BIRZEIT UNIVERSITY

FACULTY OF NURSING AND ALLIED HEALTH PROFESSIONS

NURS 341

Student’s Name: Rania shaabna Date of nursing care: 06\09\2020

Patient’s Initial: A.D.A Room Number: 112/2
Birth Date: 24\7\1964 Ward : CCU
Gender: Male Admission date: 03\09\2020
Marital Status: Married Diagnosis: ACS-NSTEMI

1.Chief Complaints:
Chest pain radiated to left arm, burning, sweating, nausea and vomiting.

2.History of present illness:

56 years old male Pt, came to the hospital with his son, was admitted to emergency ward complaining of chest
Pain, burning, sweating, nausea and vomiting, no SOB, no fever or cough, no contact with COVID pt.

3.Past Medical History:

Free.

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4.Past Surgical History:
No past surgical history.

5.Family History:
Hypertension, Diabetes Mellitus.

6.Nutritional History:
Pt. said that he has a relatively normal diet (free diet).

7.Allergies:
No known drugs or food allergies (NKDFA)

Vital Signs

BP HR SPO2 Temp weight Height BMI

126\84 mmhg 78 bpm 98% 36.3c 70kg 167cm 25.09 Kg\m2

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Physical exam

 Skin: is clean and odorless, has an adequate blood flow, skin temperature is warm (not cold.), skin is not too
moist and not too dry and has a smooth texture. Skin turgor is normal, skin returning to normal within about
1second. Skin has no signs of edema. There are no protruding veins in legs, so there are no signs of varicose
veins, no cyanosis, no masses or bulging on the skin there is no bed ulcer and there is no sign of infection and
surgical wound.

 Hair: Patient has little hair, but the hair he has is clean and evenly distributed on head and body, with an even
color, texture is smooth and not too dry or moist and there are no signs of any dandruff, nits, or lice.

 Nails: are normally colored and pink, with an adequate blood flow. Capillary refill test was done and nail
bed returned to the color of pink within two second. Nails are smooth and evenly pigmented and the
surrounding tissues are smooth with no scars or lesions.

 Head, Neck, Thyroid, and Lymphatics

The patient has no history of change in the head, neck, thyroid and lymphatics.
 Head: has a normal, even shape and size. Scalp is clean and intact, with no signs of nits or lice, no lesions or
scars, the hair is clean, normal in texture and evenly distributed. Facial expression is normal and facial features
are symmetrical on both sides, full movement is present head and face are movable completely and
symmetrically, face color is clear and pink and with no signs of cyanosis or pallor.

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 Eyes: The patient has no history of changes in the eyes. Eyes are symmetrical, with straight eyelids and no
signs of drooping or puffiness in the eyelid, eyeballs have a normal appearance with no bulging and sclera is
white with no signs of redness or jaundice. Conjunctiva has a normal appearance, also with no signs of
infection or jaundice. Both pupils are equal in size, black, react to light and accommodate. Patient hasn’t a
history of eye problem.

 Neck: skin on neck is pink, intact, with no scars or lesions and has adequate blood flow. On palpation, no
lymph nodes are felt and no limitations of neck movement are exhibited. Carotid artery pulse is palpable, both
carotid arteries are symmetrical in pulse and rate. On auscultation of the carotid arteries, no bruits are heard,
and pulses and rates are normal. Trachea is in the midline, and neck is symmetrical and shape is normal. There
are no signs of jugular vein distention.

 Thyroid: On thyroid gland palpation, no enlargement was present.

 Lymphatics: no history of any changes in lymph nodes was noticed.

 Nose, Mouth, Throat, Ears, and Hearing:

 Nose: appearance of the nose is straight, nostrils are equal and no scars or lesions are present. Nasal discharge
is present. Septum is straight and there are no signs of a deviated septum. Olfactory nerve is fully functional
and has ability to smell through both nostrils. Palpation of external nose shows no tenderness, swelling, or
masses. Palpation and percussion of frontal and maxillary sinuses causes no pain and no swelling was found.

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 Mouth: shows no scars or lesions, lips are symmetrical, smooth and pink with no signs of cyanosis or dryness.
The patient has a full set of teeth. They are aligned straight Hygiene is good and teeth are stable and in place,
no tenderness was present. Hard and soft palates are dark pink in color and are moist with no scars or lesions,
there are no signs of infections or swellings. Mucous membrane is pink in color with no pain, and it is moist
with saliva with a good flow of blood. There is an adequate amount of saliva and the mucous membrane is not
dry and does not show signs of cyanosis. Tongue is pink, smooth and moist, tongue movement is present.
Gums are moist and pink, and have adequate blood flow with no signs of cyanosis.

 Throat: is pink in color, with no signs of inflammation or swelling. Posterior pharynx is pink in color, with no
signs of swelling or inflammation in the tonsils. Uvula is in normal position and is pink in color, with no signs
of infection or inflammation.

 Ears: skin on ears is pink, smooth texture and no scars or lesions are visible. Auricles have a normal position
and shape, auricle on palpation shows no pain or abnormalities, no inflammation, no tenderness, on palpation
of the mastoid process, no pain is felt and it is in its normal position with no swelling or inflammation. Patient
hears everything around him with no difficulties.

 Chest and lungs:

Clavicle at the same height, sternum midlines, symmetrical scapula, vertebra in midline, transverse equal twice
of anterior posterior, normal respiratory rate, symmetrical chest movement. Nail was pink color which means
it was good oxygenation, no clubbing finger was present. No tenderness on trachea. Thoracic was expansion
bilateral. All normal breath sound was hear, lung sound normal, normal chest expansion, normal tactile
fremitus.

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 Breast Assessment:
Both breasts were pink, symmetrical in shape and equal in size prominent. No palpable lymph nodes, normal
nipples equal in size and out of prominent, absence of abnormal discharges no sores.

 Heart and circulatory system and peripheral vascular:

There is no past history of chest pain or HTN or cardiovascular disorders.
Carotid artery is visible bilateral and palpable. Pink color of hand and fingers. Hands color is pink and appropriate
without erythematic or cyanosis or skin lesions and normal temperature is equal bilateral. No edema and capillary
refill less than 2 second. The pulse is regular and within normal range in right and left (Radial, Ulnar and Brachial).
Both legs equal in size, the legs skin color is pink, warm extremities no redness, no edema in arms and legs.
Apical impulse regular, Pulse normal (78bpm), heart sounds normal (no murmurs).

 Abdomen:
Patient’s appetite is good and eats well. Abdomen has soft no lesions or scars and skin is smooth, warm and not
dry, with no dilated veins. Masses are not present during palpation. Umbilicus is clean, with no discharge or smell
and is in the center of the abdomen. Patient has no hemorrhoids and bowel movements are normal.

 Urinary system:
The patient has no history of changes in the urinary system, and dose not complains of pain upon urination.

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  Sex and Reproductive:
Patient has no history of changes in the reproductive system.

• Skeletal system:
Patient is able to move and walk with no pain or struggle. He has no weakness in the limbs or joints, or any
muscular degeneration or pain. Normal movements of sitting up and laying down are done with no struggle or
pain and patient is completely mobile. There are no signs of swelling or tenderness in the joints.

• Neurological system:
Patient is fully conscious, oriented to (time, person and place) and reason for being in a hospital. Patient is well-
dressed and groomed and has good hygiene. Appropriate behavior shows that patient follows directions and
speech is smooth, clear, with a normal tone and rate. Facial expressions and tone of voice match context and
content of communication mood and emotion reflect the current situation appropriately.

 Pain assessment:
Pain scale 1\10 according to numeric scale.

 Psychosocial environment:
Pt is married, and he has 5boys and 1girl, Pt. smoker.

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 Diagnostic procedures:
 ECG

- HR=76 bpm
- Regularity= regular
- PR interval= 0.19 s
- QRS duration= 0.088 s
- Presence of P-wave: presence
- Isoelectric ST-segment: isoelectric
- T weave : presence

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  Echo
- Normal LV size
- EF=50%
- Normal MV
- Normal AV
- No pericardial effusion

 X-Ray (Normal)

 Laboratory Tests
Laboratory Data:

Test Date Patient’s Value Normal Unit Meaning of Abnormal Value

(Result) Value
Creatinine 06\09\2020 0.89 0.7-1.2 Mg\dl Normal
Random blood 06\09\2020 108 74-110 Mg\dl Normal
sugar
BUN 06\09\2020 14.7 6-20 Mg\dl Normal
Sodium 06\09\2020 136 135-145 Mmol\l Normal
MCV 06\09\2020 84 80-100 Fl Normal
Monocytes(%) 06\09\2020 6.8 3-7 % Normal
Eosinophils(%) 06\09\2020 0.36 0.0-0.4 % Normal
WBCs 06\09\2020 9.5 4.6-11 K\ul Normal
RBCs 06\09\2020 4.72 4.7-6.3 M\ul Normal
Troponin I 06\09\2020 24.6 0-0.029 Ng/ml Abnormal due to myocardial
damage or inflammation on the
myocardial

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 CK-total 06\09\2020 256 0-190 U\l Abnormal due to myocardial
infarction
Potassium 06\09\2020 4.1 3.5-5.3 Mm0l\l Normal

 Pathophysiology: of the current disease

A.The disorder is characterized by a narrowing of coronary arteries due to atherosclerosis, spasm or, rarely, embolism.
B. Atherosclerotic changes in coronary arteries results in damage to the inner layers of the coronary arteries with
stiffening of vessels and diminished dilatory response.
C. Accumulation of fatty deposits and lipids, along with development of fibrous plaques over the damaged areas in the
vessels, causes narrowing of the arteries, thus reducing the size of the vessel’s lumen and impeding blood flow to the
myocardial tissues.
D. Decreased delivery of oxygen and nutrients to the tissues causes transient myocardial ischemia and pain.
E. Hard plaque causes hardened arteries, whereas soft plaque can cause formation of blood clots.

Signs and symptoms :

1. SOB
2. Chest pain
3. Sweating
4. Pain in neck and jaw
5. Nausea and vomiting

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Treatment:
 Improve blood flow and O2
 Relieve pain
 Improve heart function
 Gave medication like Antiplatelet, B blockers, ACE inhibitor, statin, Fibrinolytic, Anticoagulation.
 Catheterization (PCI)
 Rest

Medications:

Name/ Dosage Action Rational Evaluation Side Effects

Aspirin 100mg (ASA) reduce fever To prevent fever and irritation of the stomach,
1*1 non-steroidal anti- and pain and relief pain nausea, vomiting, bleeding
inflammatory drug inflammation
(NSAIDs)
Plavix 75mg 1*1 (Clopidogrel) Pt has ACS, to To prevent clot Bleeding, jaundice, purple
prevents platelets lower risk of formation spots.
in blood from blood clot
sticking together
(Antiplatelet)
Mepral 20mg 1*1 (Omeprazole) Decrease acid To prevent heartburn Stomach pain, gases, nausea,
proton pump secretion in and peptic ulcer vomiting, diarrhea, and
inhibitor: decreases stomach. headache.
the amount of acid
produced in the
stomach.

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Concor 2.5 mg (Bisoprolol) Used for the To prevent Headache, nausea, stomach
1*1 Beta blocker treatment of high hypertension pain, bradycardia.
Antihypertensive blood pressure
drug

Clexane 80mg (Enoxaparin Pt has ACS, to To prevent clot confusion, fever, pain,
1*2 Sodium) lower risk of formation edema, nausea, diarrhea,
Anticoagulant , blood clot. hemorrhage, anemia,
Low molecular irritation, rash
weight Heparin
Factor II III x

 List of Nursing Diagnosis:

-Acute pain
- Risk for decreased Cardiac Output
-Risk for decrease cardiac tissue perfusion
-Risk for ineffective peripheral tissue perfusion
- Risk for excess Fluid Volume
- Activity Intolerance
-Anxiety
-Deficient knowledge about post-ACS self-care

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1- Diagnosis: acute pain related to coronary artery occlusion a.m.b. Chest pain with radiation, restlessness and
change in pulse, blood pressure.

Planning Intervention Rational Evaluation

Goal\Desired -obtain full description of pain -pain is a subjective After nursing

outcome: from patient including location, experience and must be intervention if pt.
intensity, duration, characteristic described by patient, provide becomes no chest pain
Relief/control of and radiation. baseline for comparison to aid so goal is met.
chest pain within in determining effectiveness
appropriate time of therapy, resolution and
frame for progression of problem.
administered
medications.
-instruct patient to report pain -decrease external stimuli,
immediately, provide quite which may aggravate anxiety
environment, calm activities and and cardiac strain, limit
comfort measures. coping abilities and
adjustment to current
situation.

-instruct patient to do relaxation -helpful in decreasing

techniques: deep and slow perception and response to
breathing, distraction behaviors, pain.
guided imagery.

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-check vital signs before and after
narcotic medication.
-administer supplemental oxygen
by face mask or nasal cannula.
-hypotension and respiratory
depression can occur as a
result of narcotic medication
and may increase myocardial
damage.
-increase amount of oxygen
available for myocardial
uptake and therapy may
relieve discomfort associated
with tissue ischemia.
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 2- Diagnosis: risk for decreased cardiac output related to changes in rate, rhythm, electrical conduction and reduced
preload.

Planning Intervention Rational Evaluation

Goal\Desired
outcome: -evaluate quality of pulses on both -decreased cardiac output After nursing
pulse points. result in diminished weak intervention if pt.
Maintain or therapy pulses, becomes normal
hemodynamic irregularities suggest hemodynamic so goal
stability. dysrhythmias, which may is met.
require evaluation and
monitor.

-note response to activity and -overexertion increase

promote rest appropriately. oxygen consumption and
demand that can
compromise myocardial
function.

-monitor laboratory data, cardiac -enzymes monitor

enzymes, ABGs and electrolytes.
resolution or extension of
infarction, presences of
hypoxia indicates need for
supplemental oxygen,
electrolyte imbalances
adversely affects cardiac
rhythm and contractility.

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3- Diagnosis: risk for ineffective tissue perfusion related to reduction of blood flow.

Planning Intervention Rational Evaluation

Goal\Desired -investigate sudden changes or -cerebral perfusion is directly
outcome: continued alternation in related to cardiac output and is After nursing
mentation. also influenced by electrolyte intervention if pt.
Demonstrate and acid-base variations, becomes normal vital
adequate perfusion, hypoxia. sign, skin warm and
skin warm and dry, dry, peripheral pulse
vital sign with -systemic vasoconstriction present and absence of
normal range. -inspect for pallor, cyanosis, resulting from diminished edema so goal is met.
mottling, cool and clammy skin. cardiac output may be
evidenced by decreased skin
perfusion and diminished
pulses.

-decreased intake or persistent

-monitor intake, note changes in nausea may result in reduced
urine output. circulating volume.

-enhances venous return,

reduces venous stasis,
-encourage active or passive leg isometric exercise can affect
exercise, avoidance of isometric cardiac output by increasing
exercise. myocardial work.

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  Home health teaching and continuing care( specific for you patient)
Pt. should remain supervised and continuing care receives full time care.
When he feels pain or any signs and symptoms go to the doctor due to prevent the complication and keep on the
normal diet and take your medication exactly as directed do not skip doses. Stop smoking and increase activity.

 Gained experience:
I learned more about this disease, its types, know the Pathophysiology of ACS, signs and symptoms, treatment, what
type of medication can give it for patient, and how we can teaching the patient to adapt with his disease.
I also learned more about assessing a Pt. and the intervention to prevent complication. I become familiar with teaching
and continued home care of the Pt., so that I can use it in the future with other Fracture Pt.

 Citation of the reference

https://www.medicalnewstoday.com/articles/161255#side_effects

https://www.drugs.com/sfx/plavix-side-effects.html

https://www.webmd.com/drugs/2/drug-3766-2250/omeprazole-oral/omeprazole-delayed-release-tablet-oral/details

https://www.webmd.com/drugs/2/drug-14206/bisoprolol-fumarate-oral/details

https://en.wikipedia.org/wiki/Enoxaparin_sodium#Side_effects

https://nurseslabs.com/7-myocardial-infarction-heart-attack-nursing-care-plans/

https://www.ncbi.nlm.nih.gov/books/NBK513228/

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