IV BID

NSG.
INDICATION/CONTRAIND SIDE / ADVERSE
DRUG CONSIDERATI
ICATION EFFECTS
ON
Generic: Indication: CNS: Headache, Avoid NSAIDs
Levofloxaci Treatment of maxillary insomnia, while taking
n sinusitis, acute exacerbations CV: Prolonged QT levofloxacin, if
of bacterial bronchitis, interval possible.
Brand: community-acquired GI: Nausea,
Levox pneumonia, uncomplicated vomiting, dry mouth,
skin/skin structure infections, diarrhea,
Classificat UTI, acute pyelonephritis GU: Abnormal renal
ion: caused by susceptible function, acute renal
Antibiotic bacteria; acute bacterial failure, UTI, urine
sinusitis; chronic bacterial retention
Dosage: prostatitis; bacterial Hematologic:
750mg IV conjunctivitis Elevated BUN, serum
Q24 Contraindication: creatinine,
-Contraindicated with allergy Other: Fever, rash,
to fluoroquinolones, photosensitivity,
lactation, myasthenia gravis, muscle
tendinitis, tendon rupture. and joint tenderness,

-Use cautiously with renal

impairment,seizures,
pregnancy.
 INDICATION/C
NSG.
DRUG ONTRAINDICAT SIDE / ADVERSE EFFECTS
CONSIDERATION
ION
Generic: Indication: CNS: Headache, dizziness, -Monitor for
Meropenem seizures superinfection and
Contraindicatio GI: Nausea, vomiting, arrange treatment as
Brand: n: diarrhea, anorexia, appropriate.
Merop -Hypersensitivity abdominal pain, flatulence,
to cephalosporins, pseudomembranous
Classificat penicillins, beta- colitis, liver toxicity
ion: lactams, Other: Superinfections,
Antibiotic abscess (redness,
tenderness, heat, tissue
Dosage: sloughing), phlebitis, rash,
1g IV Q8

INDICATION/CONTRA SIDE / ADVERSE NSG.

DRUG
INDICATION EFFECTS CONSIDERATION
Generic: Indication: Dermatologic: -Arrange for serial
Potassium -Prevention and Rash serum potassium levels
Chloride correction of potassium GI: Nausea, before
deficiency; vomiting, diarrhea, and during therapy.
Brand: when associated with abdominal
alkalosis, use discomfort, -Administer oral drug
potassium chloride; when Hematologic: after meals or with
Classificat associated with acidosis, Hyperkalemia food
ion: use potassium acetate, increased and a full glass of
Electrolyte bicarbonate, citrate, serum potassium, water to decrease GI
or gluconate ECG changes upset.
Dosage: -IV: Treatment of cardiac Local: Tissue
20mL arrhythmias due to sloughing, local -Monitor cardiac
cardiac glycosides necrosis, local rhythm carefully during
phlebitis, and IV
Contraindication: venospasm with administration.
-Contraindicated with injection
allergy to tartrazine,
aspirin
 - Use cautiously with
cardiac disorders,
especially
if treated with cardiac
glycosides, pregnancy,
lactation.

SIDE / NSG.
INDICATION/CONTRAINDIC
DRUG ADVERSE CONSIDERATIO
ATION
EFFECTS N
Generic: Indication: CNS:Headache,
Piperacillin Treatment of moderate to insomnia, fever. Obtain history of
+Tazobacta severe appendicitis, GI:Diarrhea, hypersensitivity to
m uncomplicated and complicated constipation, prior to
skin and skin structure nausea, administration.
Brand: infections, endometritis, pelvic vomiting,
Piptaz inflammatory disease, or dyspepsia, C&S prior to first
nosocomial or CPAP. pseudomembran dose of the drug.
Classificat ous colitis.
ion: Contraindication: Skin:Rash, Monitor patient
Beta- Hypersensitivity to piperacillin, pruritus, carefully during the
Lactam tazobactam, penicillins, hypersensitivity first 30 min after
Antibiotic cephalosporins, or beta- reactions. initiation of the
lactamase inhibitors such as infusion for signs of
Dosage: clavulanic acid and sulbactam. hypersensitivity.

INDICATION/CON SIDE / ADVERSE NSG.

DRUG
TRAINDICATION EFFECTS CONSIDERATION
Generic: Indication: CNS:headache -Assess allergic reactions:
Paracetamol Temporary relief of CV:chest rash, urticaria; if these
pain and discomfort pain,dyspnea occur, drug may have to
Brand: for headache, fever GI:hepatictoxicit be discontinued.
Aeknil cold, flu, and minor, y
muscular aches, andfailure, jaund -Monitor patients vital
Classification overexertion. ice signs
: Hematologic:
Analgesic Contraindication: hemolyticanemi
-Contraindicated with a,neutropenia,le
Dosage: allergy to ucopenia
30mg IV acetaminophen Hypersensitivi
-Use cautiously with ty:
impaired hepatic fever,rash
function, chronic
alcoholism,
pregnancy, lactation.

SIDE /
INDICATION/CONT NSG.
DRUG ADVERSE
RAINDICATION CONSIDERATION
EFFECTS
Generic: Indication: CNS: dizziness, -Assess fluid status.
Furosemide -Edema associated vertigo,
with heart failure xanthopsia, -Monitor daily weight,
Brand: -Cirrhosis weakness intake and output, amount
Lasix -Renal disease CV: orthostatic and location of edema,
Acute pulmonary hypotension, lung sounds, skin turgor
Classification edema thrombophlebitis and mucous membranes
: -Hypertension GI: Nausea,
Loop diuretic vomiting, -Monitor pulse and blood
Contraindication: anorexia, pressure before and
Dosage: -Allergy to constipation, during administration.
40mg IV furosemide, GU: urinary
sulfonamides, bladder spasm
tartrazine INTEG: Rash,
-Anuria urticaria,
-Severe renal failure photosensitivity,
-Hepatic coma pruritus
-Pregnancy HEMA:
-Lactation leucopenia,
anemia
 Others: muscle
cramps, muscle
spasms

Laboratory and diagnostics

NORMAL 03/03 03/04 03/05 03/06 03/07

VALUES

Hgb 13-17 g/dl 17.9 12

Hct 40.0-52 % 48.9 33.8

RBC 4.7-6.1 5.51 3.82

mil/mm3

WBC 4800-10800 17690 13220

Neutrophi 40-74 84 87
ls

Monocyte 3-9 8 5
s

Lymphocy 19-48 8 8
tes

Eosinophil 0-7 0
s

Platelet 150000- 225000 111000

 400000

PTT 29.5-39.5 39.5

Na 136-145 136 134 137 141 146

K 3.5-5.1 5.5 3.5 4.2 3.5 4.1

Mg 1.8-2.4 2.3 2.4 2.4 2.5

BUN 7-18 15 22 22 25

Creatinin 0.6-1.12 1.43 1.49 1.24 1.11

e

Albumin 3.4-5 2.3 2.5

Globulin 1.5-3 3.2

ABG (Arterial Blood Gas)

NORMAL VALUES 03/03 03/06

PH 7.350-7.450 7.385 7.47

PC02 35-45 mmHg 32.8 35

P02 80-100 mmHg 102.4 89.6

HC03 22-26 mmol/L 19.7 2.2

INTERPRETATION: Metabolic Respiratory Alkalosis

Nursing responsibilities

Management:

Administer oxygen to maintain SpO2 >90%

Establish IV access
 Perform cardiac monitoring
Administer Sublingual Nitroglycerin tablets or oral spray, every 5 minutes x 3
doses. If pain persists, IV nitroglycerin may be started.
Monitor for hypotension and headaches from vasodilation
Administer aspirin and have patient chew it, if not on a daily dose.
Administer IV Morphine, 2-4mg every 15 minutes until pain is controlled
Monitor for hypotension and respiratory depression
Unless contraindicated administer beta-blocker
Perform 12L ECG
Lab work: cardiac markers: creatine kinase (CK), creatine-kinase myocardial
band (CK-MB), troponin I, troponin T anf myoglobin
Focus on pain radiation, SOB, and diaphoresis
Obtain a 12L ECG and lab draw for cardiac markers

Discharge Plan

Medications

Discuss to the patient and family the dosage, frequency, and adverse effects
of the drugs. Explain that the drugs used for effective control of elevated BP
will likely produce adverse effect.
Explain to the patient and family members the importance of taking
medicines.
 The patient will able to take medications as what had been prescribed by the
physician religiously and be able to follow directions as instructed by the
nurse.

Economic status

Inform the patient to avail to some government programs such as philhealth.

Explain to significant others that the rehabilitation may be prolonged to be
able to for the family to prepare financial needs.
Have occupational therapist to help re-learn everyday activities or ADL.

Treatment

Emphasized the importance of regular follow-up check-ups and as instructed

by physician.
Advised patient and family members to seek medical advise if any unusuality
arises
Reinforced the importance of having blood sugar checked every day.
Admit patient in cardiac rehabilitation, this is a monitored exercise and
education program that can help the patient return to an active lifestyle.

Health teaching

Encouraged client to do at least 30 minutes of walking a day as a form of

exercise.
Instructed to monitor blood sugar regularly. Adjustments in diet, medication
and exercise can be made accordingly.

Adjust of activities to avoid over exertion and fatigue, allow rest periods

Out-patient

The patient could avail his medication from government hospitals that he
could get some benefits.
 Instruct patient to seek regular medical check-up

Diet

Reduce the amount of fat you eat by choosing fewer high-fat foods and
cooking with less fat.
Eat more fiber by eating at least 5 servings of fruits and vegetables every
day.
Eat fewer foods that are high in sugar like fruit juices, fruit-flavored drinks,
sodas, and tea or coffee sweetened with sugar.
Use less salt in cooking and at the table. Eat fewer foods that are high in salt,
like canned and packaged soups, pickles, and processed meats.

Spirituality

Emphasized the importance of prayers in healing

Encouraged to ask for divine assistance in everything and to encourage
continuing to pray to God.
Encouraged to continue to have a positive outlook in life.
Encouraged to keep faith in God and not to give up easily when hardtimes
come
Encouraged to verbalize feelings when feeling anxious about the disease or
treatment.