INTRODUCTION

An acute coronary syndrome (ACS) is a set of signs and symptoms (syndrome) related to the heart. ACS is compatible with a diagnosis of acute myocardial ischemia, but it is not pathognomonic. The term ACS was adopted because it was believed to more clearly reflect the disease progression associated with myocardial ischemia. ACS should be distinguished from stable angina, which develops during exertion and resolves at rest. In contrast with stable angina, unstable angina occurs suddenly, often at rest or with minimal exertion, or at lesser degrees of exertion than the individual's previous angina ("crescendo angina"). New onset angina is also considered unstable angina, since it suggests a new problem in a coronary artery.

Though ACS is usually associated with coronary thrombosis, it can also be associated with cocaine use. Cardiac chest pain can also be precipitated by anemia, bradycardias (excessively slow heart rate) or tachycardias (excessively fast heart rate).

The cardinal sign of decreased blood flow to the heart is chest pain experienced as tightness around the chest and radiating to the left arm and the left angle of the jaw. Chest pain associated with NSTEMI is normally longer in duration and more severe than chest pain associated with unstable angina.

Populations more likely to experience a silent MI include people with diabetes, women, older adults, and those with a history of heart failure. As the prevalence of diabetes rises, silent ischemia may also become more common.

In the United States, approximately 1.7 million cases of acute coronary syndrome were diagnosed in 2001. Rates of first-listed admission diagnosis of unstable angina fell 87% from 29.7/10,000 in 1988 to 3.9/10,000 in 2001 for all age and sex groups, and rates of acute coronary syndrome as a primary diagnosis declined 44%. Internationally, cardiovascular diseases cause 12 million deaths throughout the world each year, according to the third monitoring report of the World Health Organization, 1991-1993. Cardiovascular disease causes almost half of all deaths in the developed world and 25% of deaths in the developing world.

The incidence of acute coronary syndrome demonstrates a male predominance to approximately 70 years of age, when incidences converge in both sexes.

Women are more likely than men to be older and to have more comorbid conditions at the time of first presentation. Abnormal locations of pain, nausea, vomiting, fatigue, dyspnea, and other atypical presentations are most common in women.

Acute coronary syndrome often reflects a degree of damage to the coronaries by atherosclerosis. Primary prevention of atherosclerosis is controlling the risk factors: healthy eating, exercise, treatment for hypertension and diabetes, avoiding smoking and controlling cholesterol levels; in patients with significant risk factors, aspirin has been shown to reduce the risk of cardiovascular events. Secondary prevention is discussed in myocardial infarction.

Our quest of enhancing and widening our knowledge has pushed us to choose ACS as the subject of our case study since we still havent encountered such health deficit in our previous hospital duties. Curiosity and eagerness to learn are the sole reasons why we immediately grab the opportunity to know more about the case plus the fact that whatever learning we will gain from this study will prepare us to the near future in rendering safe and quality nursing care.

GENERAL OBJECTIVES

The completion of this case study aims to equip student nurses of the knowledge, skills and attitude necessary to form critical nursing abilities in rendering promotive, preventive, curative, rehabilitative and palliative care to patients with schizophrenia thus promoting optimum level of health and wellness.

SPECIFIC OBJECTIVES

This study will bridge the student nurses on the achievement of relevant information about the disease thus being able to: * Familiarize themselves with Schizophrenia, its associated signs and symptoms, its incidence rate and the preventive measures that can be done as well as appropriate treatment for better understanding of the disease process. * Describe the clients past and current health history as well as the family, personal, social and psychological history as reference for clients health status. State the clients profile including the date of admission, physician, chief complaint, admitting and final diagnoses for documentation purposes. * Elaborate and present meaningful ways in identifying the cause and process of the disease or its pathophysiology. * Formulate an efficient nursing care plan and implement appropriately for the improvement of the clients health status. * Comprehend the subjective data given by the patients mother as well as the objective data gained which will significantly help in formulating and rendering healthcare to the client.

Patients Profile

Name:

Patient LS

Address: Age: Gender: Status: Religion: Chief Complaint: Admitting Diagnosis:

Pastorville Subd., Batangas City 50 Male Married Roman Catholic Chest discomfort Acute Pulmonary Congestion secondary to Acute Coronary Syndrome, Cardiac dysrrhythmia, DM 2 poorly

controlled, Final Diagnosis:

COPD Acute Pulmonary Congestion secondary to Acute Coronary Syndrome

Physician: Diet: Date of Admission:

Dr. Romulo Rosita Diabetic diet January 3, 2012

Clinical Appraisal

General Survey The patient looks well-groomed and in proper hygiene. He is coherent and willing to cooperate in conversation. PAST HEALTH HISTORY According to patient LS, he had no illnesses during his childhood years. He just experienced headache oftentimes. He had a complete vaccination and no known allergies to any drugs, foods or insect bites. Moreover, he hadnt been involved in any serious injury or accident. This is his third hospitalization. First, he had been hospitalized because he had undergone operation due to abscess in the buttocks area, in the year 1992 while he was in Saudi Arabia. And the second hospitalization is when he acquired chickenpox in the year 1995. He started using Diatab when he was in Saudi for maintaining DM. FAMILY HISTORY The family is composed of four members. Patient LS, 50 years old, is the head of the family and Mrs. OS, 50 years old too, is his wife who was taking care of him. He has two children. His daughter is already 27 years old and his son is 22. His parents were both deceased. He has nine siblings and hes the third one. In his father side, they had a history of heart disease, liver cancer, hypertension and Diabetes Mellitus. PERSONAL HISTORY Patient LS smokes for 30 years and he is an alcohol drinker. He only drinks alcohol when there is an occasion. Vegetables and fish were included in his daily meal but his diet is mostly made of red meat. He has a good sleeping pattern, having 6 to 7 hours of sleep. He also commended that he was able to exercise every morning.

SOCIAL HISTORY Their family has a harmonious relationship among each member. All of them are Catholic. The client had just finished second year college. Recently, he was working in abroad in Saudi Arabia. He works there for 12 to 14 hours a day causing him to become over fatigue. His wife is managing a flower shop. Their income is enough to support the family since both of them have occupation. They reside at a subdivision where the houses are not congested. He was not able to consult the health center from their barangay because it is far from their house. PSYCHOLOGIC HISTORY The factor that causes stress to the client involves acquiring illnesses due to over fatigue and the way of coping is maintaining an open communication among the family members. HISTORY OF PRESENT ILLNESS The client experienced difficulty of breathing and chest pain at about ten in the evening of January 3, 2012. He was rushed at Batangas Regional Center. He was apparently well until few minutes prior to admission. When he was about to sleep, he suddenly developed chest heaviness in the left anterior chest wall, now radiating and persisting associated with diaphoresis and difficulty of breathing. Dr. Rosita made the admitting diagnosis which is Acute Pulmonary Congestion secondary to Acute Coronary Disease.

PHYSICAL ASSESSMENT

Date General Appearance Vital signs

August 3, 2012 The patient is cooperative, conscious and coherent. He is generally clean and wellgroomed. Temp: 36 PR: 123 beats per minute RR: 30 breaths per minute BP: 160/120 mmHg

Body Parts Skin

Method Inspection and Palpation

Findings Dry and skin

Analysis wrinkled NORMAL aging

due

to

Cold and clammy NOT NORMAL due skin to insufficient blood supply to the peripheries Head Hair Scalp Inspection Inspection Inspection No presence of lice NORMAL or any infestations. Presence of white NORMAL and grayish hair aging (-) seborrhea (-) abrasions (-) dandruff NORMAL due to

Face

Inspection

Symmetrical NORMAL Presence of NORMAL mucolytic spots and aging freckles Symmetrical Symmetrically aligned (-) lesions Symmetrically aligned (-) discharges Symmetrically aligned (-) discharges NORMAL NORMAL

due

to

Eyes Eyebrow

Inspection Inspection

Ears

Inspection

NORMAL

Nose

Inspection

NORMAL

Mouth Lips Gums Tongue Teeth Neck

Inspection Inspection Inspection Inspection Inspection

Presence lining Dark gums Tongue midline

of

dark NOT NORMAL due to chronic smoking NOT NORMAL due to chronic smoking the NORMAL NOT NORMAL due to chronic smoking

at

Yellowing of teeth

(-) enlargement of NORMAL lymph nodes (-) enlargement of thyroid gland Presence crackles gurgles of NOT NORMAL due and to the passing of air through fluid or mucus/secretions in any air passage related to pulmonary congestion

Chest and Lungs

Auscultation

Heart

Auscultation

Presence of thrills NOT NORMAL: it accompanied by indicates a bruits turbulence of blood flow due to a narrowed arterial lumen and

Upper Extremities

Inspection

Summary of Physical Assessment Mr. LS is an aged man who has freckles and mucolytic spots on some exposed parts of his body and has dry skin due aging. Mr. Ls has a slightly wrinkled face and has evenly distributed gray and white hair which is normal normal as one ages. Mr. Ls also has a dark lining on his lips and slightly dark gums which caused by his lifestyle of being a chain smoker for approximately 30 years. Upon auscultation on his chest, gurgles were heard because of his pulmonary edema that also causes him to cough out white phlegm. And when his heart was auscultated, thrills which are accompanied by bruits were heard with a 5-second interval.

PATHOPHYSIOLOGY
Patient LS

Non-modifiable factors: Male Increased age

Modifiable factors: Smoking Hypertension Diabetes Mellitus

fatigue, shortness of breath, cold, clammy skin, increased heart rateand Inability of mostofCORONARY Narrowing of blood Destructionheart to pumpthe coronary arteries CK-MB and vessel the commonlyin blood ACUTE an area in the Elevated respiratory rate myocardiumbody Decreased sufficient for the the heart tissues blood SYNDROME supply to elevated Troponin I and T

Accumulation of plaque along arterial lumen

ANATOMY AND PHYSIOLOGY

In order for the various systems, organs, muscles and tissues of our bodies to

function properly, they all need nutrients, and they all need wastes removed. The vehicle for both of these processes is blood; the engine causing the blood to pump around our body, ferrying nutrients and wastes, is the heart.
The heart is a muscular organ responsible for pumping blood throughout the

blood vessels by repeated, rhythmic contractions. The term cardiac (as in cardiology) means "related to the heart" and comes from the Greek , kardia, for "heart." The heart is composed of cardiac muscle, which is an involuntary striated muscle tissue found only within this organ.
The heart is enclosed in a double-walled sac called the pericardium. . This sac protects the heart, anchors its surrounding structures, and prevents

overfilling of the heart with blood. . The heart is composed of three layers, all of which are rich with blood vessels. The superficial layer, called the visceral layer, the middle layer, called the myocardium, and the third layer which is called the endocardium. The right and left sides of your heart are divided by an internal wall of tissue called the septum.

The heart has four chambers, two superior atria and two inferior ventricles. The atria are the receiving chambers and the ventricles are the discharging chambers. Both are divided into two. The right and left atria and the right and left ventricles. The right atrium receives de-oxygenated blood from the body through the superior vena cava (head and upper body) and inferior vena cava (legs and lower torso). The left atrium receives oxygenated blood from the lungs through the pulmonary vein. As the contraction triggered by the sinoatrial node progresses through the atria, the blood passes through the mitral valve into the left ventricle. On the other hand, right ventricle receives de-oxygenated blood as the right atrium contracts. The pulmonary valve leading into the pulmonary artery is closed, allowing the ventricle to fill with blood. The left ventricle receives oxygenated blood as the left atrium contracts. The blood passes through the mitral valve into the left ventricle. The aortic valve leading into the aorta is closed, allowing the ventricle to fill with blood. The papillary muscles attach to the lower portion of the interior wall of the ventricles. They connect to the chordae tendineae, which attach to the tricuspid valve in the right ventricle and the mitral valve in the left ventricle. The chordae tendineae are tendons linking the papillary muscles to the tricuspid valve in the right ventricle and the mitral valve in the left ventricle. As the papillary muscles contract and relax, the chordae tendineae transmit the resulting increase and decrease in tension to the respective valves, causing them to open and close. The chordae tendineae are string-like in appearance and are sometimes referred to as "heart strings." The pathway of blood through the heart consists of a pulmonary circuit and a systemic circuit. The blood flow is a one-way affair; there are valves at the entrance and exit of each ventricle. The entrance valves are called atrioventricular and the exit valves are semilunar.. Tricuspid valve is the one located at the entrance of the right ventricle. It closes as the right ventricle contracts, preventing blood from returning to the right atrium; thereby, forcing it to exit through the pulmonary valve into the pulmonary artery. It gets its name from the three cusps or flaps that make up the valve. Pulmonary semilunar valve is located between the right ventricle and the pulmonary artery. As the ventricles contract, it opens to allow the de-oxygenated blood collected in the right ventricle to flow to the lungs. It closes as the ventricles relax, preventing blood from returning to the heart. Mitral valve is made of very heavy cusps and is located at the entrance of the left ventricle. This is a powerful valve that closes as the left ventricle begins each of its contractions to ensure the oxygenated blood doesnt re-enter the left atrium. Aortic valve is located, as its name would imply, between the left ventricles exit and the aorta itself. As the ventricles contract, it opens to allow the oxygenated blood collected in the left ventricle to flow throughout the body. It closes as the ventricles relax, preventing blood from returning to the heart. Starting in the right atrium, the blood flows through the tricuspid valve to the right ventricle. Here, it is pumped out the pulmonary semilunar valve and travels through the pulmonary artery to the lungs. From there, blood flows back through the pulmonary vein to the left atrium. It then travels through the mitral valve to the left ventricle, from where it is pumped through the aortic semilunar valve to the aorta. The aorta forks and the blood is divided between major arteries which supply the upper and lower body. The blood travels in the arteries to the smaller arterioles and then, finally, to the tiny capillaries which feed each cell. The (relatively) deoxygenated blood then travels to the venules, which coalesce into veins, then to the inferior and superior venae cavae and finally back to the right atrium where the process began. The heart is composed primarily of muscle tissue. A network of nerve fibers coordinates the contraction and relaxation of the cardiac muscle tissue to obtain an efficient, wave-like pumping action of the heart. The Sinoatrial NodeI [1] (often called the SA node or sinus node) serves as the natural pacemaker for the heart. Nestled in the upper area of the right atrium, it sends the electrical impulse that triggers each heartbeat. The impulse spreads through the atria, prompting the cardiac muscle tissue to contract in a coordinated wave-like manner. The impulse that originates from the sinoatrial node strikes the Atrioventricular node [2] (or AV node) which is situated in the lower portion of the right atrium. The atrioventricular node in turn sends an impulse through the nerve network to the ventricles, initiating the same wave-like contraction of the ventricles. The electrical network serving the ventricles leaves the atrioventricular

node through the Common AV Bundles [3] that extends to Right and Left Bundle Branches [4]. These nerve fibers send impulses that cause the cardiac muscle tissue to contract. Specialized muscle fibers called Purkinje fibers, it then conduct the signals to the apex of the heart along and throughout the ventricular walls. The Purkinje fibers form conducting pathways called bundle branches. The impulses generated during the heart cycle produce electrical currents, which are conducted through body fluids to the skin, where they can be detected by electrodes and recorded as an electrocardiogram (ECG or EKG). Needless to say, the timing and coordination required by the heart to make all of these things happened simultaneously is quite complex. In literature and poetry the human heart is often portrayed as the center of the human soul. In medicine the human heart is no less important. Without the heart beating in rhythm, you can measure your life in seconds. When it's functioning well, it can supply you body with the vital blood supply needed to support life for decades without stopping.

Medical Management

Initial therapy for acute coronary syndrome should focus on stabilizing the patient's condition, relieving ischemic pain, and providing antithrombotic therapy to reduce myocardial damage and prevent further ischemia. Morphine (or fentanyl) for pain control, oxygen, sublingual and/or IV nitroglycerin, soluble aspirin 162-325 mg, and clopidogrel with a 300- to 600-mg loading dose are given as initial treatment. In complete vessel occlusion without collateralization of the infarct-related vessel, there is little utility in pushing nitrates. High-risk patients with non-ST-segment elevation myocardial infarction (NSTEMI ACS) should receive aggressive care, including aspirin, clopidogrel, unfractionated heparin or lowmolecular weight heparin (LMWH), intravenous platelet glycoprotein IIb/IIIa complex blockers (eg, tirofiban, eptifibatide), and a beta blocker. The goal is early revascularization. Intermediate-risk patients with NSTEMI ACS should rapidly undergo diagnostic evaluation and further assessment to determine their appropriate risk category. Low-risk patients with NSTEMI ACS should undergo further follow-up with biomarkers and clinical assessment. Optimal medical therapies include use of standard medical therapies, including beta blockers, aspirin, and unfractionated heparin or LMWH. The Clopidogrel in Unstable Angina to Prevent Recurrent Events (CURE) study showed that clopidogrel would be beneficial even in low-risk patients. If no further pain occurs, and follow-up studies are negative, a stress study should drive further management. Monitor and immediately treat arrhythmias in the first 48 hours. Pay attention to exacerbating factors, such as disturbances in electrolytes (especially potassium and magnesium), hypoxemia, drugs, or acidosis. Correct these factors accordingly. Humidified oxygen may reduce the risk of nosebleeds in patients with ACS who are receiving antiplatelet and antithrombin therapy.

Do not administer nitrates if the patient is hypotensive (systolic BP < 90 mm Hg); if RV infarction, large pericardial effusion, or severe aortic stenosis is suspected; or if the patient recently received phosphodiesterase-5 inhibitors (eg, sildenafil). Patients with known hypersensitivity to antiplatelet agents, active internal bleeding, and bleeding disorders should not receive antiplatelet or antithrombotic therapy. Some patients with intractable chest pain or severe hypotension may require the insertion of an intra-aortic balloon pump. The EuroHeart survey showed a nearly 40% reduction in the risk of death in patients with ACS who received support with an intraaortic balloon pump. This benefit was independent of the status of the ST segment. Congestive heart failure (CHF) can be due to systolic dysfunction or diastolic dysfunction in the setting of myocardial infarction. Aggressive treatment is indicated to prevent worsening of the situation. Patients presenting with cardiogenic shock should undergo percutaneous coronary intervention (PCI) as soon as possible. Cardiogenic shock is associated with a high mortality rate. Pressor agents, such as dopamine, and inotropic agents, such as dobutamine, may be needed. In a prospective, natural-history study of coronary atherosclerosis, patients underwent 3-vessel coronary angiography and gray-scale and radiofrequency intravascular ultrasonographic imaging after PCI.

Nursing Management

Advised the relatives to provide calm and quiet environment. Emphasized the importance of stress and injury-free environment to prevent trauma and any other complication. Stressed to provide smoke-free environment through social mobilization. Stated the importance of engaging in mild activities in patients easy recovery just like ambulation. Informed the patient regarding the importance of his compliance to medication as part of his treatment regimen. Advised the relatives to initiate therapy to prevent recurrent of the condition. Advised the patient to eat variety of food but taking into account low amount of sugar, salt and sodium. Instructed to avoid high cholesterol foods Advised to ensure adequate caloric intake for energy requirements.

PROGNOSIS

The 50-year-old patient was admitted on January 3, 2012 at around 10:42 pm with the chief complaint of chest discomfort (8/10). He was diagnosed of Acute Pulmonary Congestion secondary to Acute Coronary Syndrome (STEMI Kellips II), cardiac dysrhythmia, diabetes mellitus II poorly controlled and Chronic Obstructive Pulmonary Disease.

Together with the presence of crackles mid to base of the lungs, his initial vital signs are as follows: blood pressure of 160/120 mmHg, pulse rate of 123 beats per minute and O2 saturation of 78-83%.

Throughout almost five days of hospitalization and medical interventions, the patient demonstrated improvements in his condition. Thus, the prognosis is fair. Supplementary oxygen was removed and the patient was able to ambulate. Also, his vital signs improved and became stable with the following values: temperature of 36 C, blood pressure of 110/80 mmHg, pulse rate of 79 beats per minute and respiratory rate of 16 breaths per minute.

The patient was discharged on January 8, 2012 in compliance with the medical advice. He was just instructed on the medications to be taken at home and some important points to hasten recovery.

However, due to the nature of his condition, the prognosis is only classified as fair. Though his current condition is getting better, it cant still be denied that he has acquired series of diseases causing a severe condition. To name are diabetes mellitus and COPD, which are both chronic states.

ACKNOWLEDGMENT

Every ounce of effort is rewarded. A valuable and priceless reward we received was the fulfillment of our task as nursing students in this hospital exposure here in Batangas Regional Hospital. The success of our duty would not be possible without God. He is the source of our strength to every weakness and the light to brighten up the vagueness in our minds. With all due respect, a heartfelt thank you we offer to our dear God. We would also like to acknowledge our Clinical Instructor, Mrs. Carmina Tolentino, who guided us all throughout our duty. He provided us new learning that will be engraved within our hearts to render quality nursing care leading to a competent and efficient nurses someday. More importantly, we acknowledge the members of the hospital staffs for the cooperation, trust and for over whelming sense of genuine altruism they showed to us. It was a great opportunity for us to work with them even for a little while. We would also like to thank our dear parents for the support they continuously endowed to us. Lastly, we thank each and every one of us in the group as we collaborated and worked with one another to achieve success.

RERENCES:

Brunner and Suddarths textbook of Medical-Surgical Nursing 11th Edition Volume 1 pages 613, 620 Kozier and Erbs Fundamentals on Nursing 8th edition Volume 1 Doenges Nurses Pocket Guide, 11th Edition Davis Drug Guide for nurses, 11th Edition www.wikipedia.com

http://juns.nursing.arizona.edu/articles/Fall%201999/A%20Case%20Study%20of %20Psychiatric%20Medication%20Noncompliance.pdf

In fulfillment of the requirements of the College of Nursing

Case Presentation (Acute Coronary Syndrome)

Submitted by: Alo, Neriza M. Bagsit, Lea Joy Boongaling, May Ann R. Buenaflor, Sabrina Candava, Trixia Mae D. Candelaria, Gleemy Glance Carandang, Gesta Casanada, Maria Cristina Ceniza, Karla Jane Claveria, Chenennaih C. Cullarin, Mia Dhel M. GROUP A IV - C