CASE PRESENTATION ON ACUTE CORONARY SYNDROME

By: Group B-A November 28, 2012

INTRODUCTION
Acute is a medical term for an illness, or a medical problem that begins and progresses rapidly. It may also refer to an illness that begins and ends quickly. Coronary on the other hand, may refer to as the heart or relating to the heart. While syndrome is defined as a set of signs and symptoms that tend to occur together and which reflect the presence of a particular disease or an increased chance of developing a particular disease.

INTRODUCTION
Acute Coronary Syndrome (ACS) is defined as a spectrum of conditions involving chest discomfort or other symptoms caused by lack of oxygen to the heart muscle (the myocardium). The unification of these manifestations of coronary artery disease under a single term reflects the understanding that these are caused by a similar pathophysiology (sequence of pathologic events) characterized by erosion, fissuring, or rupture of a pre-existing plaque, leading to thrombosis (clotting) within the coronary arteries and impaired blood supply to the heart muscle.

INTRODUCTION
In many developed countries, Acute Coronary Syndrome ranks high. With the trend towards globalization, socioeconomic, cultural and demographic transitions are taking place in many less developed countries, Acute Coronary Syndrome has become an important contributor to the total burden of disease and death in many countries of the developing world. On the other hand, the economic burden of Acute Coronary Syndrome (ACS) in the Philippines has not yet been determined.

OBJECTIVES
General Objective: The study aims to explore the concepts about the condition of the client who was diagnosed with Acute Coronary Syndrome. This study also intends to provide an effective nursing care and to acquire deeper knowledge by understanding the disease process and discussing the management and treatment done.

OBJECTIVES
Specific Objectives:

To discuss the anatomy and physiology, pathophysiology of the patients condition, and usual clinical manifestations of Acute Coronary Syndrome To gain knowledge and be familiar with clients medications To formulate workable nursing care plan with the subjective and objective cues gathered through nursepatient interaction

NURSING ASSESSMENT
Personal Data

Name: A.D.A Age: 64 years old Sex: Female Religion: Roman Catholic Civil Status: Married Nationality: Filipino Height: 149 cm Weight: 65 kg Occupation: Housewife Admission Date: November 20, 2012 Chief Complaint: Chest pain and shortness of breath Final Diagnosis: Acute Coronary Syndrome (NSTEMI)

NURSING ASSESSMENT
Health History (Chief Complaint) The patient was admitted at World Citi Medical Center last November 20, 2012 due to the complaint of chest pain and difficulty breathing. She was attended at the emergency room but later was transferred to the intensive care unit for further medical treatment. Dr. Anunciacion, a resident physician of the said hospital, attended her.

NURSING ASSESSMENT
History of Past Illness The patient had no history of hypertension and diabetes mellitus.

NURSING ASSESSMENT
History of Present Illness Few hours prior to admission, the patient had a sudden onset of chest pain, diaphoresis and difficulty of breathing but had no cough, no fever, no palpitations, and no dizziness while washing the dishes. She was brought to World Citi Medical Center and was attended at the emergency room.

NURSING ASSESSMENT
History of Present Illness At the emergency room, the patient was treated with ASA, Dexone, and Atorvastatin but still had a chest pain. Isoket drip was also started and titrated accordingly. Then, Tri-mag tag and Kalium durule was given as well to the patient who was later admitted at the intensive care unit. There, she had difficulty breathing and crackles were present. Her chest pain did not subside and her blood pressure was taken with a result of 90/60, hence Dobutamine was started. She also received Furosemide and Ivabradine. She was later advised to have coronary angiogram and possible revascularization; thus, she needed to transfer to hospital of choice.

NURSING ASSESSMENT
Psychosocial History The patient has been married for a long time with her 65-year old husband. They were blessed with 4 children who were all working now but still living with them. Her daughter named Sheena, who was working abroad (Qatar), was the one helping the patient in paying her hospital bills and expenses.

PHYSICAL EXAMINATION
Head

Skull

Round No tenderness noted upon palpation

Scalp

Lighter in color than the complexion\ Moist No scars and lesions noted Free from lice, nits and dandruff No tenderness nor masses on palpation

Hair

Black in color (pt. used in dye) Evenly distributed, covers the whole scalp Thick and smooth Straight hair

Face

Round in shape Symmetrical No involuntary muscle movements Can move facial muscles at will
Evenly placed and in line with each other None protruding Brown in color Eyebrows are white in color Eyebrows are being shaved Eyelashes are white in color Evenly distributed Turned outward With nasal cannula Nose is in the midline No discharge No bone and cartilage deviation noted on palpation No tenderness on palpation Nasal septum is in the midline and not perforated

Eyes

Nose

Mouth

Symmetrical lips Dark red lips Dry lips With dentures Gums is pink in color Coherent speech Symmetrical The upper connection of the earlobe is parallel with the outer canthus of the eyes Skin is same in color as in the complexion No discharge or lesions noted Both ears with earrings Straight Symmetrical Short No visible mass The trachea is palpable Lymph nodes are not palpable Symmetrical Shallow breathing HR of 69 bpm Presence of crushing pain in the heart with pain scale of 5/10

Ears

Neck

Thorax

Hands

Warm to touch Symmetrical Skin is same in color No lesions and tenderness noted Warm to touch Symmetrical Skin is same in color No lesions and tenderness With nail polish

Feet

Mental State

Conscious Coherent Complete bed rest Low salt and low fat (LSLF)

Activities

Diet Bladder/Bowel
Intake and output Use of diapers
Oral care

Hygiene

ANATOMY AND PHYSIOLOGY

THE HEART
The heart is a muscular pump that contains four chambers: right atrium, left atrium, right ventricle and left ventricle. The two small atria make up the top of the heart, and the two large ventricles make up the bottom of the heart. The right atrium pumps blood to the right ventricle, and the left atrium pumps blood to the left ventricle. A wall, called the septum, separates the right atrium and right ventricle, from the left atrium and left ventricle. Blood flows through the heart in the following manner:

The right atrium receives oxygen-poor blood from the body, and then pumps the blood through the tricuspid valve and into the right ventricle. The right ventricle pumps the blood through the pulmonic valve and to the lungs, where it picks up more oxygen. The left atrium receives an oxygen-rich blood from the lungs, and then pumps the blood through the mitral valve and into the left ventricle. The left ventricle pumps blood through the aortic valve and to the rest of the body. The blood supplies oxygen to the body and the cycle starts again.

Coronary Arteries

The coronary arteries supply oxygen to the heart muscle.

The heart has three main coronary arteries:

Right coronary artery: supplies the right ventricle Left coronary artery: supplies the left ventricle Posterior circumflex artery: supplies the posterior aspect of both ventricles

Cardiac Conduction System An electrical impulse stimulates the muscle fibers in the heart to contract. The impulse spreads through the heart in a very organized manner, so that the atria contract first, followed by the ventricles.

The electrical impulse proceeds in the following manner:

The electrical impulse originates at the sinoatrial (SA) node, which is located in the wall of the right atrium. The SA node is the heart's natural pacemaker: it regulates the heart rate. The impulse proceeds through the atria, stimulating them to contract. After the atria are stimulated to contract, the atrioventricular (AV) node slows the electrical impulse before it proceeds to the ventricles. This pause allows the ventricles to fill with blood before they contract. The AV node is located between the atria and the ventricles. After the pause, the impulse then proceeds through the ventricles, stimulating them to contract.

Parts of the Heart: Superior Vena Cava Oxygen-poor blood from the upper parts of the body returns to the heart through the superior vena cava. Right Atrium The chamber of the right atrium collects oxygen-poor blood returning from the body and then forces it through the tricuspid valve and into the right ventricle. Tricuspid Valve Controls blood flow from the R.A into the R.V Right Ventricle The chamber of the R.V collects oxygen-poor blood from the right atrium and then forces it through the pulmonary valve into the lungs. Pulmonary Valve Controls blood flow from the R.V into the pulmonary arteries. Pulmonary Arteries Carry blood from the heart to the lungs to pick up oxygen. Pulmonary Veins Carry oxygen-rich blood from the lungs back to the heart.

Left Atrium Collects oxygen-rich blood returning from the lungs and then forces it through the mitral valve into the left ventricle. Mitral Valve/Bicuspid Valve Controls blood flow from the L.A into the L.V. Left Ventricle The largest and strongest chamber in the heart. The L.V a wall is only about a half inch thick, but it has enough force to push blood through the aortic valve and into the body. Aortic Valve Controls blood flow from the L.V into the aorta. Aorta This is the largest artery. It carries oxygen-rich blood from the heart to the rest of the body. Inferior Vena Cava Oxygen-poor blood form the lower parts of the body returns to the heart through the inferior vena cava.

NURSING MANAGEMENT

Assess response to bte-blocker therapy

HR/BP Arrhythmia control Need for higher or lower dose

Reassess oxygen saturation after 6 hours and discontinue O2 if saturation is more than 90%. Assess for complications related to specific type of MI

Assess heart sounds for new holosystolic murmurs Risk for myocardial rupture

Observe for signs of left ventricular dysfunction, including hypotension or clinical signs of heart failure.

Monitor ECG for conduction disturbances and arrhythmias Assess presence of RV infarct

Utilize cardiac monitoring

ST-segment monitoring Uninterrupted monitoring for first 24-48 hours

Include the family

Focus on holistic approach to anxiety reduction

MEDICAL MANAGEMENT

Initial therapy for acute coronary syndrome should focus on stabilizing the patients 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 162-325mg. And clopidogrel with a 300-600mg loading dose are given as initial treatment. High-risk patients with non-ST segment elevation myocardial infarction (NSTEMI) should receive aggressive care, including aspirin, clopidogrel, unfractionated heparin or low-molecular weight heparin (LMWH), into venous patient glycoprotein llb/lla complex blocker (e.g., tirofiban, eptifibatide) and a beta-blocker. The goal is early revascularization. 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.