CASE PRESENTATION

ON
NON-ST SEGMENT
ELEVATION
MYOCARDIAL
INFARCTION
(NSTEMI)
 CARDIOVASCULAR NURSING

INTRODUCTION

Cardiovascular disease (CVD) generally refers to conditions that involve narrowed or blocked

blood vessels that can lead to a heart attack, chest pain (angina) or stroke. Other heart conditions, such

as those that affect your heart’s muscle, valve rhythm, also are considered forms of heart disease. It is

one of the leading cause of death worldwide, accounting for 17.3 million deaths in 2008 (or ~ 30% of all

deaths worldwide). ACS is now a leading cause of mortality in the Asia-Pacific region, accounting for

around half of the global burden. In fact, due to rapid industrialization, fewer than 50% of patients across

the Asia-Pacific region attain the National Cholesterol Education Program Adult Treatment Panel lII low-

density lipoprotein cholesterol target.

Myocardial infarction (MI), commonly known as a heart attack, occurs when blood flow decreases

or stops to a part of the heart, causing damage to the heart muscle. The most common symptom is chest

pain or discomfort which may travel into the shoulder, arm, back, neck, or jaw. Often it occurs in the

center or left side of the chest and lasts for more than a few minutes. The discomfort may occasionally

feel like heartburn. Other symptoms may include shortness of breath, nausea, feeling faint, a cold sweat,

or feeling tired. About 30% of people have atypical symptoms. Women more often present without chest

pain and instead have neck pain, arm pain, or feel tired. Among those over 75 years old, about 5% have

had an MI with little or no history of symptoms. An MI may cause heart failure.

Myocardial infarction (MI) refers to tissue death (infarction) of the heart muscle. The phrase

“heart attack” is often used specifically to refer to a myocardial infarction and sudden cardiac death. An

MI is different from-but can cause-cardiac arrest, where the heart is not contracting at all or so poorly
that all vital organs cease to function, thus causing death. It is also distinct from heart failure, in which the

pumping action of the heart is impaired. However, an MI may lead to heart failure.

Chest pain may be accompanied by sweating, nausea or vomiting, and fainting, and these

symptoms may also occur without any pain at all. Loss of consciousness due to inadequate blood flow to

the brain and cardiogenic shock, and sudden death, frequently due to the development of ventricular

fibrillation, can occur in myocardial infarctions. Cardiac arrest, and atypical symptoms such as palpitations,

occur more frequently in women, the elderly, those with diabetes, in people who have just had surgery,

and in critically ill patients.

Non-ST segment elevation myocardial infarction (NSTEMI) is a heart attack or MI that may not

cause changes on electrocardiogram. However, chemical markers in the blood indicate that damage has

occurred to the heart muscle. In NSTEMI, the blockage may be partial or temporary, and so the extent of

the damage relatively small.

According to the latest WHO data published in 2017 Coronary Heart Disease Deaths in Philippines

reached 122,950 or 19.86% of total deaths. The age adjusted Death Rate is 191.79 per 100,000 of

population ranks Philippines #28 in the world.

Percutaneous coronary intervention (PCI): Procedure to reopen a partially or completely dilate

as needed to enable the heart to receive a fixed amount of oxygen. Increases in myocardial oxygen

demand such as physical exertion or an increase in BP causes the arterioles to dilate to maintain oxygen

supply to the heart. In atherosclerosis, plaque narrows the larger conductance vessels, causing the

arterioles to dilate under normal or resting conditions to prevent ischemia. Stress, exercise, or any

increase in myocardial oxygen demand in the setting of limited oxygen supply results in ischemia and

angina.
 Patients Profile

Name: R.B

Address: Cabaguan St., Linao West, Tuguegarao City, Cagayan

Birthday: February 21, 1976

Age: 42 years old

Sex: Male

Religion: Roman Catholic

Civil Status: Married

Occupation: Works At PDEA

Chief Complaint: Chest Pain

Date/Time of Admission: August 16, 2018/ 11:17 AM

Initial V/S: BP-150/100 mmhg, PR-110 bpm, RR-30 cpm, temp- 37

Brief discussion of the Case

 Non-ST segment elevation myocardial infarction (NSTEMI) is a heart attack or MI that may not

cause changes on electrocardiogram. It cause less damage to a person’s heart. An electrocardiogram or

ECG that displays each heartbeat as a waveform is used to determine if an NSTEMI or a STEMI has occurred

in a person. When looking at the waveforms of a person who has had an NSTEMI, they appear very distinct

from those of someone who has had a STEMI. The damage to the heart from an NSTEMI is less serious

than that from a STEMI. However, any heart attack can be very frightening.

An ECG in the case of an NSTEMI will show:

 A depressed ST segment or T-wave inversion

 No progression to Q wave

 The coronary artery only partially blocked

HISTORY
HISTORY OF PRESENT ILLNESS:

Few hours prior to admission, the patient had chest pain radiating to the right shoulder and upper

extremities while he was working that why his officemates decided to bring him home. While at home,

the pain increases and he loss consciousness that’s why his wife decided to bring him to the hospital.

HISTORY OF PAST ILLNESS:

He was admitted at Divine Mercy Wellness Center (2010) due to hypertension. He was given

Amlodipine 10mg OD as his maintenance.

HISTORY OF FAMILY ILLNESS:

According to the patient, both his parents died due to heart disease.
 ANATOMY AND PHYSIOLOGY

Our hearts beats 100, 000 times a day, pushing 5,000 gallons of blood through our body every 24
hours. It delivers oxygen-and nutrient-rich blood to our tissues and carries away waste.

The heart consists of four chambers:

 Atria- the two upper chambers

 Epicardium- protective layer mostly made of connective tissue.
 Myocardium- the muscles of the heart.
 Endocardium- lines the inside of the heart and protects the valves and chambers.
 These layers are covered in a thin protective coating called pericardium.

The heart contracts at different rates depending on many factors. At rest, it might beat around 60 times
a minute, but it can increase to 100 beats a minute or more. Exercise, emotions, fever, disease, and some
medications can influence heart rate.

The left and right side of the heart work in unison. The right side of the heart receives deoxygenated blood
and sends it to the lungs; the left side of the heart receives blood from the lungs and pumps it to the
system. Newly oxygenated blood returns to the left atrium via pulmonary artery to the lungs, it travels
through tiny capillaries on the surface of the lung’s alveoli (air sacs). Oxygen travels into the capillaries,
and carbon dioxide travels from the capillaries into the air sacs, where it is breathed out into the
atmosphere.

The muscles of the heart need to receive oxygenated blood, too. They are fed by the coronary arteries on
the surface of the heart.

Where blood passes near to the surface of the body, such as at the wrist or neck, it is possible to feel your
pulse; this is the rush ventricle and the pulmonary artery.

Tricuspid valve: between the right atrium and right ventricle.

Most people are familiar with the sound of a human heartbeat. It is often described as a “lub-DUB” sound.
The “lub” sound is produced by the tricuspid and mitral valves closing, and the “DUB” sound is caused by
the closing of the pulmonary and aortic valves.
The heart’s electrical system

To pump blood throughout the body, the muscles of the heart must be coordinated perfectly- squeezing
the blood in the right direction, at the right time, at the right pressure. The heart’s activity is coordinated
by electrical impulses.

The electrical signal begins at the sino-atrial strong and stretchy, which helps push blood through the
circulatory system. Their elastic walls help keep blood pressure consistent. Arteries branch into smaller
arterioles.

Veins: these carry deoxygenated blood back to the heart and increase in size as they get closer to the
heart. Veins have thinner walls than arteries.

Capillaries: they connect the smallest arteries to the smallest veins. They have very thin walls, which allow
them to exchange compounds with surrounding tissues, such as carbon dioxide and water.

GORDON’S HEALTH FUNCTIONAL PATTERN

FUNCTIONAL PATTERN BEFORE HOSPITALIZATION DURING HOSPITALIZATION

Health Perception- Health According to the patient, he The patient perceives himself

Management Pattern perceives himself as a healthy unhealthy due to his illness.

individual prior to admission

because they are having a

yearly physical fitness test

which is required in their

profession. He consider proper

diet and exercise during his off

to be fit and healthy. He added

that smoking and drinking

alcohol is not good for the

health.

According to the patient, he Patient is not able to consume

Nutritional- Metabolic Pattern
eats 3x a times a day with 1-2 food served per meal due to

snacks if they are not busy. He easy fatigability and decrease

prefers vegetables than appetite. Still, he drinks a lot of

meat/beef. He drinks 8-10 glass water.

of water a day.

Elimination Pattern Patient has a regular bowel Patient has a regular bowel

pattern once a day pattern once a day

characterized as semi formed, characterized as semi formed,

 yellow to dark brown in color. yellow to dark brown in color.

He voids more than 5x a day He voids more than 5x

characterized as straw to characterized as straw to amber

amber colored urine. colored urine.

Activity- exercise Pattern Patient is able to do activities of Patient experienced easy

daily living. He said that “Kapag fatigability. He was advised to

off ko pumpunta ako have a complete bed rest with

nagjojogging every afternoon”. assisted ADL’s.

Sleep-Rest Pattern Patient sleeps 8-10 hours a day During confinement, patient

during his off but during their sleeps 6-8 hours. Patient naps 2-

duty, they are not allowed to 3 hours during daytime.

sleep. They have their duty for

48 hours straight and 2 days off

after. During their duty, they

are only allowed to take a nap

for 30 mins-1 hour if they are

not busy.

Cognitive- Perceptual Pattern Patient is able to understand Patient is able to understand

and follow directions. He is a and follow directions, he is able

college graduate and works at to remember and retain

PDEA for almost 11 years.


Self- perception and Self- concept
Pattern
Roles- Relationship Pattern
Sexuality- Reproductive Pattern
information quite well, make
decisions on his own.
Patient sometimes do self-pity.
Patient describes herself as an
He couldn’t believe that he has
independent and a strong man.
heart disease.
He thinks he is fit and healthy
because he doesn’t feel
anything unusual and also he is
taking his maintenance daily for
hypertension (Amlodipine 10
mg once a day).
There are no problems in his
The patient is married and has 3
relationship with his family. His
children (2 daughters and a
boss said that he can have his
son). He and his wife are both
duty from 8am-5pm while he is
working but still they manage
recovering.
to have time for their children.
There are no problems in his
relationship with his family.
He has no problems with his
According to the patient, he has
sexual relationship with his wife.
a very satisfying relationship
He was advised by the doctor to
with his wife.
avoid sex for a week for him to
 have a complete rest and his

wife understands it. He is happy

with his marriage.

Coping- Stress Tolerance Pattern According to the patient, his Patient considers his illness a big

children are his best stress change in his life and during

reliever. Whenever he has a these times, he faces Crisis;

problem at work, he just pray to physically, emotionally and

God to make him strong and financially. During these times,

guide him to surpass all this the patient feels hopeless and

problems. depressed, but with the help of

his family members and loves

ones, patient was able to cope

with the stress.

Values- Belief Pattern Patient considers the almighty Patient considers the almighty

God as his source of strength God as his source of strength

and his faith with the Lord is his and his faith with the Lord is his

ultimate weapon to fight ultimate weapon to fight against

against his illness. his illness. His faith definitely

helps him cope with the disease

process.
 Laboratory exams/ diagnostic exams

1. Electrocardiogram
 It record the electrical activity of the heart over a period of time using electrodes
placed on the skin.
 Result: Non-ST segment elevation

2. CPKMB
 Is a cardiac marker used to assist diagnoses of an acute myocardial infarction
 Result: 20.95 U/L Normal Value: 0-24 U/L

3. Troponin T
 Is useful in the laboratory diagnosis of heart attack because it is released into the
blood-stream when damage to heart muscle occurs.
 Result: POSITIVE
4. Troponin I
 Is a cardiac and skeletal muscle protein useful in the laboratory diagnosis of heart
attack
 Result: 0.52 ng/mL Normal Value: <0.3 ng/mL
 NURSING CARE PLANS

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Acute pain At the end of At the end of
Instruct patient to Pain and decreased cardiac
“Sobrang sakit ng r/t to the shift, the the shift, the
dibdib ko saka decrease patient patient
notify nurse output may stimulate the
nhihirapan akong myocardial reports reports
huminga”, as blood flow decrease or decrease
immediately when sympathetic nervous
verbalized by the no chest pain chest pain
patient. as evidenced from pain
chest pain occurs. system to release excessive
by stable scale of 7/10
Objective: vital signs to 4/10.
amounts of norepinephrine,
 (+) grimaced and decrease
noted pain scale.
which increases platelet
 Restlessness
 Pain scale of
aggregation and release of
7/10
thromboxane A2. This potent

vasoconstrictor causes

coronary artery spasm, which

can precipitate, complicate,

and/or prolong an anginal

attack. Unbearable pain may

cause vasovagal response.

Place patient at Reduces myocardial oxygen

complete rest during demand to minimize risk of

anginal episodes. tissue injury.

Monitor heart rate and Patients with unstable angina

rhythm. Monitor vital have an increased risk of

signs every 5 min acute life-threatening

during initial anginal dysrhythmias, which occur in

attack response to ischemic

changes and/or stress. Blood

pressure may initially rise

because of sympathetic

stimulation, then fall if

cardiac output is

compromised. Tachycardia

also develops in response to

sympathetic stimulation and

may be sustained as a

compensatory response.

Maintain quiet, Mental/emotional stress

comfortable increases cardiac workload

environment. Restrict

visitors as necessary.

Provide supplemental

oxygen as indicated.
Increases oxygen available

for myocardial uptake and

reversal of ischemia.
ASSESSMENT DIAGNOSIS PLANNING NURSING RATIONALE EVALUATION
INTERVENTIONS
Subjective: Activity At the end Document heart rate Trends determine Goal met. The
“hinihingal ako kapag Tolerance of the shift, and rhythm and patient’s response to patient reports
pumupumta ako sa CR saka R/t the patient changes in BP before, activity and may decreased
sumasakit ang dibdib ko”,as Imbalance reports during, and after indicate myocardial chest pain and
verbalized by the patient. between absence or activity. Correlate oxygen deprivation shortness of
myocardial decrease with reports of chest that may require breath when
Objective: oxygen chest pain pain or shortness of decrease in activity doing ADL’s
 BP=150/100 supply and and breath. level and/or return to with support.
 HR=110 demand shortness bedrest, changes in
 Generalized of breath medication regimen,
weakness when or use of
doing supplemental
ADL’s oxygen.

Encourage rest Reduces myocardial

initially. Thereafter, workload and oxygen
limit activity on basis consumption,
of pain and/or reducing risk of
adverse cardiac complications.
response. Provide
nonstress diversional
activities.

Instruct patient to Activities that require

avoid increasing holding the breath
abdominal pressure and bearing down
(straining during (Valsalva maneuver)
defecation). can result in
bradycardia
(temporarily reduced
cardiac output) and
rebound tachycardia
with elevated BP.

Explain pattern of Progressive activity

graded increase of provides a controlled
activity level: getting demand on the heart,
up to commode or increasing strength
sitting in chair, and preventing
progressive overexertion.
ambulation, and
resting after meals.
ASSESSMENT DIAGNOSIS PLANNING NURSING RATIONALE EVALUATION
INTERVENTONS
Subjective: Fear/Anxiety At the end of the Identify and Coping with the Goal met. The
“Natatakot ako r/t shift, the patient acknowledge pain and emotional patient verbalized
baka hindi na ako Threat to or verbalize patient’s trauma of an MI is reduction of
makabalik sa change in health reduction of perception of difficult. Patient anxiety/fear.
trabaho ko”,as and anxiety/fear. threat and may fear death
verbalized by the socioeconomic situation. and/or be anxious
patient. status Encourage about immediate
expressions of, environment.
Objective: and do not deny Ongoing anxiety
>restlessness feelings of anger, (related concerns
>Focus on self, grief, sadness, about impact of
expressions of fear. heart attack on
concern about future lifestyle,
current and future matters left
events unattended or
unresolved, and
effects of illness on
family) may be
present in varying
degrees for some
time and may be
manifested by
symptoms of
depression.

Patient and SO can

Maintain be affected by the
confident manner anxiety/uneasiness
(without false displayed by health
reassurance). team members.
Honest
explanations can
be alleviate
anxiety.

Observe for verbal Patient may not

and nonverbal express concern
signs of anxiety directly, but words
(restlessness, and actions may
changes in vital convey sense of
signs), and stay agitation,
with patient. aggression, and
Intervene if hostility.
patient displays Intervention can
help patient regain
destructive control of own
behaviour. behaviour.

Accurate
information about
Answer all the situation
questions reduces fear,
factually. Provide strengthens nurse-
consistent patient
information; relationship, and
repeat as assist patient and
indicated. SO to deal
realistically with
situation.
Attention span
may be short, and
repetition of
information helps
with retention.

Sharing
information elicits
Encourage patient support and
and SO to comfort and can
communicate with relieve tension of
one another, unexpressed
sharing questions worries.
and concerns.
Conserves energy
and enhance
Provide rest coping abilities.
provides and/or
uninterrupted
sleep time, quiet
surroundings, with
patient controlling
type, amount of
external stimuli. Helps patient
and/or SO identify
Encourage realistic goals,
discussion about thereby reducing
postdischarge risk of
expectations. discouragement in
face of the reality
of limitations of
condition and/or
pace of
recuperation.
 DRUG STUDY

NAME CLASSIFICATION MECHANISM OF INDICATION CONTRAINDICATION ADVERSE NURSING

ACTION AND CAUTION EFFECTS CONSIDERATIONS
ASPIRIN Analgesic Exhibits This drug is Hypersensitivity Bleeding, Give drug with
antipyretic, given to dyspepsia, G.I
Anti- antiinflammatory patient due distress, food or after
and analgesic to chest bruising,
inflammatory effects. pain NSAIDS-induced urticaria, meals if GI upset
hypersensitivuty
Antiplatelet The antipyretic sensitivity reactions reactions. occurs
effect is due to an
Antipyretic action on the G6PD deficiency or
hypothalamus, bleeding disorders
NSAIDS resulting in the such as haemophilia Do not crush or
heat loss by chew enteric-
vasodilation of coated tablets.
peripheral blood
vessels.

Anti-
inflammatory
effects are are
mediated by a
decrease in
prostaglandin
synthesis. It also
decreases
platelet
aggregation.
NAME CLASSIFICATION MECHANISM OF INDICATION CONTRAINDICATIONS ADVERSE NURSING
ACTION AND CAUTIONS EFFECTS CONSIDERATIONS
CAPTOPRIL Ace Inhibitor Blocks ACE from Treatment of Hypersensitivity Patient’s Administer 1hr or
converting exhibit no
angiotensin I to hypertension Hx of angiodema adverse 2hrs after meals
angiotensin II, a effects
potent alone or with
vasoconstrictor,
leading to combination Used cautiously with: Monitor patient
decrease blood
pressure, with thiazide Impaired renal closely for fall of
decreased function, CHF, salt or
aldosterone type diuretics. volume depletion BP secondary to
secretion, a small
increase in reduction in fluid
potassium level,
and sodium and Treatment of volume (excessive
fluid loss;
increased CHF in perspiration and
prostaglandin
synthesis also patients dehydration,
involve in the
antihypertensive unresponsive vomiting,
action.
to diarrhea);

conventional excessive

therapy; used hypotension may

with diuretics occur.

and digitalis Reduce dosage in

patients with
impaired renal
function.
Treatment of
left ventricular
dysfunction
after MI
NAME CLASSIFICATI MECHANISM INDICATION CONTRAINDICATI ADVERSE EFFECTS NURSING
ON OF ACTION ONS AND CONSIDERATIONS
CAUTIONS
LIFEZAR Angiotensin II It works by It is used for the Hypersensitivity Body as a Whole: Observe for
Receptor blocking the treatment, control, to any component Facial edema, Systemic
antagonist/an action of prevention and of lifezar. fever, orthostatic Hypertension
tihypertensiv natural improvement of the effects, syncope. and t
e. substances following diseases, It can cause injury achycardia especially i
that tighten conditions and and even death to Cardiovascular in patients with CHF,
the blood symptoms: the developing system: Angina hyponatremia,
vessels.  High blood fetus when used pectoris, 2nd high dose diuretics
pressure in pregnancy degree AV block, or severe
 Kidney disease during the 2nd and CVA, hypotesion, volume depletion.
in high blood 3rd trimesters. MI, arrhythmias
pressure including atrial Monitor BP in
patients fibrillation, supine
 Kidney disease palpitation, sinus position,
in type 2 bradycardia, electrolytes,
diabetes ventricular urinalysis and CBC.
mellitus tachycardia,
patients ventricular
 Chronic heart fibrillation.
failure
 Stroke in heart Digestive System:
disorder Diarrhea,
patients dyspepsia,
 Stroke in high anorexia,
blood pressure constipation,
patients dental pain, dry
mouth,
flatulence,
gastritis,
vomiting.

Respiratory
System: Cough,
dyspnea,
bronchitis,
sinusitis,
pharyngeal
discomfort,
epistaxis, rhinitis,
respiratory
congestion.
NAME CLASSIFICATION MECHANISM INDICATION CONTRAINDICATIONS ADVERSE NURSING
OF ACTION AND CAUTIONS EFFECTS CONSIDERATIONS
ALDACTONE Potassium- Mild diuretic Primary Acute renal Dizziness, Take as directed
sparing diuretic that acts on hyperaldosteronism, insufficiency, headache, with a snack or
the distal adjunctive therapy progressive renal drowsiness, meals to
tubule to in the treatment of failure, hyperkalemia, rash, minimize GI
inhibit edema associated and anuria. Clients cramping, upset. Report if
sodium with CHF, nephrotic receiving potassium diarrhea, nausea, bloating,
exchange for syndrome, hepatic supplements, hyperkalemia, anorexia,
potassium, cirrhosis, treatment amiloride or hirsutism, vomiting or
resulting in of hypokalemia or triamterene. gynecomastia, diarrhea persist.
increased prevention of deepening of
secretion of hypokalemia in the voice, Instruct client not
sodium and patients at high risk irregular to drive/operate
water if hypokalemia menses. machinery until
conservation occurs; essential drug effects are
of hypertensiom. realized; may
potassium. cause drowsiness
An or uneasy galt.
aldosterone
antagonist. Report if deep,
rapid
respirations,
headaches or
mental slowing
occurs; may
indicate
hyperchloremic
metabolic
acidosis.

Remind client
that intake of
spironolactone
may cause breast
swelling and
diminished sex
drive due to
reduction of
testosterone
levels.
Since the drug is
metabolized in
liver, report
jaundice, tremors
or mental
confusion’ may
develop hepatic
encephalopathy
with liver disease.