ANGELES UNIVERSITY FOUNDATION

Angeles City
College of Nursing

ACUTE CORONARY SYNDROME

CASE-REPORT

Presented by:

Andujar, Ana Jay

Greenwood, Ana Maris P.

Llacer, Carlo Joseph I.

Rodriguez, Mary Ann P.

Santiago, Shanan M.

Suarez, Ivory Camille A.

Presented to:

Mr. Roden Cuyugan R.N, MAN

 I. INTRODUCTION

Acute coronary syndrome (ACS) is a decreased blood flow in the coronary arteries.
A part of the heart muscle is unable to function properly or dies. Many people with acute
coronary syndrome present with symptoms other than chest pain, particularly, women,
older patients, and patients with diabetes mellitus. One of the most common symptoms
is chest pain, usually radiating to the left shoulder or angle of the jaw, crushing, central
and associated with nausea and sweating.

Acute Coronary syndrome (ACS) can be distinguished from stable angina, it

develops during physical activity or stress and resolves at rest. On the other hand 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. New-onset angina is
also considered unstable angina, since it suggests a new problem in a coronary artery

Acute coronary syndrome (ACS) is commonly associated with three clinical

manifestations: the appearance of the electrocardiogram (ECG) shows ST elevation in
myocardial infarction, non-ST elevation myocardial infarction or unstable angina. There
can be some variation as to which forms of myocardial infarction (MI) are classified
under acute coronary syndrome.

A. CURRENT TRENDS

In United states several randomized trials have demonstrated the benefits of an

invasive strategy for older patients with acute coronary syndromes (ACS); however,
there are limited real-world data of the temporal trends in the use of percutaneous
coronary intervention (PCI) in this population. This was a retrospective observational
analysis. The National Inpatient Sample database from 1998 to 2013 for patients aged
≥70 years who had non–ST-elevation acute coronary syndrome or ST-elevation
myocardial infarction. They reported the temporal trends of PCI and in-hospital
mortality.
 The advancement of medical therapy and percutaneous coronary interventions
(PCI) have reduced mortality rates in patients with acute coronary syndrome (ACS).
However, the age remains a significant confounding factor that leads to reduced
adherence to guideline-directed therapies and invasive strategies for stable Coronary
Artery Disease (CAD) and ACS, a pattern that is largely based on physicians’ discretion.
Despite that, the risk of complications and mortality remain higher in older compared
with younger population. A previous study demonstrated that the use of appropriate
guideline-directed therapies in elderly patients has increased in the last 2 decades with
no increase in the risk of in-hospital mortality despite an increase in the age and
comorbidities of the included cohorts. Another US population-based study (1991-2006)
including patients >75 years of age, suggested some improvement in the post-PCI
outcomes over the study period despite a significant increase in their comorbidities.
Importantly, recent randomized trials have demonstrated the merit of an early invasive
strategy in patients with non-ST-elevation ACS in this population. Previous non–US-
based cohorts have demonstrated beneficial outcomes with PCI in elderly with ACS;
however, no contemporary US cohorts have addressed the practice and outcomes of
PCI for elderly with ACS. Thus, we aimed to examine the temporal use and outcomes of
PCI in elderly with ACS using the largest inpatient database in the United States.
(https://www.ajconline.org/article/S0002-9149(18)31851-4/fulltext).

B. STATISTICS

In the Philippines and in accordance to the World Health Organization, Acute coronary
syndrome is caused by sudden, reduced blood flow to the heart muscle. These
conditions are a major cause of mortality and morbidity in the Asia-Pacific region and
account for around half of the global burden from these conditions, Around seven million
deaths and 129 million disability-adjusted life years (DALYs) annually from 1990 to
2010. Significantly, during this period associated mortality and morbidity accounted for
nearly two-thirds of all DALYs and over half of deaths from acute coronary syndromes
occurring in low- and middle-income countries. The management of acute coronary
syndromes varies widely between countries in Asia. In this area, hospital admission can
create significant financial hardships for participants as treatment costs in many settings
are borne largely out-of-pocket. (https://www.who.int/bulletin/volumes/94/3/15-
158303/en/)

C. REASONS FOR CHOOSING

The group has chosen this case because this is one of the major cause of mortality
and morbidity in the Asia-Pacific, it is very important to understand and gain more
knowledge about this disease. This will help us provide appropriate nursing care
managements and reliable health teachings to our patients. The group needs to
understanding from basic pathology about this disease condition to be more competent,
skilled and knowledgeable student nurses but not only on the disease condition and also
the new trends in the management of the disease to attain the maximum health we can
give to our patient. We also wanted to help other health care providers through this case
study by contributing to the understanding of the past studies and to recommend to the
future studies about this disease condition.

NURSE-CENTERED OBJECTIVES:

A. SHORT-TERM OBJECTIVES

After 1 day of student-nurse- patient interaction, the student nurses will be able to:

• Introduce themselves to the patient and or significant other

• Explain the purpose of the study to the patient and significant other
• Collect data on the patient’s demographic profile
• Assess the patient through cephalocaudal approach and enumerate signs and
symptoms
• Identify the Modifiable and Non-Modifiable factors of Acute Coronary Syndrome
• Determine the nursing interventions and health teachings to be implemented
based on the patient’s disease condition according to significant physical assessment
discoveries.
B. LONG-TERM OBJECTIVES

After the completion of this study, the student nurses will be able to:

• Name different ways on how to prevent and manage the disease.

• Identify and explain the significance and purpose of the different diagnostic
procedures and various medical management done to the patient with Acute
Coronary Syndrome.

• Offer quality care and formulate effective nursing care plans to their patient and
others who have the same condition.

PATIENT-CENTERED OBJECTIVES:

A. SHORT-TERM OBJECTIVES
After 1 day of student-nurse-patient interaction, the patient/significant others will
be able to:

• Understand the purpose of the study

• Establish cooperation and trust with the student nurses throughout the process
• Answer the student nurses' questions truthfully
• Expand their awareness about the patient’s health problems
• Willingly involve themselves with the activities of the student nurse

B. LONG-TERM OBJECTIVES:

After the completion of this study, the patient/significant others will be able to:

• Cooperate with the student nurses' interventions to help solve the patients identified
problem
• Recognize inappropriate health habits that may have contributed to Acute Coronary
Syndrome
• Respond to the student nurse's health teachings and interventions
• Understand the causes of Acute Coronary Syndrome for proper management
• Participate in the implementation phase of the nursing interventions
• Verbalize the understanding of the disease process of Acute Coronary Syndrome

Anatomy
Cardiovascular System:

Over View of the Heart

The heart which is shaped like a blunt cone and is about the size of a closed fist, is
muscular organ that is essential for life because it pumps the blood through the body.
Like a pump that forces water through a pipe, the heart contracts forcefully to pump blood
through the blood vessels of the body. Together, the heart, the blood vessels, and the
blood make up the cardiovascular system. The heart of a healthy adult, at rest, pumps
approximately 5 liters of blood per minute. For most people, the heart continues to pump
at approximately that rate for more than 75 years. But if the heart loses its pumping ability
for even a few minutes, blood flow through the blood vessels stop, and the person’s life
is in danger. The heart is actually two pumps in one. The right side of the heart pumps
blood to the lungs and back to the left side of the heart through the vessels of the
pulmonary circulation. The left side of the heart pumps blood to all the other tissues of
the body and back to the right side of the heart through the vessels of the systemic
circulation.

The functions of the heart are:

1. Generating blood pressure

2. Routing blood

3. Ensuring one way blood flow

4. Regulating blood supply

Anatomy of the Heart

The heart lies in the pericardial cavity. The pericardial cavity consists of 2 layers, the
fibrous pericardium, the tough fibrous connective tissue outer layer, and serous
pericardium, which is the inner layer of flat epithelial cells, with a thin layer of connective
 tissue. The portion of the serous pericardium lining the serous pericardium is called the
parietal pericardium, whereas the portion covering the heart surface is called the
visceral pericardium or the epicardium. The pericardial cavity that lies in between the
visceral and the parietal pericardium is filled with a thin layer of pericardial fluid, which is
produced by the serous pericardium, and reduces the friction as the heart moves with the
pericardium.

I. The External Anatomy

The right and left atria are located at the base of the heart, and the left and right ventricle

extend from the base of the heart extend toward the apex. A coronary sulcus extends

from round the heart, separating the atria from the ventricles. In addition, two grooves, or

sulci, which indicate the division between the right and left ventricles, extend inferiorly

from the cornoary sulcus. The anterior interventricular sulcus extends inferiorly from the

cornoary sulcus on the anterior surface of the heart, and the posterior interventricular

sulcus extends inferiorly fom the coronary sulcus on the posterior surface of the heart. Six
 large veins carry blood to the heart: the superior vena cava, inferior vena cava, and two

pulmonary veins. There are also two arteries, which are the pulmonary trunk and the

aorta.

II. Heart Chambers and Internal Anatomy

The heart is a muscular pump consisting of four chambers: the right and left atria and the

right and left ventricles.

 Right and Left Atria

The atria of the heart receive the blood from the veins. The atria function primarily as the

reservoirs, where blood returning from the veins collects before it enters the ventricles.

Contraction of the atria forces the blood into the ventricles to complete ventricular filling.

The right atrium receives blood through the three major openings. The superior and inferior

vena cava drain blood mostly from most of the body and the smaller coronary sinus drains

blood from most of the heart muscle. The left atrium receives blood through the four

pulmonary veins, which drain blood from the lungs. The two atria are separated from each

other by a partition called the interatrial septum.

 Right and Left Ventricles

The ventricles of the heart are its major pumping chambers. They eject blood into the

arteries and force it to flow through the circulatory system. The atria open into the ventricles,

and each ventricle has one large outflow route located superiorly near the midline of the

heart. The right ventricle pumps blood into the pulmonary trunk, and the left ventricle pumps

blood into the aorta. The two ventricles are separated from each other by the muscular

interventricular septum.
 Heart Valves
The atrioventricular (AV) valves are located between the right atrium and right ventricle and

between the left atrium and left ventricle. The AV valve between the right atrium and the

right atrium and the right ventricle has three cusps called the tricuspid valve. The AV valve

between the left atrium and left ventricle is called the bicuspid valve or mitral valve. These

valves allow blood to flow from the atria into the ventricles but prevent backflow into the

atria.

 Route of Blood Flow

Blood enters the right atrium from the systemic circulation through the superior and inferior

vena cava and from heart muscle to the coronary sinus. Most of the blood flowing into the

right atrium flows into the right ventricle while the right ventricle relaxes following the

previous contraction. Before the end of ventricular relaxation, the right atrium contracts, and

enough blood is pushed form the right atrium into the right ventricle to complete right

ventricular filling.

Following the right atrial contraction, the right ventricle begins to contract. This contraction

pushes the blood against the tricuspid valve, forcing it closed. After the pressure within the

right ventricle increases, the pulmonary semilunar valve opens, and blood flows into the

pulmonary trunk. As the ventricle relaxes, its pressure falls rapidly, and pressure in the

pulmonary trunk increases, becoming greater than the right ventricle. The backflow of blood

forces the pulmonary semilunar valve to close. The pulmonary trunk branches to form the

right and left pulmonary arteries which carry blood to the lungs, where CO₂ is released and

O₂ is picked up. Blood returning from the lungs enters the left atrium through the four
pulmonary veins. Most of the blood flowing into the left atrium passes into the left ventricle

while the left ventricle relaxes following the previous contraction. Before the end of

ventricular relaxation, the left atrium contracts, and enough blood is pushed from the left

atrium into the left ventricle to complete left ventricular filling.

Following the left atrial contraction, the left ventricle begins to contract. The contraction

pushes the blood against the bicuspid valve, forcing it closed. After the pressure within the

left ventricle increases, the aortic semilunar valve is forced open, and blood flow into the

aorta. Blood flowing through the aorta is distributed to rest of the parts of the body. As the

left ventricle relaxes, its pressure falls rapidly, and pressure in the aorta becomes greater

than in the left ventricle. The back flow of blood forces the aortic semilunar valve to close
and the cycle repeats.
III. Blood Supply to the Heart

 Coronary Arteries
The cardiac muscle in the wall of the heart is thick and metabolically very active. Two

coronary arteries supply blood to the walls of the heart. The coronary arteries originate from

the base of the aorta, just above the aortic semilunar valves. The left coronary artery

originates in the left side of the aorta. It has three major branches: the anterior

interventricular artery lies on the anterior interventricular sulcus; the circumflex artery

extends around the coronary sulcus on the left to the posterior surface of the heart; and the

left marginal artery extends inferiorly along the lateral wall of the left ventricle from the

circumflex artery.

The right coronary artery originates on the right side of the aorta. It extends around the

coronary sulcus on the right to the posterior of the heart and gives rise to the posterior

interventricular artery, which lies in the posterior interventricular sulcus. The right marginal
 artery extends inferiorly along the lateral wall of the right ventricle. The coronary artery and

its branches supply most of the wall of the right ventricle

 Cardiac Veins
The cardiac veins drain blood from the cardiac muscle. Their pathways are nearly parallel

to the coronary arteries and most of them drain blood to the coronary sinus, a large vein

located within the coronary sulcus on the posterior aspect of the heart. Blood flows from

the coronary sinus to the right atrium.

IV. Histology of the Heart

 Heart Wall
The heart wall is composed of three layers of tissue: the epicardium, the myocardium, and

the endocardium. The epicardium, aka the visceral pericardium, is a thin, serous membrane

forming the smooth outer surface of the heart. It consists of simple squamous epithelium
 overlying a layer of loos connective tissue and adipose tissue. The thick middle layer of the

heart, the myocardium, is composed of cardiac muscle cells and is responsible for the

contraction of the heart chambers. The smooth inner surface of the heart chambers is the

endocardium, which consists of a simple squamous epithelium over a layer of connective

tissue. The endocardium allows blood to move easily through the heart.

The surfaces of the interior walls of the ventricles are modified by ridges and columns of

cardiac muscle called trabeculae carneae.

 Cardiac Muscle

Cardiac muscles are elongated, branched cells that contain one, or occasionally two,

centrally located nuclei. Cardiac muscle cells contain actin and myosin myofilaments

organized to from sarcomeres, which are joined end-to-end to from myofibrils. The actin

and myosin myofilaments are responsible for muscle contraction, and their organization

gives cardiac muscle a striated appearance much like that of skeletal muscle. However,

the striations are less regularly arranged and less numerous than in the skeletal muscle.

Cardiac muscle cells are organized into spiral bundles or sheets. When cardiac muscle fibers

contract, not only do the muscle fibers shorten but they twist to compress the contents of the heart
chambers. Cardiac muscle cells are bound end-to-end and laterally to adjacent cells by

specialized cell-to-cell contacts called intercalated disks. The membranes of the intercalated disks

are highly folded, and the adjacent fit together, greatly increasing contact between them and

preventing cells from pulling apart. Specialized cell membrane structures in the intercalated disks

called gap junctions, allow cytoplasm to flow freely between cells. This enables action potentials

to pass quickly and easily from one cell to another.

A. Schematic Diagram of Pathopyhsiology (Book Based):
 A. Synthesis of the disease (BOOK-BASE)

Definition of the disease

Acute coronary syndrome is a term used to describe a range of conditions
associated with sudden, reduced blood flow to the heart secondary to plaque formation
(atherosclerosis).
One of its manifestation is Angina pectoris. Angina pectoris gets its name from
the nature of the pain: The Latin angere for choke describes the characteristics
suffocating sensation and pectoralis for chest, where it is located. Angina is the direct
result of insufficient blood reaching your heart muscle (ischemia). When you exert
yourself, your heart requires more oxygen to do the extra work. When the coronary
arteries that serve your heart are narrow and unable to accommodate the increase in
flow of blood demanded by the exercise, nerves in your heart transmit pain messages to
your brain. The discomfort usually lasts for a minute or two; sometimes as long as 10 to
15 minutes. The pain may be severe and may be accompanied by a constricting feeling
behind the breastbone (sternum) that may extend into the throat or down one and or the
other. It may also be a mild heaviness, tightness, or burning discomfort.

Synthesis of the disease

Coronary arteries normally supply blood flow sufficient to meet the demand of the
myocardium. If needs are not met, healthy coronary arteries can dilate to increase the
flow of oxygenated blood to the myocardium.

The most common cause of acute coronary syndrome is atherosclerosis or

formation of plaques in the arterial system that occludes the blood vessels depriving the
myocardium of oxygen and nutrients. Thrombi may form in the coronary arteries as
result of atherosclerotic plaques. The growing mass of plaque, platelets, fibrin and
cellular debris eventually can narrow lumen enough to impede blood flow.

Platelet aggregation release the prostaglandin thromboxane A2, a potent

vasoconstrictor that can cause spasm of the coronary arteries and promote platelet
aggregation.
 Acute coronary syndrome develops if the flow or oxygen content of coronary
blood is insufficient to meet the metabolic demands of myocardial cells. Imbalance
between blood supply and myocardial demand can result from conditions reducing
supply such as increase heart rate, hypotension and hypoxemia.

Ischemia occurs if demand exceed supply and develops within 10 seconds of

coronary occlusion.
After several minute the heart cell loses the ability to contract, thus hampering pump
function and depriving the myocardium of a glucose source necessary for aerobic
metabolism. Anaerobic process takes over and lactic acid accumulates.
Cardiac cells remain viable for approximately 20 minutes under ischemic
condition. If blood flow is restored, aerobic metabolism resumes, contractility is restored
and cellular repair begins.
If perfusion is not restored, then myocardial infarction. (Sue E Huether & Kathryn L.
McCance).

One of its manifestation is Angina is a symptom, not a disorder. It can be the

result of arteries narrowed by a passing spasm. More likely, a limitation of blood flow is
the result of atherosclerosis in which the arteries are narrowed by an accumulation of
deposits of fatty plaque.
Angina pectoris is chest pain caused by myocardial ischemia. The discomfort is
usually transient, lasting approximately 3 to 5 minutes. If blood flow is restored, no
permanent change or damage results.
Angina pectoris is typically experienced a sub sternal chest discomfort, ranging
from a sensation of heaviness or pressure to moderately severe pain. Individuals often
describe the sensation by clenching a fist over the left sternal border. Discomfort may
radiate to the neck, lower jaw, left arm, and left shoulder, or, occasionally, to the back or
down the right arm. Discomfort is commonly mistaken for indigestion. The pain is
presumably caused by the buildup of lactic acid or abnormal stretching of the ischemic
myocardium that irritates myocardial nerve fibers. Pallor, diaphoresis, and dyspnea,
may be associated with pain.
 Thus, angina often is one of the warning signs of coronary artery disease. When
the attacks come frequently and are not linked to physical activity, they may be warning
signs of an impending heart attack. (MAYO CLINIC Family Health Book, David E.
Larson M.D.)

B. Modifiable and Non- Modifiable Factors (BOOK-BASED)

b.2.a. Modifiable Factors

Hyperlipidemia – high dietary fat intake, saturated fats and trans-fatty acid can
predispose in the deposition of plaque in the blood vessel leading to
atherosclerosis. (Sue E Huether & Kathryn L. McCance)
Hypertension - Elevated blood pressure can precipitate or exacerbate
atherosclerotic process by causing trauma to arterial walls. (Sue E Huether &
Kathryn L. McCance)
Cigarette smoking- nicotine stimulate catecholamine release leading to
peripheral vasoconstriction. Impeding systemic and cardiac circulation. (Sue E
Huether & Kathryn L. McCance)
Diabetes Mellitus- often associated with increased lipid level, obesity, and
hypertension. Insulin resistance contribute to arterial damage. (Sue E Huether &
Kathryn L. McCance)
Obesity – with increased obesity heart enlarge, with increased oxygen
consumption and work load. Also predisposed individual to hypertension and
hyperlipidemia. (Sue E Huether & Kathryn L. McCance)
Sedentary-life style- Immobilization predispose to decrease blood supply, and
blood stasis that form thrombi that eventually block the circulation leading to
ischemia. (Sue E Huether & Kathryn L. McCance)
Estrogen Deficiency- estrogen helps to suppress the RAAS Production of
angiotensin 2 a substance that triggers sympathetic nervous system. When
estrogen levels drop your heart and blood vessels become stiff and elastic. (Sue
E Huether & Kathryn L. McCance)
 Heavy alcohol consumption- Alcohol increases body weight, trigylceride levels,
and systolic blood pressure. A direct cardiotoxic effect with excessive alcohol
also a contribute in vasoconstriction.
Hyperhomocystinemia- Genetic or dietary cause (inadequate folate intake);
increased serum levels of homocysteine can damage coronary artery
endothelium and are strongly correlated with risk for coronary artery disease.
 Cystine amino acid work as an antioxidant in the production of collagen.

b.2.a. Non- modifiable Factors

Genetic Predisposition- family history with certain gene that predispose client
in developing coronary disease. (Sue E. Huether)
Age – under age 55 years old for men and under 70 years old for women.
Gradual changes in heart function are associated with aging. (seeley’s Essentials
of anatomy and physiology)

Gender- Incidence is greater in males than premenopausal women; after

menopause the incidence is about the same; gender difference appear to be
attributable to differences in circulating estrogens and androgenic hormones
 low HDL levels appears to be riskier for women than high LDL levels; the male
pattern of obesity- gaining weight in the abdomen- puts women at high risk
(waist/hip ratio, and diabetes appears to be riskier in women than men.
Personality- Persons with suppressed or expressed hostility are more likely to
develop coronary heart disease. Perception of stress and availability of coping
strategies
Unknown/ Idiopathic - Sustained activation of the renin- angiotensin system

C. Signs and Symptoms with Rationale (BOOK-BASED)

Angina Pectoris (Chest Pain) The pain is presumably caused by the buildup of
lactic acid or abnormal stretching of the ischemic myocardium that irritates
myocardial nerve (Sue E. Huether). Angina is the direct result of insufficient
blood reaching your heart muscle (ischemia). When the coronary arteries that
serve your heart are narrow and unable to accommodate the increase in flow of
 blood demanded by the exercise, nerves in your heart transmit pain messages to
your brain. (MAYO CLINIC Family Health Book, David E. Larson M.D.)
Nausea or vomiting – stimulation of the diaphragm and nervous pherenicus,
non-cardiogenic vomiting is caused by drug stimulation.
Indigestion- Extreme cold can cause it as can ingestion if a heavy meal or
emotion such as extreme fear, anger, grief, or frustration. (MAYO CLINIC Family
Health Book, David E. Larson M.D.) Angina pectoris commonly mistaken for
indigestion (Sue E. Huether)
Shortness of breath (dyspnea) – Association in chest pain sensation. (Sue E
Huether & Kathryn L. McCance) and when plaque build-up it narrows coronary
arteries decreasing blood flow to the heart eventually decrease blood flow to
respiratory system impedes its function in gas exchange.
Diaphoresis –Association in chest pain sensation. (Sue E Huether & Kathryn L.
McCance) and also compensation of hypotension secondary to ischemic
coronary arteries when body do not get enough oxygen and nutrients.
Lightheadedness, fainting, dizziness -decrease oxygenation due to plaque
formation (atherosclerosis). Signs of hypotension secondary to ischemic
coronary arteries when body do not get enough oxygen and nutrients.
Fatigue and Restlessness – Association in chest pain sensation. reduce blood
flow to the heart may lead to a decrease in contraction function of the heart in
supplying oxygenated blood to the peripheral circulation, poor circulation affects
energy level because blood carries oxygen for energy production. (Sue E.
Huether).

COMPLICATION

Myocardial infarction (heart attack) -is the irreversible hypoxia and cellular death
of myocardial cells caused by prolonged ischemia. (Sue E Huether & Kathryn L.
McCance).
REFERENCE
Understanding Pathophysiology 2nd Edition (Sue E. Huether, Kathryn L. McCance)
Seeley’s Anatomy and Physiology 9th Edition (Vanputte / Regan / Russo)
Mayo Clinic Family Health Book (David E. Larson MD) (WILLIAM MORROW AND
COMPANY, INC New York) Huether Mc Cance Mosby Elsevier 4th edition
B. PLANNING

Nursing Problem #1: Ineffective Breathing Pattern r/t pain as evidence by difficulty of breathing
ASSESSMENT DIAGNOSIS SCIENTIFIC OBJECTIVES INTERVENTIONS RATIONALE EXPECTED
EXPLANATION OUTCOME

Patient manifested: Ineffective Patient X was Short Term 1. Monitor 1. To assess the Short Term
Breathing experiencing Objective: patientsO2 level of oxygen Objective:
Subjective : Pattern r/t respiratory saturation level within the body.
After 5 hours of 2. Positioned 2. For better lung The patient’s
pain as distress due to
 Patient X nursing patient in a expansion respiratory rate
complained of evidence by Increased intervention the semi-fowler’s 3. To reduce pain shall remain
pain with a difficulty pulmonary patient’s position. and anxiety. within established
pain scale of breathing capillary oncotic respiratory rate 3. Teach the 4. To assist client in limits.
8/10 pressure from remains within client about taking control of
established limits. deep breathing her breathing
 Feeling left-sided
breathless backflow causes exercises 5. To facilitate
4. Encourage deeper Long Term
extravasation of
Objective: Long Term slow/deeper respiratory effort. Objective:
fluid into the respiration, use 6. To promote
Objective:
 Dyspnea pulmonary purse lip better respiration The patient shall
 Altered in interstitium, After 3 days of technique. 7. To evaluate maintain an
breathing which then leads nursing 5. Encourage use presence/ effective
intervention the of characteristic of breathing pattern,
depth to reduced
patient will respirator/diap breath sounds as evidenced by
pulmonary relaxed breathing
Patient may maintains an hragmatic 8. To promote
compliance and at normal rate
manifest: effective breathing stimulator. deeper respiration
increased airway 6. Encourage to and cough and depth and
pattern, as
 Altered resistance. evidenced by develop 9. To facilitate better absence of
chest During pain the relaxed breathing smoking re-oxygenation dyspnea.
excursion most common at normal rate and cessation 10. For management
 Increase associated depth and absence 7. Auscultate and of underlying
anterior- of dyspnea percuss chest pulmonary
symptoms during
posterior 8. Assist client in condition.
pain is difficulty performing
diameter
relaxation
 Use of
 accessory in breathing. technique
muscle 9. Medicate with
when analgesic
breathing
10. Administer
Vital Signs oxygen at the
• T: 35.5 *C lowest
concentration
• PR: 76 bpm indicated
• RR: 12 bpm
• BP: 100/60 mmHg
 Nursing Problem #2: Decreased Cardiac Output related to a blockage in the artery resulting to a decrease in the preload

ASSESSMENT DIAGNOSIS SCIENTIFIC OBJECTIVES INTERVENTION RATIONALE EXPECTED

EXPLANATION OUTCOME

Subjective: Ø Decreased Decreased cardiac Short term:  Establish  To promote SHORT TERM:
Cardiac output is defined as therapeutic cooperation
Output inadequate blood After 1-2 relationship The patient shall have
related to a pumped by the heart hours of with client increased her
Objective:
blockage in to meet the nursing  Monitor and  To have a baseline knowledge on how to
Patient manifested: the artery metabolic demands interventions, record vital data, assess manage underlying
resulting to a of the body. In acute the patient will signs changes in cardiac diseases and
 Angina be able to be complaint on
 Anxiety, decrease in coronary syndrome, neurologic status
the preload. there is Occlusion in increase her  To detect changes taking medications on
restlessness knowledge on  Perform time and proper diet is
 Decreased the artery which indicative of
decreases blood how to GCS worsening or a must.
activity manage monitoring
tolerance/fatigue supply to the heart. improving
Plaque is made up underlying as ordered condition
 Decreased cardiac
peripheral of fat,  To determine
cholesterol, calcium, diseases and blood circulation
pulses; cold, be complaint
clammy and other substance
found in the on taking  Check
skin/poor medications
capillary refill blood. Plaque capillary refill
narrows the arteries on time and and  To promote
and reduces blood proper diet is conjunctiva circulation
Vital Signs flow to your a must. for paleness
• T: 35.5 *C heart muscle. It also  Elevate
makes it more likely  Allows detection of
• PR: 76 bpm head of bed
that blood clots will Long Term: to 30 underlying
• RR: 12 bpm LONG TERM:
form in your arteries. complications
degrees as
• BP: 100/60 mmHg Blood clots can After 2-3 days ordered The patient shall have
partially or of nursing  Assess for  HPN usually demonstrated
 completely block interventions, abnormal occurs with adequate cardiac
blood flow. After the patient will heart and decreased CO output as evidenced
Patient may that, there will be be able to lung sounds by blood pressure
manifest: decreased venous demonstrate  Monitor  Decreased cardiac and pulse rate and
 Decreased return which then adequate blood output may mean a rhythm within normal
cardiac output decreases the cardiac output pressure decrease in the parameters and
 Decreased amount of blood as evidenced and pulse. perfusion to the ability to tolerate
venous and expelled by by blood  Assess peripheries activity without
arterial oxygen ventricles leading to pressure patient’s skin symptoms of
decreased cardiac and pulse temperature  Blockage of the dyspnea, syncope, or
saturation
 Dysrhythmias output. rate and and artery may cause chest pain.
 Ejection fraction rhythm within peripheral pain
less than 40% normal pulses.  Provides
 Increased parameters  Assess for information
pulmonary and ability to pain. regarding the
tolerate heart’s ability to
artery pressure
(PAP) activity  Monitor perfuse
 Tachycardia without oxygen  Assists in
 decreased urine symptoms of saturation alleviating
output dyspnea, and ABGs. hypoxia/hypoxemia
syncope, or  To prevent further
chest pain.  Give oxygen formation of plaque
as indicated  To facilitate blood
by patient flow
symptoms.
 Encourage  To prevent further
increase in plaque formation
fluid intake
 Encourage
diet
modification
 Implement  Reduces cardiac
 strategies to workload
treat fluid
and
electrolyte  Allows better chest
imbalances. and lung
 Encourage expansion for an
periods of effective breathing
rest and pattern
assist with  Enough rest is
all activities. needed to
 Assist the conserve energy
patient in and to prevent
assuming a fatigue
high
Fowler’s  To avoid
position obstruction of
 Advise arterial and venous
patient to blood flow
have enough  Aids in difficulty of
rest and breathing
sleep

 Avoid neck  To maximize

flexion and cardiac output and
extreme prevent decreased
hip/knee cerebral perfusion
flexion associated with
 Provide and hypovolemia
maintain  To promote
oxygen as wellness
ordered
 Restore or
 maintain
fluid balance

 Administer
medications
as ordered
 Nursing Problem #3: Ineffective tissue perfusion r/t decreased cardiac output

ASSESSMENT DIAGNOSIS SCIENTIFIC OBJECTIVES INTERVENTIONS RATIONALE EXPECTED

EXPLANATION OUTCOME

Subjective: Chest Ineffective Heart failure is SHORT Independent SHORT TERM:

pain of 8/10 tissue when the heart TERM:
perfusion r/t  Assess patient’s  To assist in accurate The patient shall
cannot pump pain for intensity, diagnosis and
decreased After 8 hours of have
efficiently enough location and implementation
cardiac nursing demonstrated
Objective: output AEB blood to circulate precipitating
oxygen-rich blood interventions, factors interventions and
blurring of
Patient manifested: throughout the the patient will activities that
vision, pallor,
weakness, be able to  A quiet environment decreases
 Blurring of vision body. When the  Establish a quiet
 Pallor fatigue, heart becomes demonstrate reduces the energy oxygen demand
environment
 Weakness weak or when it interventions demands on the
 Fatigue becomes and activities patient
 High creatinine that decreases
thickened and
level of 133.1 oxygen
mmol/L stiff, the heart LONG TERM:
muscles cannot demand
keep up with its The patient shall
LONG TERM: have manifested
workload. When  Elevate head of  Elevation improves
bed chest expansion and effective tissue
Vital Signs this happens, After 3 days of perfusion AEB
there isn’t enough nursing oxygenation
• T: 35.5 *C absence of
oxygenated blood interventions, pallor, weakness
• PR: 76 bpm reaching the the patient will and fatigue
be able to
• RR: 12 bpm brain, causing
manifest  Tachycardia and
• BP: 100/60 mmHg confusion, the effective tissue  Monitor vital elevated blood
muscles, causing perfusion AEB signs frequently pressure usually
weakness, other absence of occur with angina
vital organs such pallor, and reflect
as kidneys, liver, weakness and compensatory
mechanisms
Patient may manifest: and fatigue secondary to
gastrointestinal sympathetic nervous
 Cyanosis tract, causes system stimulation
 Decreased urine various
output impairments and
 Confusion organ
 Tachypnea dysfunctions. The
lack of oxygen  Anginal pain is often
 Teach patient
causes the main precipitated by
relaxation
symptoms of emotional stress that
techniques and
can be relieved non-
heart failure, such how to use them
pharmacologicall
as fatigue, to reduce stress
such as relaxation
shortness of
breath, and
difficulty
completing tasks
that require  Reposition
 To prevent bed sores
exertion. patient every 2
hours

 Instruct patient  To prevent heartburn

on eating a small and acid indigestion
frequent
feedings

 Assist patient in  To prevent injury

ADLs brought by fatigue
and weakness
Dependent
 Administer  To relieve certain
medications as symptoms and aid in
ordered the treatment of the
patient

 Oxygenation
 Provide oxygen increases the amount
and monitor of oxygen circulating
oxygen in the blood and,
saturation as therefore, increases
ordered the amount of
available oxygen to
the myocardium,
decreasing
myocardial ischemia
and pain

 Assess results of  These enzymes

cardiac markers elevate in the
presence of
myocardial infarction
at differing times and
assist in ruling out a
myocardial infarction
as the cause of chest
pain
Nursing Problem #4: Acute Pain R/T decreased blood supply in the heart AEB chest pain

ASSESSMENT DIAGNOSIS SCIENTIFIC OBJECTIVES INTERVENTIONS RATIONALE EXPECTED

EXPLANATION OUTCOME

Subjective: Acute Pain Coronary SHORT TERM: Monitor skin color To obtain baseline SHORT TERM:
R/T artery disease and temperature data because these
Patient X decreased After 1-2 hours of and vital signs may alter in acute The patient shall
(CAD) is a condition
verbalized chest blood nursing pain. have been able to
supply in in which plaque interventions, follow prescribed
pain.
the heart builds up inside patient will be pharmacological and
AEB chest the coronary able to follow nonpharmacologic
prescribed To determine the methods to provide
pain arteries. Coronary Use pain rating
Objective: pharmacological intensity and relief and verbalize
arteries are arteries scale (0 to 10
and severity of pain. management of pain.
that supply the scale)
nonpharmacologic
heart muscle with
Patient X’s pain methods to
oxygen-rich blood. provide relief and Observations may
scale of 8/10, it is LONG TERM:
Plaque is made up verbalize Observe not be congruent
localized,
of fat, management of nonverbal cues with verbal reports.
described as a The patient shall
cholesterol, calcium, pain. and pain
narrowing feeling have verbalized relief
and last for about and other behaviors
from pain and
few minutes. She substance found in manifest stable vital
also manifested the blood. Plaque LONG TERM: signs, absence of
facial grimaces and Maintain quiet, Mental/emotional muscle tension and
narrows the arteries
restlessness. After 2-3 days of comfortable stress increases restlessness
and reduces blood
nursing environment. myocardial
flow to your Restrict visitors as workload.
Vital Signs interventions the
heart muscle. It also necessary.
patient will
• T: 35.5 *C makes it more likely verbalize relief
that blood clots will from pain and
• PR: 76 bpm
form in your manifest stable Provide light
• RR: 12 bpm arteries. Blood clots vital signs, Decreases
meals. Have
• BP: 100/60 mmHg can partially or absence of patient rest for 1 myocardial
muscle tension
 completely block and restlessness hr after meals. workload
blood flow. When associated with
the coronary work of digestion,
Patient may arteries are reducing risk of
manifest: narrowed or anginal attack.
blocked, oxygen-
> Guarding rich blood can’t Provide
behavior supplemental Increases oxygen
reach the heart
oxygen if available for
> facial grimaces muscle.
indicated. myocardial uptake
and reversal of
> Restlessness ischemia.
> Irritability

> elevated blood Provide comfort To promote

measures such nonpharmacological
pressure and
as positioning the pain management.
respiratory rate
patient to desired
comfort.

Instruct in and
encourage use of To distract attention
relaxation and reduce tension.
techniques such
as deep breathing
exercise.

Encourage
verbalization of
feelings about the
pain.
To evaluate coping
 abilities and to
identify areas of
Administer additional concern.
antianginal
medications
promptly as
indicated. To treat and
prevent anginal
pain.
Nursing Problem #5: Fatigue RT decrease blood flow in the heart AEB verbalization of lack of energy

ASSESSMENT DIAGNOSIS SCIENTIFIC OBJECTIVES INTERVENTIONS RATIONALE EXPECTED

EXPLANATION OUTCOME

Subjective: Fatigue RT Coronary artery disease SHORT TERM: Monitor vital signs. To evaluate fluid SHORT TERM:
decrease (CAD) is a condition in status and
Patient X verbalized blood flow in After 1-2 hours cardiopulmonary The patient shall
which plaque builds up
lack of energy even the heart of nursing response to have been able to
AEB inside the coronary interventions, able to identify
after sleep and activity.
verbalization arteries. Coronary patient will be basis of fatigue
complained about
of lack of arteries are arteries that able to identify and individual
noisy surroundings. basis of fatigue areas of control.
energy supply the
and individual Fatigue can
heart muscle with
areas of restrict the
oxygen-rich blood. patient’s ability to
Objective: control. Assess the
Plaque is made up of participate in LONG TERM:
patient’s ability to
fat, self-care and do
perform ADLs. The patient shall
cholesterol, calcium, his or her role.
Patient X was and other substance LONG TERM: have report
observed to be improved sense of
found in the
restless and has After 2-3 days energy and
narrowed focus. blood. Plaque narrows of nursing Fatigue may be a perform activities
the arteries and interventions symptom of of daily living at
Vital Signs reduces blood flow to the patient will protein-calorie the level of ability.
your heart muscle. It report improved malnutrition, vit.
• T: 35.5 *C
also makes it more sense of Assess the deficiencies, or
• PR: 76 bpm likely that blood clots energy and patient’s nutritional iron deficiencies.
perform ingestion for
• RR: 12 bpm will form in your
activities of adequate energy
• BP: 100/60 mmHg arteries. Blood clots daily living at sources and Changes in these
can partially or the level of metabolic physiological
completely block blood ability.
demands. measures may
Patient may manifest: flow. When be associated
the coronary
> Lethargic arteries are narrowed with fatigue.
or blocked, oxygen-rich
> Listless Review results of
blood can’t reach the
diagnostic
heart muscle. procedures such Changes in sleep
> Drowsy
as CBC, blood pattern may be a
> Increase in physical glucose and O2 contributing
complaints saturation. factor.

>Compromised libido
Assess the To promote
patient’s sleep adequate rest
patterns for quality. and sleep.

Restrict
environmental
stimuli, specially
during planned
times for rest and To promote
sleep. adequate rest
and sleep.

Plan interventions
to allow individual
adequate rest
periods. To maximize
participation.

Schedule activities
for periods when
client has the most
energy.
Instruct in methods To let the patient,
to conserve energy relax and reduce
like sit instead of from being
standing, restless.
simplifying
activities and
delegate tasks.

To allow the
Assist patient with patient to
self-care needs conserve energy.
and ambulation.

It can negatively
Avoid or limit impact energy
exposure to level.
temperature and
humidity extremes.
Name Of The Date Route Of General Action; Mechanism Of Indication And Client’s Response To
Drugs Ordered, Administered Action Purpose The Medication W/
Taken/Given, , Dosage And Actual Side Effects
Date Frequency
Changed/ D/C

Generic Date ordered: 1gm IV Ceftriaxone is a third-generation This medication Patient responded well to
Name: cephalosporins. It inhibits cell- was indicated to the the medication.
08-20-19 wall synthesis promoting osmotic patient to prevent
Ceftriaxone instability. It is usually from contacting
Sodium bactericidal. infections.

Brand Name:
Rocephin

Trimetazidine is used in The medication is

combination with other drugs for given to the patient
Trimetazidine
the symptomatic treatment of with angina, chest Patient that taking this
Date Ordered: PO, 35mg/tab stable angina pectoris, chest pain pain and difficulty medication was relieved
08-20-19 1tab BID caused by decreased oxygen breathing from chest pain and
Generic supply due to reduced blood flow
Name: to the heart. This medicine is used difficulty breathing
Trimetazidine when patients do not respond
Hydrochloride adequately to other agents or are
intolerant to first line anti-angina
agents.
Brand Name:
Metacard

Inhibits HMG-CoA reductase, an

early (and rate-limiting) step in
cholesterol biosynthesis.

The medication is
Atorvastatin given to the patient
Calcium with clinically
evident coronary
The patient taking this
artery disease, to
medication was free from
Date Ordered: PO 80mg/tab reduce the risk of
Generic stroke and angina
08-20-19 1tab OD nonfatal MI, fatal
Name: and non-fatal stoke,
Atorvastatin angina, heart failure
Calcium and
revascularization
procedure
Brand Name:
Lipitor
 This medication
was given to the
Platelet aggregation inhibitor. It patient to reduce
works by slowing or stopping the rate of
platelets from sticking to blood atherothrombotic
vessels or injured tissues. events in patient
with unstable
Generic angina.
Name:
Clopidogrel
This medication The patient did not
was given to the experience any
Brand Names: Date Ordered: 75 mg/tab OD patient as an hypersensitivity to the
Plavix, Norplat 08-20-19 adjunct to diet and drug but still experiencing
exercise to improve intermittent chest pain.
Empagliflozin is a sodium- glycemic control.
glucose co transporter 2
inhibitors. It works by inhibiting
renal reabsorption of glucose and
lowers renal threshold for
Generic glucose, resulting in increased
Name: urinary excretion of glucose.
Empagliflozin This medication
was given to the The patient did not
patient since the experience any elevated
patient is slightly blood glucose level.
Brand Name:
This medication works by hypokalemic but
Jardiance Date Ordered:
25 mg/tab antagonizing aldosterone in the creatinine is
08-20-19 distal tubules, increasing sodium elevated and to
and water excretion. prevent congestion
since the patient is
 hypertensive.
Generic
Name:
Spiranolacton
e
This medication is The patient responded
Brand Name: given to the patient well to the medication as
Aldactone to manage angina. the blood pressure was
100/60 and did not
experience any shortness
Date Ordered: of breath. However,
08-20-19 creatinine was still
25 mg/tab increased (1.40 mg/dl) as
of August 22, 2019.
Antianginal and a nitrate. It
relaxes vascular smooth muscles
with a resultant decrease in
venous return and decrease in
arterial BP, which reduces left
Generic ventricular workload and
The patient is still
decreases myocardial oxygen experiencing intermittent
Name: ISDN
consumption chest pain.
Brand Name:
The medication is
Isoket
This medication belongs to a given to patient to
group of medicines called relieve anxiety
tension or agitation
benzodiazepines which are
that is associated
thought to work by their action on with normal stress.
Date Ordered: brain chemicals.
08-20-19
5 mg/tab with
 chest pain

Generic
Name:
Bromazepam

Brand Name: Patient was seen either

It reduces the viscosity of drowsy or sleeping during
pulmonary secretions by splitting the nurse patient
Lectopam,
disulfide linkages between interaction.
Brazepam mucoprotein molecular
complexes. This medication
was given to the
patient due to
increased
creatinine level.
Generic Date Ordered:
Name: 08-20-19
30cc ODHS
Acetylcysteine

Brand Name:
Fluimucil,
Acetadote

Patient’s creatinine level

was 1.49 mg/dl as of
August 22, 2019.
Date Ordered:
08-20-19

1.2 g/IV
Diagnostic and Laboratory Procedures:

Quantitative Date Ordered: This test was 0.20 ug/mL 0.000 – 0.016 Troponin I
Troponin I 08-21-2019 done to detect ug/mL level is higher
any heart than the
Troponin is the Date Result injury or normal range
preferred in: damage. which means it
Test for a 08-21-2019 has heart
suspected injury and
heart injury. It decreased
is also used for oxygen to the
patients who heart.
experience
heart-related
chest pain,
discomfort, or
other
symptoms and
do not seek
medical
attention for a
day or more.
CPK-MB Date It is reflects 6.13mg/ml 10-120mcg/L An elevated
Ordered: myocardial CPK-MB it
The CKM-MB
08-21-2019 injury. reflects
test is a cardiac
myocardial
marker used to
Date Result injury, including
assist diagnoses
in: acute
of acute
08-21-2019 myocardial
myocardial
infraction,
infarction. It
myocarditis,
measure the
cardiac trauma,
blood level of
cardiac surgery
CK-MB (creatine
and
kinase-
endomyocardial
muscle/brain)
biopsy.
the bound
combination of
the variants
(isoenzymes
CKM and CKB)
of the enzyme
phosphocreatine
kinase.
Diagnostic/Laborator Date Ordered Indications of Purpose Results Normal Values (units Analysis and interpretation of results
y Procedures (1st,2nd, 3rd,4th, used in the hospital)
Date Results IN General description 5th, 6th )

HEMATOLOGY August 21, 2019 General Description: 7.3 10^ 9/L WBC is within the normal range

WBC Most important cellular 4.50 - 11.00

components of immunity,
WBC are produce in bone
marrow lymphatic tissue and
released into the blood

Indication :

-it determines infection or

inflammation.

-it determines further test

such as WBC differential
(inspection and quantification
of WBC types present in
peripheral blood values)

Differential Count: August 21, 2019 General Description:
Neu% -first cell to enter infected
tissue from blood in large
number, neutrophils often die
after phagocytizing a single
microorganism
- -dead neutrophils, cell
0.05 10^ 9/L -Increase in neutrophil count indicated a
bacterial infection. high neutrophil count
0.18- 0.70 is brought about by inflammatory
responses and phagocytosis of neutrophils
in response to bacterial infection.
Neutrophil is the first cell to enter
infected tissue from the blood they often
die after phagocytizing a single
 debris, and fluid can microorganism
accumulate as pus at sites of
infection. -due an increase bacterial infection
neutrophils is again activated to and
Indication: perform its primary action, to phagocytize
microorganism and inflammatory action.
-to determine
bacterial(Primary defense in
bacterial infection.)

Lym % August 21, 2019 General Description: 0.15 10^ 9/L Increase due to chronic inflammation.

-Smallest WBC play an 0.10 – 0.48

important role in body’s
immune responses

-it produce antibodies and

other chemicals that destroy
microorganism, contribute to
allergic reaction, reject graft,
control tumor and regulate
immune system

Indication :

-to measure number of

lymphocytes in the peripheral
blood
Mon% August 21, 2019 General Description:
-large phagocytic cells that are
involved in early stage of
inflammatory response
0.05 10^ 9/L Increase to phagocytize dead neutrophil
enlarge and become macrophages which
0.00 - 0.04 phagocytize bacteria, dead cell debris.

-enlarge and become

macrophages which
phagocytize bacteria, dead cell
debris.

Indication:

-it measures number of

monocytes, which are white
blood cells that move out of
the circulating blood and into
the tissues, where they
mature into macrophages

Eos% August 21, 2019 General Description: 0.08 10^ 9/L Increase in eosinophil indicate positive for
allergies and parasite.
Types of WBC, involves in 0.00 - 0.03
inflammatory responses
associated with allergies and
destroying certain worm
parasites.
 -this test is used to diagnose
allergic infection, assess
severity of infestation with
worms and other larges
parasites, and to monitor
response to treatment

Hemoglobin August 21, 2019 General description : 93 g/L Decrease due to decrease blood flow to
the systemic circulation leading to
The main components of 140 -175 ischemia
erythrocytes serve as a vehicle
for the transportation of
oxygen and carbon dioxide

Indication

-it is used to screen disease

associated with anemia to
determine the severity of
anemia, to monitor response
to treatment for anemia, and
to evaluate polycythemia

HCT August 21, 2019 General Description: 0.28 % The ration of volume of Red Blood Cell to
the total volume of blood (concentration
Concentration of hemoglobin ( 0.41 – 0.50 of blood volume) is below the normal
in gram per deciliter) range due hypoxemia secondary to
 ischemia

Indication :

-used to determine the

percentage volume of packed
RBC in whole blood

-indirectly measure Hgb

content and RBC mass

-important measurement in
determination of anemia or
polycythemia

PLT August 21, 2019 General Description: 392 10^9/L PLT count is within the normal range.

-play an essential role in 150-400

control of bleeding

When vascular injury occurs,

platelets collect at site and are
 activated, adhere to site of
injury and form plug to stop
bleeding

Indication:

To determine if the patient is

at risk for bleeding

HEMATOLOGY TEST

Prior:

 - identify the name of the client in 3 ways

( check the name in the chart, ask the name of the client, and look at name tag )
 introduce yourself
 Explain and instruct the patient about purpose and procedure test (tell the patient that a blood sample will be taken. Explain who will perform the
venipuncture and when.)
 If the patient is apprehensive, explain that a local anesthetic can be used
During;
  Explain to the patient that he may feel slight discomfort from the needle puncture and the tourniquet

After:

 Evaluate color, sensation, degree of warmth, capillary refill time and quality of pulse in the affected extremity or at the puncture site
 Monitor puncture site and dressing for arterial bleeding for several hours. No vigorous activity of the extremity should be undertaken for 24hrs
If a hematoma develops at the venipuncture site, apply warm soaks

Diagnostic/Laboratory Date Ordered Indications of Purpose Results Normal Values Analysis and interpretation of results
Procedures (units used in the
Date Results IN hospital)
CHEMICAL RESULT

Creatinine August 21, 2019 General Description: 1.149 71.07-115.0 Creatinine is within the normal range
mEq/L
Is a byproduct in the breakdown of
muscle creatinine phosphate resulting
from energy metabolism

Indication:

-this test diagnoses impaired renal

function

-it is more specific indicator of kidney

 disease and evaluate renal problem

ELECTROLYTES August 21, 2019 General Description : 127.3 135-145 mEq/L Decrease sodium level due to the side
effect of medical management
Sodium Primary function are to maintain
osmotic pressure and acid-base
balance chemically and to transmit
nerve impulses.

Indication :

Determination of plasma sodium levels

detect changes in water balance rather
that sodium balance.

-use to determine electrolytes, acid-

base, water balance, water intoxication
and dehydration.

Potassium August 21, 2019 General description: 2.96 3.5 - 5.5 mEq/L Decrease potassium level due to the
side effect of medical management
Principal electrolyte of intracellular
fluid

Plays an important role in nerve

conduction, muscle function, acid-base
balance, and osmotic pressure.
 Indication :

This test is used to evaluate changes in

the body potassium levels and
diagnoses acid-base and water
imbalances

CHEMICAL AND ELECTROLYTE TEST

Prior:

 identify the name of the client in 3 ways

( check the name in the chart, ask the name of the client, and look at name tag )
 introduce yourself
 Explain and instruct the patient about purpose and procedure test (tell the patient that a blood sample will be taken. Explain who will perform the
venipuncture and when.)
 If the patient is apprehensive, explain that a local anesthetic can be used
During:

 Explain to the patient that he may feel slight discomfort from the needle puncture and the tourniquet

After:

 Inform the patient that he need not restrict food or fluids as per doctors order
 Ensure that subdermal bleeding has stopped before removing pressure.
 If a hematoma develops at the venipuncture site, apply warm soaks.
Diagnostic/Laboratory Date Ordered Indications of Purpose Results (1st) Normal Values (units Analysis and interpretation of results
Procedures used in the hospital)
Date Results IN General description

ARTERIAL BLOOD GAS August 21, 2019 General Description: 7.435 7.350- 7.450 mmHg BLOOD PH is within the normal range
ANALYSIS
The pH is the negative logarithm
BLOOD PH of the hydrogen ion
concentration in the blood. Blood
pH measures the body’s chemical
balance and represents a ratio of
acid to base. It is also an indicator
of the degree to which the body
is adjusting to dysfunctions by
means of its buffering systems. It
is one of the best way to
determine whether the body is
too acidic or too alkaline and is an
indicator of the patient metabolic
and respiratory status.

PARTIAL PRESSURE OF August 21, 2019 General Description: 125 80.0 -100.0 mmHg The result indicate an increase in PO2 level
OXYGEN (PO2) which is associated with dyspnea and or
Oxygen is carried in the blood in
 two forms: dissolve in the plasma hyperventilation and chest pain (angina
(<2%) and combined with pectoris)
hemoglobin(98%) the partial
pressure of gas determines the
force exerts in attempting to
diffuse through pulmonary
membrane . the PO2 reflects the
amount of O2 passing from the
pulmonary alveoli into the blood.
This test measures the pressure
exerted by the O2 dissolve in the
plasma. It evaluates the ability of
the lungs to oxygenate blood and
is used to assess the effectiveness
of oxygen therapy. The PO2
indicates the ability of the Lungs
to diffuse O2

PARTIAL PRESSURE OF August 21, 2019 General Description: 41.4 35.0 - 45.0 mmHg The result is within the normal range due
CARBON DIOXIDE
>This test measure the pressure
(PCO2)
or tension exerted by dissolve
CO2 in the blood (10% of CO2 is
carried in the plasma and 90% in
the red blood cell) and is
proportional to the partial
pressure of CO2 in the alveolar
air. The test is commonly used to
detect a respiratory abnormality
and to determine alkalinity and
acidity of the blood.

> to maintain CO2 within normal

limits, the rate and depth of
respiration vary automatically
with changes in metabolism. This
 test is an index of the
effectiveness of alveolar
ventilation. It is the most
physiologically reflective blood
gas measurement. An arterial
sample directly reflect how well
air is exchanged with blood in the
lungs.

Oxygen Saturation August 21, 2019 General Description: 2.9 75.0 – 99.0 % Oxygen Saturation is below the normal
(SO2) ranges indicates that adequate
This measurement is a ratio
oxygenation is not achieved
between the actual O2 content of
the hemoglobin and the potential A decrease in oxygen saturation is
maximum O2 carrying capacity of
probably a signs for hypoxemia
the hemoglobin, it does not
indicate O2 content.

BICARBONATE August 21, 2019 General Description: 22 to 28 mEq/L.

(CHCO3) Bicarbonate is a form of carbon

dioxide (CO2), a gas waste left
when your body burns food for
energy. Bicarbonate belongs to a
group of electrolytes, which help
keep your body hydrated and
make sure your blood has the
right amount of acidity.
Bicarbonate is an electrolyte, a
negatively charged ion that is
used by the body to help
maintain the body's acid-base
(pH) balance. It also works with
the other electrolytes (sodium,
potassium, and chloride) to
maintain electrical neutrality at
the cellular level. This test
measures the total amount of
carbon dioxide (CO2) in the
blood, which occurs mostly in the
form of bicarbonate (HCO3-). The
CO2 is mainly a by-product of
various metabolic processes.

Measuring bicarbonate as part of

an electrolyte or metabolic panel
may help diagnose an electrolyte
imbalance or acidosis or alkalosis.
Acidosis and alkalosis describe
the abnormal conditions that
result from an imbalance in the
pH of the blood caused by an
excess of acid or alkali (base). This
imbalance is typically caused by
some underlying condition or
disease.
ARTERIAL BLOOD GAS ANALYSIS

Prior:

-instruct the patient about purpose and procedure test (tell the patient that a blood sample will be taken. Explain who will perform the venipuncture and when.)

-If the patient is apprehensive, explain that a local anesthetic can be used

-observe standard precaution (aseptic technique)

During;

-Explain to the patient that he may feel slight discomfort from the needle puncture and the tourniquet.

*Age Issue: If the patient is a child, explain to her (if she’s old enough) and his parents that a small amount of blood will be taken from his finger or ear lobe.

-For adults and older children, draw venous blood into a 3- or 4.5-ml EDTA sodium metabisulfide solution tube.

-For younger children, collect capillary blood in a microcollection device.

After:

-Ensure that subdermal bleeding has stopped before removing pressure.

-evaluate color, sensation, degree of warmth, capillary refill time and quality of pulse in the affected extremity or at the puncture site

-monitor puncture site and dressing for arterial bleeding for several hours. No vigorous activity of the extremity should be undertaken for 24hrs

-If a hematoma develops at the venipuncture site, apply warm soaks.

 I. MEDICAL MANAGEMENT
a. IVFs, BT, NGT Feeding, Nebulization, TPN, Oxygen Therapy, etc.
Medical Date Ordered General Indication (s) or Client’s
Management Date(s) Description purpose (s) Response to
treatment Performed Date the treatment
Change/D/C
PNSS Date ordered: Aqueous solution of For patient Patient is free
1L@40cc/hr 08-22-19 0.9 percent sodium hydration and from
chloride, Isotonic medication. dehydration and
with the blood and take all the
tissue fluid used in medication that
medicine, and in need to
sterile form as a administer.
solvent for drugs
that are to be
administered
parenterally to
replace body fluid.

Nursing Responsibility

Prior
o Verify doctor’s order
o Be acquainted the patient with the requirement and need of IV infusion
o Know the reason why patient is receiving the medication
o Explain the procedure
o Performed sterile technique due to breaking the continuity of the body’s defense against infection
 o Wash hands to eliminate contamination

During
o Select a suitable vein to permit access to a vessel
o Thoroughly cleanse the area of insertion
o Regulate flow of rate as ordered
o Check for the integrity of the line and infusion
o Maintain environment that conducive to the patient

After

o Monitor flow rate every two hours for accuracy

o Check for the IV insertion for phlebitis frequently
o Wash hand after procedure
o Document action done.
 Medical Date Ordered, Client’s
Management Date Performed, General Indication Response to the
Treatment Date Change, Description Treatment
D/C
Oxygen Therapy Date Ordered: The nasal It was prescribed It’s give patient
via Nasal Cannula 08-22-19 cannula (NC) is a to the patient to relieved from
at 2-3L/min device used to provide difficulty of
-ongoing deliver supplementa supplemental breathing and
l oxygen or oxygen because chest pain.
increased airflow of difficulty of
to a patient or breathing that the
person in need of patient is
respiratory help. experiencing and
This device to increase
consists of a oxygen to heart
lightweight tube muscle to support
which on one end oxygen.
splits into two
prongs which are
placed in the
nostrils and from
which a mixture of
air and oxygen
flows.

Nursing Responsibility:

Before
o Verify written order for oxygen therapy, including methods of delivery and flow rates.
 o Assess the patient for obstruction of the nasal passages by observing breathing patterns and, if indicated,
inspecting of nasal passages with penlight.
o Notify the physician if significant obstruction is present.
During
o Adjust flow rate to the prescribed amount.
o Assess the patient’s nares, face and ears every 4 hours for signs of skin irritation or breakdown.
After
o Observe for signs of infiltration, swelling, warmth and pain on the surroundings of the oxygen therapy site.
o Observe for the reaction of the patient to the treatment given.
o Document implementation of the prescribed oxygen therapy in the chart.
NURSING RESPONSIBILITIES:

PRIOR:

 Wash hands and prepare prescribed medications.

 Check for allergies; check doctor’s order and Kardex.
 Recheck the dose needed and drug calculation.

DURING:

 Verify with other nurses or pharmacists the doses of drugs that are potentially toxic.
 Identify the patient and the ordered medications.
 Assist client to appropriate position depending on the route of administration.
 Stay with the client until the medications are given.

AFTER:

 Chart; record drugs given, dose, time, route, and your initials.
 Record drugs promptly after given, especially stat doses.
 Report and record drugs that were refused by patient.
 Assess for allergic reactions.
DIET

MEDICAL MGT/TX DATE GENERAL INDICATION/ CLIENT’S

ORDERED/DATE DESCRIPTION PURPOSE RESPONSE TO
PERFORMED/DATE THE TX
CHANGED/D/C

1. NPO DO: August 22, 2019 NPO means the This was ordered by Patient complied
patient should the doctor in with the prescribed
DP: August 22, 2019 receive absolutely
preparation to the diet.
nothing by mouth, no
food or drink. There anticipated
are many reasons procedure which
and circumstances
was coronary
that warrant a
physician's order of angiogram with
NPO. Say for possible
example, the client
angioplasty.
has undergone
surgery or
experience nausea,
vomiting, and
diarrhea.

2. DAT DO: August 22, 2019 Diet as tolerated is This particular diet is The patient was
usually advised in only given when able to eat in her
relation to surgery. client can now regular eating
 DP: August 22, 2019 Once a surgical tolerate any food pattern consisting
procedure is she desires that is of healthy foods
complete, individuals nutritious, if this will and fruits.
are given only not lead to any
liquids, such as complications and if
water. The diet the client needs
progresses to solid further monitoring
foods in the form of for lab test. It also
purees, chunks and makes the patient to
finally a regular diet. stay healthy and just
Diet as tolerated is a moderation
term that indicates
that the
gastrointestinal
tracts is tolerating
food and is ready for
advancement to the
next stage.

PRIOR:

 Check the doctor’s order for the prescribed diet for the patient.
 Educate the SO and the patient about the importance of the diet.
  Provide the SO with the list of foods to be taken and/or avoided.

DURING:

 Monitor regularly if the prescribed diet is being followed.

 Reinforce diet as ordered.
 Note for any reactions the client may manifest.

AFTER:

 Document the client’s response to the prescribed diet.

 Note and refer to the physician if the client manifested any reactions related to the ordered diet.

ACTIVITIY/EXERCISE
MEDICAL MGT/TX DATE GENERAL INDICATION/ CLIENT’S RESPONSE
ORDERED/DATE DESCRIPTION PURPOSE TO THE TX
PERFORMED/DATE
CHANGED/D/C

1. BED REST DO: August 22, 2019 Bed rest involves To provide adequate Patient responded well

DP: August 22, 2109 restriction of a patient rest to the bed rest as
to bed for therapeutic evidenced by ability to
reasons either perform ADL.
partially or completely.
The goal of this is to
minimize activity and
allow recovery from
disease
Nursing Responsibilities:

PRIOR:

 Check the doctor’s order for the type of activity prescribe to the patient
 Explain to the patient the principles of complete bed rest.

DURING:

 Monitor the position of the patient regularly.

 Check the patient’s comfort.

AFTER:

 Document the client’s response to complete bed rest.

 Refer to the physician if the client manifested any unwanted signs and symptoms .
IV. SUMMARY OF FINDINGS
 Acute coronary syndrome (ACS) is a decreased blood flow in the coronary
arteries. A part of the heart muscle is unable to function properly or dies.

 Acute Coronary syndrome (ACS) can be distinguished from stable angina, it

develops during physical activity or stress and resolves at rest.

 The electrocardiogram (ECG) shows ST elevation in myocardial infarction, non-ST

elevation myocardial infarction or unstable angina.

 Predisposing Factors (MODIFIABLE) Hyperlipidemia, Hypertension, Cigarette

smoking, Diabetes Mellitus, Obesity, Sedentary-life style, Estrogen Deficiency,
Heavy alcohol consumption, Hyperhomocystinemia (NON-MODIFIABLE) Genetic
Predisposition, Age Gender, Personality,Unknown/ Idiopathic
 Different signs and symptoms Angina Pectoris (Chest Pain), Nausea or vomiting,
Indigestion, Shortness of breath (dyspnea) Diaphoresis, Lightheadedness,
fainting, dizziness, Fatigue and Restlessness.
 Differents diagnosis CT Scan, MRI and Cerebral Angiography
 V. LEARNING DERIVED

This case on acute coronary syndrome has helped me taught regarding different
complications that may arise when a person has this condition. I was also able to review
on different mechanisms of action of every drug that were commonly used in this
condition. Furthermore, I learned about the different management being done to patients
with these kinds of cases for them to recover and also the different diagnostic tests that
were commonly used. This rotation also helped me on how to be flexible and how to
manage my time properly as well as dealing with clients and improving nurse patient
interaction.

-Andujar, Ana Jay

Every duty and rotation, I always learned new things that I can always use it for
my future profession. In our last rotation we had duty in medicine ward and I learned
different diagnosis and medication of the patient. Also I apply a lot of nursing intervention
to appropriate patient, before I only memorize it. I realized that it is really important that
everything you learned inside the class room put it in heart. Once again we going to do
the case report, it is interesting to do the case report because we don’t know what case
we going to further study, I’m always looking forward to it because we are going to focus
in that case that’s why we learned more about it that the other case. Case repot if it’s by
group. It is very important the cooperation of the group member in order to finished and
pass it on time. Also every member need to communicate each other. I always thankful
to my group member because they help me for the part that I’m not good of doing it.

-Greenwood, Ana Maris P.

In this case report, I was able to learn more about heart failure, acute coronary
syndrome, and different heart complications. Aside from the lectures and discussions of
these disease conditions, having the opportunity to handle an actual patient with such
illness, is a significant step for me on reaching my goal of becoming specialized in
cardiology. I may be familiar with certain manifestations already, but upon reading and
exploring the pathophysiology and pathogenesis of the disease, I was able to identify and
point out, significant aspects, factors, and events the lead to the development of this
condition.

In general, my exposure to the ICU, and my duty of handling a patient with such
condition, I was a challenge, especially by the fact that I may have repressed some of the
basic responsibilities and interventions of a nurse upon caring for certain clients. But aside
from it being a challenge, it was an opportunity for me to develop my skills and knowledge
in handling and taking care of patient suffering from cardiologic illnesses.

-Llacer, Carlo Joseph I.

Having enough knowledge on the synthesis of the disease and connecting and
interrelating all signs and symptoms manifested by the client, all laboratory findings and
physical examination status, medication taken and other treatment regimen render to the
client help me to do schematic diagram about my patient condition how this manifestation
arises for me I find it very challenging because it enhances my knowledge in critical
thinking and problem solving it further guide me to the main etiology of predisposing and
precipitating factors in acquiring the disease (Acute Coronary Syndrome).
The ability to provide patients with adequate and accurate information about the
procedure perform in patient preparation provide emotional support and differentiates
expected normal result to deviated is important to achieve quality patient care. As a
student nurse the involvement in administration of drug may include events prior during
and after the procedure thus proper knowledge of the procedure must be an inherent part
of our nursing knowledge and skills, having enough knowledge not only on the procedure
but also to the mechanism of action of the said drugs its side effects, contraindication,
and nursing consideration can help the student nurse in giving health teaching to the
client instructed patient to report any abnormal findings that occurs within or after
administering the drug).
-Rodriguez, Mary Ann P.
 I was fortunate enough to have had JBL special area beforehand. So I had a little
bit of experience from my last rotation. AT AUF, it was a drastically different protocol. It
was more based on each patient rather than a group of patients with the same diagnosis.
Which would follow AUF’s primary nursing policy. I discovered that there are specific
nurses assigned to specific beds. Also, that there are special areas in ER under A,B,C.
These special areas are the ones who require the most care. I realized how fast paced it
can be out of nowhere. So a nurse must always be on their feet, ready to take action. I
also realized how at ER you must have more than basic knowledge about all the other
wards. As you get all sorts of diseases that varies in process. Lastly, I challenge myself
to be better at thinking and moving fast.
-Santiago, Mary Shanan M.

In this rotation, I was able to enhance my knowledge regarding different kinds of

disease. It opened up an opportunity and different aspect in handling situations in the
most critical areas such as in ICU and ER. The disease acute coronary syndrome is very
common among Filipinos and its very important to know the disease condition and its
complications. Beside the exposure from the ICU and ER, the pre and post conference
helped us in learning and understanding the concept of each problem of the patient, this
helped us to appreciate the beauty of nursing and putting our heart when caring for the
patients.

As we practice throughout time, we would be able to utilize all the learnings from
our Cis to become a competent nurses and be able to do the job with compassion. A
good student will always start for a good guidance from the teacher. In the future as a
registered nurse, I will devote myself in giving back to others and do my job properly
and use all the gained knowledge that we received during RLE.

-Suarez, Ivory Camille A.