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-ST-

segment 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-ST-

segment 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.

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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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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.

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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.

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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 patient’s height is 5’3” 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.

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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.

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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 ( Brunner’s & Suddarth’s 11 th 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 ( Brunner’s&Suddarth’s 11 th

edition).

Nursing Intervention for the patient include monitor vital signs, hemodynamic,

heart sounds, and cardiac rhythm to monitor the condition accurately ( Brunner’s&Suddarth’s

11th edition). 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 11 th 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 ( Brunner’s&Suddarth’s 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 5 th edition). Caution client to

avoid activities that increases cardiac workload and place the patient in a complete bed rest

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without bathroom privilege to conserve energy and to decrease oxygen demand ( Ignativiticus 5 th

edition). Provide stool softener’s to prevent straining at stool and provide bedside commode to

decrease the cardiac workload (Wilkinson’s 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 ( Brunner’s&Suddarth’s 11 th

edition).

After one hour of Nursing Interventions the patient was on a comfortable semi-

fowler’s 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 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. 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. ( Nurse’s 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 ( Nurse’s Pocket Guide 11 TH edition). Encourage and facilitate

early ambulation and other’s ADLs when possible. Assist with each initial charge dangling,

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Nursing Care Management

sitting in chair, ambulation because the longer the patient remains immobile the greater the level

of debilitation that will occur ( Nurse’s Pocket Guide 11 TH edition). Schedule activities with

adequate rest periods during the day to reduce fatigue (Nurse’s Pocket Guide 11 TH edition).

Encourage participation in self-care occupational activities to enhance self-concept and sense of

independence (Nurse’s Pocket Guide 11TH edition). Provide all personal belonging within reach

and provide bedside commode to conserve energy (Wilkinson’s 2010). Advised relatives or the

family members to stay with the patient to assist the patient if possible (Wilkinson’s 2010).

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).

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.

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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 Brunner’s &

Suddarth’s 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 (Brunner’s & Suddarth’s

11th edition).

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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)

Brunner’s and Suddarth’s Textbook of Medical-Surgical Nursing (12 th Edition)

Ignativiticus (5th edition)

Nurse’s Pocket Guide (11th edition)

Lippincott’s Nursing Drug Guideline

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