Our Lady of Fatima UniversityNursing 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 JR’s 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. . 1 likes eating foods that are high in cholesterol.com has explained that when patients report anginal chest pain.medscape. ACS develops when the vulnerable or high-risk plaque undergoes disruption of the fibrous cap which is the stimulus for thrombogenesis. diet. family history) greatly contributed to the development of atherosclerosis. gender. Most patients with ST-segment elevation MI (STEMI) ultimately develop a Q-wave MI. ECG findings. The distinction between UA and NSTEMI is the presence or absence of cardiac markers (troponin or CK-MB). and laboratory tests.R. (Brunner.is a 53 years old male. calcium. NSTEMI or STEMI.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.com) rn. 2 . It begins with the Deposit of lipids. Following disruption of the vulnerable plaque. Plaque can progress to cause coronary stenosis. As an end result of inflammatory process there will be a production of a fibrous atherosclerotic plaque. These determine if the patient is having stable angina. A smaller number will develop a non-Q-wave MI. These factors (age. fibrin. and has a family history of CAD and hypertension. Thrombus resorption may be followed by collagen accumulation and smooth muscle cell growth. 2010) J. and other cellular substances within the lining of the arteries. the goal is to immediately classify them into one of three groups based on their symptoms. Patients with anginal pain may present with or without ST-segment elevation on the ECG. (emedicine. the most common cause of ACS. Patients who do not have ST segment elevation have UA or a non-ST-segment Elevated MI (NSTEMI). unstable angina. These initiate a progressive inflammatory response in an effort to heal the endothelium. 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. 3 . Char. (Douglas M. resolution of vasoconstriction or flow from collateral sources limits the resulting ischemic injury. et al. The spectrum of clinical conditions that range from UA to NQMI and QwMI is referred to as Acute Coronary Syndrome (ACS) (Antman. MD. NSTEMI occurs when myocardial perfusion is disrupted due to persistent thrombotic occlusion or vasospasm.. 2005) Spontaneous thrombolysis.Our Lady of Fatima University 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.) In this case JR developed non-ST segment elevation MI. JR then developed complications of ischemia: acute pulmonary congestion probably secondary to left ventricular dysfunction. 2004. male who work as a government employee. On the day of confinement there was a persistence of chest pain. He came in due to chest pain. has a family history of CAD and hypertension. There was no dyspnea. infarct wall. No consultation was done and no medication was taken. No history of asthma attacks and diabetes mellitus. He has no known allergies.Our Lady of Fatima University Nursing Care Management HISTORY JR is a 53 years old. He was admitted on September 18. No recent surgery. no headache. 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. killip I. 2012 at around 2:00 pm as a case of Acute Pulmonary Congestion probably secondary to left ventricular dysfunction and/or Acute Myocardial Infarction. He is an occasional drinker. and he usually eats high cholesterol foods. ACS NSTEMI. interrupted with work at the hospital. 4 . appeared pale and weak. non-tender and slightly cold.Our Lady of Fatima University Nursing Care Management Nursing Physical Assessment J. no clubbing of the fingers and no edema. The patient skin was soft. was coherent. On the first day. J. pulse rate was 78 bpm. the patient bowel sound was normoactive and stated no bowel movements. respiration rate was 38 cpm. The patient’s height is 5’3” and he weighs 140 lbs.R. apical pulse was 78 bpm. his chest pain was precipitated with light activities.R. time. The urine output from 2-10 pm was 480 ml. alert and oriented to person. The patient was placed in a complete bed rest without bathroom privileges even though he was able to performed independent actions. and place. The patient temperature was 36. The patient chief complaint was chest pain radiating to his left arm. 9 C. The patient was in a low fat and low salt diet. 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. no murmur but there was irregular rhythm. and a blood pressure of 130/85. 5 . K. He was also advised to remain in high back rest to reduce myocardial oxygen consumption. Clopidogrel 75 mg/tab for inhibition of platelet aggregation. BUN. CBC with PO. PT/PTT every six hours. Medications given were: ASA 80 mg/tab 4 tabs chewed then 1 tab OD for vasodilation and inhibition of platelet aggregation. According to Brunner (2010) thrombolytics must be administered as early as possible after the onset of symptoms. a thrombolytics. Heparin side drip 5000 IU in D5W 100 cc x 12 ugtts/min. Heparin 3000 IU bolus for inhibition of thrombus and clot formation. On second day. for hypertension. creatinine.5 million units in 100 cc D5W in soluset. JR had no chest pain until Day 6 and medications were continued.Our Lady of Fatima University Nursing Care Management RELATED TREATMENTS The patient undergone several diagnostic exams: 12 lead ECG ICB. Simvastatin 40 mg/tab for inhibition of HMG-CoA reductase. generally within 3 to 6 hours. JR still had chest pain but no DOB. 6 . Streptokinase. Ca. Mg. Metoprolol 50 mg q6 for the first 48 hours upon confinement. 1. should avoid over exertion. Na. and should have had a 24 hour bedside watcher. Lactulose 30 cc OD at HS. Troponin I. 2D echo and chest xrays. Diphenhydramine 50 mg/tab for antihistamine and Captopril 25 mg/tab for hypertension were given. urinalysis. 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.Our Lady of Fatima University Nursing Care Management NURSING CARE PLAN 1 J. Instruct the client to stop all activities and position the patient in a sitting position or semi-fowler’s position to reduce the oxygen requirement of the ischemic myocardium and decrease chest discomfort and dyspnea ( Brunner’s&Suddarth’s 11th edition).559ng/ml. heart sounds. pulse rate was 88 and respirations was 36.R. The short term goal include immediate and appropriate treatment in angina these includes to reduce chest pain and prevention of complications ( Brunner’s&Suddarth’s 11 th edition). 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. 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 ( Brunner’s&Suddarth’s 11th edition). According to ( Ignativiticus 5th edition) ACS is the most prevalent type of cardiovascular disease in adults. and cardiac rhythm to monitor the condition accurately ( Brunner’s&Suddarth’s 11th edition). blood pressure was 130/85.’s Focus for Nursing diagnosis is Ineffective Tissue Perfusion Secondary to Acute Coronary Syndrome (ACS) as evidenced by chest pain ( Brunner’s & Suddarth’s 11th edition). heart rhythm was irregular. Vital sign was taken. Caution client to avoid activities that increases cardiac workload and place the patient in a complete bed rest 7 . Patient appearance was pale. hemodynamic. 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). a 12 lead ECG was done and revealed a myocardium ischemia as evidence by T-wave inversion. Nursing Intervention for the patient include monitor vital signs. Administer Oxygen therapy at 2 L/min. Troponin I was obtained with the result of 0. 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 ( Nurse’s Pocket Guide 11TH edition). According to Brunner’s & Suddarth’s (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. its treatment. Patient stated that pain is relieved promptly. ( Nurse’s Pocket Guide 11TH edition).R. Provide information to the patient and primary caregiver about his illness. The short term goal include promote optimal level of function & prevent complications. After one hour of Nursing Interventions the patient was on a comfortable semifowler’s position with no signs of chest pain. The patient stated that upon his movement he experienced chest pain and discomfort. Assist with each initial charge dangling. Provide stool softener’s to prevent straining at stool and provide bedside commode to decrease the cardiac workload (Wilkinson’s 2010). (Ignativiticus 5th edition). NURSING CARE PLAN 2 J. 8 .Our Lady of Fatima University Nursing Care Management without bathroom privilege to conserve energy and to decrease oxygen demand ( Ignativiticus 5th edition). Encourage and facilitate early ambulation and other’s ADLs when possible. Patient appearance was pale and weak with limited range of motion.’s Focus Nursing Diagnosis is Impaired Physical Mobility related to possible recurrent chest pain. and methods of preventing its progression to reduce anxiety and to promote supportive therapy for the patient ( Brunner’s&Suddarth’s 11th edition). Patient and family members was able to understand and response immediately to any nursing interventions. slowed movement and reluctance to attempt movement. ambulation because the longer the patient remains immobile the greater the level of debilitation that will occur ( Nurse’s Pocket Guide 11TH edition). Provide all personal belonging within reach and provide bedside commode to conserve energy (Wilkinson’s 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. Provide a quiet and well ventilated environment for the comfort of the patient (Wilkinson’s 2010) and limit visitors if necessary to promote good rest (Wilkinson’s 2010). 9 . Encourage participation in self-care occupational activities to enhance self-concept and sense of independence (Nurse’s Pocket Guide 11TH edition). Schedule activities with adequate rest periods during the day to reduce fatigue (Nurse’s Pocket Guide 11TH edition).Our Lady of Fatima University Nursing Care Management sitting in chair. Advised relatives or the family members to stay with the patient to assist the patient if possible (Wilkinson’s 2010). 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. preparation and dosage (Brunner’s & Suddarth’s 11th edition). its treatment. 10 . diet control. He advised to continue his medications such as aspirin and metropolol. these includes smoking cessation. physical activity and blood pressure and blood glucose control to develop a healthy heart lifestyle. According to Brunner’s & Suddarth’s lifestyle modifications and adoption of an activity program is a must. 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. (Ignativiticus 5th edition) has pointed out that nurses has a big role in educating the client about his illness. and methods of preventing its progression and helping them to adjust in any changes in their lifestyle. ac.cardionursing.medscape.com http://www.uk http://www. Char.com http://www.sign. Washington University of Medicine) Brunner’s and Suddarth’s Textbook of Medical-Surgical Nursing (12th Edition) Ignativiticus (5th edition) Nurse’s Pocket Guide (11th edition) Lippincott’s Nursing Drug Guideline 11 .rn.Our Lady of Fatima University Nursing Care Management REFERENCES http://emedicine. MD (Division of Emergency Medicine.com Douglas M.