Final Case Study - CAD

8/13/2019 Final Case Study - CAD

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ANGELES UNIVERSITY FOUNDATION

COLLEGE OF NURSING

S.Y. 2013 2014

CAS E S TUD Y ABOUT

COR ON OR Y AR TE R Y D I S E AS E W I THUN S TABLE AN GI N A

SUBMITTED BY:

BUENAFE, PATRICIA MARIE

MANALANG, MA. CLARELLE

SULA, JANNICA

BSN III 3 (GROUP 11)

SUBMITTED TO:

DENNISON JOSE C. PUNSALAN, RN, MN

CLINICAL INSTRUCTOR

OCTOBER 11, 2013


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I. INTRODUCTION

Every man's disease is his personal property.

-Alonzo Clark

A person should be able to take care of his body in order to maintain a healthy

life. It is becausehealth refers to the levels of functional or metabolicefficiency ofliving

beings. In humans, it is the general condition of a person's mind and body, usually

meaning to be free fromillness,injury or needlesspain.That is why the quote said that

a sick person is in his personality.

During the Ottawa Charter for Health Promotion in 1986, the WHO said that

health is a resource for everyday life, not the objective of living. Health is a positive

concept emphasizing social and personal resources, as well as physical capacities

(http://www.medicalnewstoday.com/articles/150999.php) but since health is a basic

need of a person and it does not mean that if you are not sick, you are healthy, it is now

presented as a complete physical, mental and social well-being and not merely the

absence of disease or infirmity or simply health is the wholeness of one person. As a

person is growing up, he or she cannot prevent a certain disease coming from his body

parts like the brain and heart. The etiology may be coming from the hereditary/genetics,

age or idiopathic. That is a disease is being manifested by a person whether it is

symptomatic or asymptomatic.

(http://www.medicalnewstoday.com/articles/150999.php)

Coronary Artery Disease happens when the arteries that supply blood to heart

muscle become hardened and narrowed. This is due to the buildup of cholesterol and

other material, called plaque, on their inner walls. This buildup is calledatherosclerosis.

As it grows, less blood can flow through the arteries. As a result, the heart muscle can't

get the blood or oxygen it needs. This can lead to chest pain (angina)or aheart attack.

Most heart attacks happen when ablood clot suddenly cuts off the hearts' blood supply,

causing permanent heart damage. Over time, this can also weaken the heart muscle
http://en.wikipedia.org/wiki/Healthhttp://en.wikiquote.org/wiki/Efficiencyhttp://en.wikiquote.org/wiki/Livinghttp://en.wikiquote.org/wiki/Humanshttp://en.wikiquote.org/wiki/Mindhttp://en.wikiquote.org/wiki/Meaninghttp://en.wikiquote.org/wiki/Illnesshttp://en.wikiquote.org/wiki/Injuryhttp://en.wikiquote.org/wiki/Painhttp://www.nlm.nih.gov/medlineplus/cholesterol.htmlhttp://www.nlm.nih.gov/medlineplus/atherosclerosis.htmlhttp://www.nlm.nih.gov/medlineplus/angina.htmlhttp://www.nlm.nih.gov/medlineplus/heartattack.htmlhttp://www.nlm.nih.gov/medlineplus/bloodclots.htmlhttp://www.nlm.nih.gov/medlineplus/bloodclots.htmlhttp://www.nlm.nih.gov/medlineplus/heartattack.htmlhttp://www.nlm.nih.gov/medlineplus/angina.htmlhttp://www.nlm.nih.gov/medlineplus/atherosclerosis.htmlhttp://www.nlm.nih.gov/medlineplus/cholesterol.htmlhttp://en.wikiquote.org/wiki/Painhttp://en.wikiquote.org/wiki/Injuryhttp://en.wikiquote.org/wiki/Illnesshttp://en.wikiquote.org/wiki/Meaninghttp://en.wikiquote.org/wiki/Mindhttp://en.wikiquote.org/wiki/Humanshttp://en.wikiquote.org/wiki/Livinghttp://en.wikiquote.org/wiki/Efficiencyhttp://en.wikipedia.org/wiki/Health


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and contribute to heart failure and arrhythmias. Heart failure means the heart can't

pump blood well to the rest of the body. Arrhythmias are changes in the normal beating

rhythm of the heart.

The most common disease of the coronary arteries is arteriosclerosis, commonly

called "hardening of the arteries." Plaque a combination of cholesterol and other fats,

calcium and other elements carried in the blood builds up in the small blood vessels

that feed the heart. When this condition exists in other parts of the body, it is called

atherosclerosis.

This plaque buildup can, in time, narrow the arteries so severely that blood flow

to the heart is inadequate and symptoms of insufficient blood flow called angina

develop. Angina is a term meaning strangling or oppressive heaviness and pain, but it

has become synonymous with angina pectoris or chest pain caused by lack of oxygen

to the heart due to poor blood supply.

In addition to angina or chest pain, arteriosclerosis can produce fatigue,

shortness of breath and an abnormal heart beat or arrhythmia. Plaque also can tear the

artery walls and form blood clots that can lead to a heart attack. Often, there are no

symptoms of arteriosclerosis until a heart attack occurs.(http://www.ucsfhealth.org/conditions/coronary_artery_disease/signs_and_symptoms.ht

ml)

Arteriosclerosis is diagnosed through various tests including:

Coronary Angiography Coronary angiography, also called cardiac

catheterization, is a minimally invasive study that is considered the gold standard

for diagnosing coronary artery disease. This test is performed under local

anesthesia and involves injecting X-ray dye or contrast medium into the coronary

arteries via tubes called catheters. An X-ray camera films the blood flow to show

the location and severity of artery narrowing. This test can show if the blood

vessels in your heart have narrowed, your heart is pumping normally and blood is

flowing correctly and your heart valves are functioning properly. It also can
http://www.nlm.nih.gov/medlineplus/heartfailure.htmlhttp://www.nlm.nih.gov/medlineplus/arrhythmia.htmlhttp://www.ucsfhealth.org/conditions/coronary_artery_disease/signs_and_symptoms.htmlhttp://www.ucsfhealth.org/conditions/coronary_artery_disease/signs_and_symptoms.htmlhttp://www.ucsfhealth.org/conditions/coronary_artery_disease/signs_and_symptoms.htmlhttp://www.ucsfhealth.org/conditions/coronary_artery_disease/signs_and_symptoms.htmlhttp://www.nlm.nih.gov/medlineplus/arrhythmia.htmlhttp://www.nlm.nih.gov/medlineplus/heartfailure.html


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identify any heart abnormalities you may have been born with or congenital

abnormalities.

Echocardiogram (ECHO) This non-invasive test translates sound waves from

your chest into pictures of your heart. It provides information about how the heart

is pumping, how blood flows in the heart and blood vessels, how large the heart

is and how the valves are working.

Electrocardiogram (ECG or EKG) The electrocardiogram records the heart's

electrical activity. Small patches called electrodes are placed on your chest, arms

and legs, and are connected by wires to the ECG machine. Your heart's electrical

impulses are translated into a wavy line on a strip of paper, enabling doctors to

determine the pattern of electrical current flow in the heart and to diagnose

arrhythmias and heart damage.

Stress Echocardiogram Stress tests are performed to see how the heart

performs under physical stress. The heart can be stressed with exercise on a

treadmill or in a few instances, a bicycle. If you can't exercise on a treadmill or

bicycle, medications can be used to cause the heart rate to increase, simulating

normal reactions of the heart to exercise. During the stress test, you will wear

ECG electrodes and wires while exercising so that the electrical signals of your

heart can be recorded at the same time.

Stress Thallium Test Stress thallium tests have two components a treadmill

stress test and heart scan after injection of a radionuclide material, such as

thallium, which allows doctors to see the coronary arteries and the shape and

function of the heart. It has been used in this manner safely for many years to

demonstrate the amount of blood the heart is getting under various conditions

rest and stress.

(http://www.ucsfhealth.org/conditions/coronary_artery_disease/diagnosis.html)

Medications and sometimes lifestyle changes, such as quitting smoking or losing

weight, can help improve heart efficiency to reduce angina but can't eliminate the

plaque blockages. Medications may include cholesterol-lowering drugs, Beta-
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blockers, nitroglycerin, calcium channel blockers, angiotensin-converting enzyme

inhibitors and others. These are the other management for CAD:

Plaque Removal - to remove plaque from arteries, the following procedures are

performed:

Angioplasty - also called percutaneous transluminal coronary angioplasty or

PTCA, involves inserting a long flexible tube called a catheter into a blood vessel

through a small incision in your skin. The catheter has a deflated balloon on its

tip. Once the catheter reaches the blocked blood vessel, the balloon is inflated

and compresses the plaque against the sides of the blood vessel. The balloon

may be inflated and deflated several times. Often, the procedure is done in

conjunction with a small metal tube called a stent that is left in the artery to serve

as a scaffold to keep the artery open and prevent the plaque from springing back

toward the center of the vessel.

Coronary Artery Bypass Graft surgery - an open-heart operation in which an

artery or a piece of vein taken from your leg is attached to the blood vessel to

detour blood around the blockage. During part of the operation, your heart will be

stopped and a heart-lung machine will be used to pump your blood and help you

breathe. As with most major large incision operations, it takes about six weeks to

recover. CABG is the most successful and most common major heart surgery in

the Western world.

Coronary Stent - a small, latticed, high-grade stainless steel tube that is used to

hold the coronary artery open and minimize the chance of abrupt closure after

angioplasty. It is placed in the coronary artery using the same procedure as the

angioplasty. The stent is typically positioned at the narrowed area of the artery.

When the catheter's balloon is inflated, the stent expands and is pressed againstthe vessel wall. The balloon is deflated and withdrawn, leaving the stent

permanently in place. After a stent is placed, you will be prescribed an

antiplatelet medication, Clopidogrel, also known as Plavix, for one month. This is

used to minimize the risk of clot formation in the stent while tissue grows around

the stent to incorporate it into the blood vessel wall. Within a month, the body no


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longer "sees" the stent, and the medication is no longer needed. You should

continue to take aspirin, if it has been prescribed, along with the Clopidogrel.

Rotational Atherectomy - widens narrowed arteries using a high-speed

rotational device to "sand" away plaque. This technique is used in particular

situations, such as with plaque with large amounts of calcium or to widen

blockages within a stent.

(http://www.ucsfhealth.org/conditions/coronary_artery_disease/treatment.html)

Although CAD can be a life-threatening condition, the outcome of the disease is

in many ways up to the patient. Damage to the arteries can be slowed or halted with

lifestyle changes, including smoking cessation, dietary modifications and regular

exercise, or by medications to lower blood pressure and cholesterol levels. Additionalgoals of treatment, which may involve medication and sometimes surgery, are to relieve

symptoms, ease circulation and prolong life.

(http://www.nlm.nih.gov/medlineplus/coronaryarterydisease.html)

A. Current trends

MANILA, Philippines - Recent data last July 9, 2012, from the National Statistics

Office (NSO) showed that five out of 10 deaths in the country were of cardiovascular

causes.

The NSO reported that 100,908 people died of heart diseases in 2009. This

accounted for 21 percent of all deaths in the country. It was followed by cerebrovascular

disease, which claimed 56,670 lives in the same year. It accounted for 11.8 percent of

all deaths in 2009. "Within three years (2007-2009), the top five causes of deaths

remained on their posts and proved to be fatal among other causes of deaths," the NSO

said. The World Health Organization (WHO) has said that an estimated 17 million

people die of cardiovascular diseases every year. Most of these were heart attacks and

strokes. "A substantial number of these deaths can be attributed to tobacco smoking,
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which increases the risk of dying from coronary heart disease and cerebrovascular

disease 23 fold. Physical inactivity and unhealthy diet are other main risk factors which

increase individual risks to cardiovascular diseases," the WHO said. The NSO also

reported that most females die in their older age compared to their male counterparts.

"It was noted that the most number of deaths was at the age of 80 and over with 85,705

or 17.8 percent. From these, 59.6 percent (51,074) were females while the remaining 40

percent (34,631) were males," the NSO said. The age group 10 to 14 had the least

number of deaths, accounting for only 1 percent of all total deaths. "It has been

observed that as the age increases, the rate of dying also increasing. From age group

10 onwards it shows that the number of deaths continuously increase though a slight

decrease were seen at ages 75-79 then it went up again at age 80 and over," the NSO

said. Deaths in 2009 reached 480,820, which was 4.2 percent higher than the previous

year. The most number of deaths in the country occurred in the National Capital Region,

which accounted for 75,019 or 15.6 percent of all deaths in the country. Learn about

coronary artery disease, its symptoms and about the latest developments in treatment.

Coronary artery disease is caused when plaque buildup creates blockages or

narrowing in the arteries. The blockages restrict blood flow and reduce the amount of

oxygen delivered to the heart, potentially putting a person at risk for a heart attack.

Common symptoms of coronary artery disease include chest pain, shortness of

breath, fatigue and overall weakness.

Simple lifestyle changes can help prevent and manage coronary artery disease.

These include managing obesity and high blood pressure, living an active lifestyle,

making healthy dietary choices and stopping smoking.

(http://www.philstar.com/breaking-news/2012/07/09/826043/5-out-10-filipinos-die-heart-

disease-nso)

Improved Treatments

Staying on top of the latest medical advances helps ensure you and loved ones

secure the best treatment available.
http://www.philstar.com/breaking-news/2012/07/09/826043/5-out-10-filipinos-die-heart-disease-nsohttp://www.philstar.com/breaking-news/2012/07/09/826043/5-out-10-filipinos-die-heart-disease-nsohttp://www.philstar.com/breaking-news/2012/07/09/826043/5-out-10-filipinos-die-heart-disease-nsohttp://www.philstar.com/breaking-news/2012/07/09/826043/5-out-10-filipinos-die-heart-disease-nso


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Last March 28, 2013, a new treatment was found for patients with CAD. One

advancement in treatment is supported by new results from the FAME 2 Study funded

by St. Jude Medical and published in the New England Journal of Medicine. The study

found that use of a blood-flow measurement technology, called Fractional Flow Reserve

(FFR) during treatment of stable coronary artery disease will result in better health

outcomes.

FFR technology offers physicians a better assessment of where blood flow

blockages occur in the coronary arteries and whether treatment to open an artery

narrowing, along with medication, can help lower a patient's risk of chest pain and heart

attack.

From less likelihood of a patient being readmitted to the hospital for urgent care,

to a reduction in health care costs, FAME 2 research demonstrates that patients who

receive FFR-guided treatment experienced better outcomes than those treated with

medication alone.

The FAME 2 Study results offer further evidence that FFR should be considered

the standard of care for treating patients with coronary heart disease," said Frank J.

Callaghan, president of the Cardiovascular and Ablation Technologies Division at St.Jude Medical.

B. Statistics

Coronary artery disease (CAD) is the leading cause of death in the United

States, affecting over 5 million Americans. CAD is a narrowing of the coronary arteries,

the vessels that supply blood to the heart muscle, generally due to the buildup of

plaques in the arterial walls, a process known as atherosclerosis. Plaques are

composed of cholesterol-rich fatty deposits, collagen, other proteins, and excess

smooth muscle cells.


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Atherosclerosis, which usually progresses very gradually over a lifetime,

thickens and narrows the arterial walls, impeding the flow of blood and starving the

heart of the oxygen and vital nutrients it needs (also called ischemia). This can

cause muscle cramp-like chest pain calledangina.

Blood clots form more easily on arterial walls roughened by plaque deposits

and may block one or more of the narrowed coronary arteries completely and cause

a heart attack. Arteries may also narrow suddenly as a result of an arterial spasm.

(Spasms are most commonly triggered by smoking.)

Heart disease is the leading cause of death for both men and women. More

than half of the deaths due to heart disease in 2009 were in men. About 600,000

people die of heart disease in the United States every yearthats 1 in every 4

deaths. Coronary heart disease is the most common type of heart disease, killing

more than 385,000 people annually.Every year about 715,000 Americans have a

heart attack. Of these, 525,000 are a first heart attack and 190,000 happen in people

who have already had a heart attack. Coronary heart disease alone costs the United

States $108.9 billion each year. This total includes the cost of health care services,

medications, and lost productivity. (http://www.cdc.gov/heartdisease/facts.htm)

According to the latest WHO data published in April 2011 Coronary Heart

Disease Deaths in Philippines reached 57,864 or 13.73% of total deaths. The age

adjusted Death Rate is 121.63 per 100,000 of population ranks Philippines #79 in

the world. Review other causes of death by clicking the links below or choose the full

health profile. (http://www.worldlifeexpectancy.com/philippines-coronary-heart-

disease)
http://www.hopkinsmedicine.org/heart_vascular_institute/conditions_treatments/conditions/angina.htmlhttp://www.worldlifeexpectancy.com/philippines-coronary-heart-diseasehttp://www.worldlifeexpectancy.com/philippines-coronary-heart-diseasehttp://www.worldlifeexpectancy.com/philippines-coronary-heart-diseasehttp://www.worldlifeexpectancy.com/philippines-coronary-heart-diseasehttp://www.hopkinsmedicine.org/heart_vascular_institute/conditions_treatments/conditions/angina.html


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C. Reason for choosing such case for presentation

The student nurses are hopeful for the realization of the essence of this study to

the involved and to those of which this study can be of any help. Since the case of

Coronary Artery Disease is very rampant, the student nurses would like to be of

service in decreasing the probability of what is fast occurring. The aim of the group is

not just to present what we have researched or learned from time to time but to put

into profession in order to be of great help to others, to increase awareness, to

educate, to prevent, to promote and to restore health.


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D. Objectives

Short Term

During the course of the study, the student nurse will be able to:

Establish rapport with the patient

Explain the purpose in conducting the interview

Collect information regarding the demographic data of the patient

Collect information regarding socio economic and cultural beliefs of the

patient and environmental factors

Collect data regarding the patients family health illness and history, post

and present illness

List the diagnostic procedures done and explain

Identify the different medical, surgical and nursing management

Emphasize the importance of health teaching

Long Term

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

Associate abnormal diagnostic findings with his disease condition

Demonstrate nursing interventions for procedure done

Formulate recommendations to be imparted to patients same condition

Provide critical thinking skills necessary for providing safe and effective

nursing care.

Provide a comprehensive assessment and implement care base on our

knowledge and skills of the condition

Familiarize us with effective inter-personal skills to emphasized health

promotion and illness prevention.

Impart the learning experience from direct patient care.


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Short Term

During the course of the study, the patient will be able to:

Develop trust with the student nurse

Understand the purpose in conducting such interview

Provide information regarding his demographic data

Provide information regarding his socio economic and cultural beliefs

Demonstrate compliance to medical regimen

Identify risk factors

Long Term

After completion of the study, the patient will be able to:

Continue cooperating with physical assessment

Express feelings regarding his condition

Will be able to accept his situation and have sense of control

Understand his manifestation related to him condition

Gain the basic information concerning Coronary Artery Disease

Eradicate activities that may worsen his condition

Comply with the treatment given upon discharge


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II. NURSING PROCESS

A. Assessment

1. Personal History

a. Demographic Data

Our patients name is Mr. Corona D. Sease for the purpose of confidentiality and

he is 56 years old. He is approximately 52 feet in height and weighs 45 kilograms in

weight. He has a pale fair skin complexion. His eyes are round and his teeth are slightly

yellowish. His role in the family is to work for his family as a grass cutter at a certain

subdivision. He does have 6 children. He lives in Bulaon Rest City of San Fernando,

Pampanga. He was born on May 16, 1957 at their house in Del Paz Norte by Normal

Spontaneous Delivery. His nationality is a Filipino and ethnicity is a Kapampangan.

He was admitted September 17, 2013 at around 1:40 AM. His chief complaint

was difficulty of breathing and chest tightness. He is still admitted at a local hospital in

Pampanga. He was diagnosed with Coronary Artery Disease with Unstable Angina.

b. Socio-Economic and Cultural Factors

Mr. Corona D. Sease lives together with his wife and his 6 children and they are

pure Kapampangan. They are currently living at Bulaon Rest City of San Fernando,

Pampanga. Their house is made of sement and wood house in a 1 story building and

only has 1 window. They are still living there even a typhoon already flooded and

destroyed some of the parts of the house like the floors.

Mr. Corona D. Seaseswork is a grass cutter during weekdays from 7AM to 5PM

at a certain subdivision. He owns 5,200 pesos every month. They are categorized aspoor because each member receives 900 pesos only. According to NEDA 2004, a

family must have a total income of 2768.60 per family member to be classified as not

poor and meet the basic needs of each member.

(http://localweb.neda.gov.ph/regional.html)


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His wife budgets the money for their basic needs. They buy their food at a local

market. Their source of water is from a distilled water company. Their garbage is

collected once a week by the city government entities. According to Mr. Sease, their

food source comes from the maket and they dont have any electricity but they use

candles as their source of light. They buy things for their hygiene purposes like

shampoo, soap, tooth brush and tooth paste. They ride tricycles and jeepneys as

means of transportation. They save money that was left for emergency purposes like

medications. He gives money for his childrens projects and allowance. Some of his

income was given to his relatives since his relatives are asking.

Basic Needs Expenses (Per Week)

Food

Rice

Viand

900 pesos

800 pesos

Water Supply 140 pesos

No Electricity Suppy but for Candles 60 pesos

Hygiene Suppy 200 pesos

Transportation 112 pesos

Savings for Emergency purposes 500 pesos

Education for his children 500 pesos

For his relatives 1500 pesos

Others 488 pesos

Mr. Sease only reached Grade 5 as his highest educational attainment in a public

school. He was forced to stop her studies because of the financial constraint in the

family. They are affliated with Roman Catholic religion and they go to mass every


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Sunday. Regarding their cultural factors affecting health, they take herbal medicines

such as Malunggay and Bawang as an alternative of a medicine but they do not believe

in faith healers. If one of the family members got sick, they immediately go to a hospital.

Mr. Sease does not smoke but he drinks alcohol 4 times a week. He is fond of eating

vegetables and has a high fat diet.

TIME ACTIVITIES OF DAILY LIVING OF

MR. CORONA D. SEASE

4:00 AM6:00AM Freshen up including dressing up for 30

minutes, Cooking and Preparing their

Breakfast for 40 minutes, Breakfast for

30 minutes, Cleaning the Dishes for 15

minutes, Getting Ready for His Work

for 5 minutes

6:00 AM6:45 AM Travel Time Going to His Work

7:00 AM12:00 NN Working Hours

12:00 NN1:00 PM Lunch Break

1:00 PM5:00 PM Working Hours

5:00 PM5:45 PM Travel Time Going Back to His House

6:00 PM6:30 PM Rest for 30 minutes

6:30 PM7:00 PM Dinner

7:00 PM7:30 PM Doing Household Chores

7:30 PM10:00 PM Bonding with Family for 30 minutes,

Going to His Friends House and Drinks

Alcohol for 2 Hours

10:00 PM4:00 AM Sleeping Hours


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C. Environmental Factors

Seases family live in Bulaon Rest, City of San Fernando, Pampanga. Theirhouse is a sement and wood type of house. It is a 1-storey building house. They have 1

window and 1. They are still living their even there was a typhoon that flooded the

house. His wife cleans the house every week.

3. History of Past Illness

Mr. Corona D. Sease is complete with his immunizations when he was 1 year old

at the year of 1958. He experienced tigdas at the age of 10 years old at the year of

1967 and did not have any chicken pox and mumps during his childhood years. He

does not have any allergies like in dust, pollens and foods such as shrimps or chickens.

Sometimes, he experience fever. His highest temperature when he experiences his

fever on October 2005 was 38.5 degree Celsius. His wife only did tepid sponge bath

and bed rest. When he has cough and colds and flu, he drinks Lagundi as his

alternative medicine when they lack of financial resources. If he is severe ill, he

immediately goes to the hospital.

4. History of Present Illness

Mr. Corona D. Sease experienced chest pain or angina pectoris in medical term

when he was 55 years old on December 2012. He experienced chest pain again lastJanuary and August 2013 and was brought at a local hospital in Pampanga. He did not

buy his take home medications because of lack of financial resources. The day before

his admission, last September 17, 2013 at around 4:30 PM, he experienced sudden

difficulty of breathing and chest tightness when he was still in work. He was brought to a

local hospital here in Pampanga at around 6:30 PM by the worker, where he was


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working. His chief complaint was difficulty of breathing and chest tightness. He admitted

that before the day of admission, he ate high fat foods like chicharon and sisig and he

drank alcohol straight 4 days in that week.

The physician made the admitting and final diagnosis as Coronary Artery

Disease. Hence, he was admitted on September 17, 2013.

5. Physical Examination

(September 17, 2013Lifted from the chart)

Skin: (-) Dermatitis

Head-EENT: AS, PPC

Lymph Nodes: (-) Claps

Chest: Lungs - SF, Crackles in BLF

Cardiovascular: Angina Pectoris

o Abdomen: Flat, Soft

o Musculoskeletal: (+) grade # edema

o Admitting Impression: T/c ACS with CHF

(September 18, 2013First Day of Assessment)

General Appearance:

Mr. Corona D. Sease is lying on bed, with an IVF of 5% Dextrose in Water 500

cc, with an O2 Inhalation. He looks weak in appearance. He has pale skin and

conjunctiva.


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Vital Signs

Temperature: 36.5 degree Celsius

Pulse rate: 74 bpm

Respiratory rate: 31 cpm

Blood Pressure: 110/80 mmHg

o HairShort, black hair, no pediculosis and lesions noted, evenly distributed

o SkinPale complexion, good skin turgor, absence of edema and jaundice

o NailsLong and untrimmed

o HeadRound, smooth without lesions

o EyesPale palpebral conjunctiva, round eyes

o EarsNo presence of discharge

o MouthNo sores, reddish in color

o NoseNo nasal discharge

o LipsPale and slightly dry

o NeckNo lymph nodes were palpated

o HeartDiminished in heart rate, irregular heart rhythm

o LungsCrackles and rales were auscultated in BLF

o Abdomen - Skin is as the same color as with that of that body or lighter. Hair is

evenly distributed. Bluish discoloration of the umbilicus is not presence. Bowel

sounds are 15 per minute/quadrant. Pain is not felt during urination.

o Legs and feetNegative Homans sign, edema

(September 19, 2013Second Day of Assessment)

General Appearance:



conjunctiva.


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Vital Signs

Temperature: 35.8 degree Celsius

Pulse rate: 77 bpm




o SkinPale complexion, good skin turgor, absence of edema and jaundice


o HeadRound, smooth without lesions

o EyesPale palpebral conjunctiva, round eyes


o MouthNo sores, reddish in color, had excessive sputum

o NosePresence of nasal discharge



o Heart - Diminished in heart rate, irregular heart rhythm



evenly distributed. Bluish discoloration of the umbilicus is not presence. Bowel sounds

are 15 per minute/quadrant. Pain is not felt during urination.

o Legs and feetNegative Homanssign, edema

(September 20, 2013Third Day of Assessment)

General Appearance



conjunctiva.


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Vital Signs

Temperature:36.8 degree Celsius

Pulse rate: 78 bpm




o Skin Slightly pale complexion, good skin turgor, absence of edema and

jaundice


o HeadSymmetrical, round, smooth without lesions

o EyesSlightly pale palpebral conjunctiva


o MouthNo sores, reddish in color

o NosePresence of nasal discharge



o Heart - Diminished in heart rate, irregular heart rhythm



evenly distributed. Bluish discoloration of the umbilicus is not presence. Bowel sounds

are 15 per minute/quadrant. Pain is not felt during urination.

o Legs and feetNegative Homanssign, edema


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Diagnostic/Laboratory

Procedures

Date Ordered

Date

Resulted

Indications or

Purposes

Results Normal

Values/

Units used

in Hospital

Analysis and

Interpretation of results

(Client-centered)

> Complete Blood

Count

Hemoglobin DO: 09-17-

2013

DS: 09-18-

2013

Measures the

amount of Hgb,

protein found in

RBC in the blood

130 115155 g/L The result is normal, can be

seen by client having the

absence of dehydration

Hematocrit DO: 09-17-

2013

DS: 09-18-

2013

Measures the

proportion of the

blood that is made

up of RBC

0.44 0.380.48 Same of Hgb, hydration

status is normal

White Blood Cells DO: 09-17-

2013

DS: 09-18-

2013

Numerates the

number of WBC in

the blood, a

decrease and

increase in this

may suggest

presence of

7 510 x

10^9/L

The client did not acquire

any infections as a result to

normal WBC


22/109

Lymphocytes DO: 09-17-

2013

DS: 09-18-

2013

This test measures

amount of

neutrophils type of

WBC in the blood

if disease or

toxicity issuspected

0.27 0.200.35 The amount of lymphocytes

in the blood is normal as

evidenced by clients

absence of infection; this is

related to WBC and

neutrophils sinceneutrophils and

lymphocytes are types of

WBC

illness

Neutrophils DO: 09-17-

2013

DS: 09-18-

2013

This test

measures the

amount of

neutrophils type of

WBC in the bloodif disease or

toxicity is

suspected

0.49 0.450.65 Client did not manifest

infection as evidenced by

normal neutophils


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Platelet DO: 09-17-

2013

DS: 06-18-

2013

To determine any

bleeding disorders

or bone marrow

diseases and for

unexplained

bruises

298 150400 x

10^9

The client did not have any

spontaneous bleeding, bone

marrow disorder or

leukemia which results to a

normal platelet count> Blood Chemistries

Fasting Blood Sugar DO: 09-17-

2013

DS: 09-18-

2013

This is to measure

the amount of

glucose present in

the body

6.02 4.19.00

mmol/L

Clients glucose level is

within normal range. No

signs of diabetes

Blood Urea Nitrogen DO: 09-17-

2013

DS: 09-18-

2013

Measures amount

of urea nitrogen is

the blood

4.1 1.7/8.3mmol/

L

Result is normal as

evidenced by clients normal

kidney function

Creatinine DO: 09-17-

2013

DS: 09-18-

2013

Measures the

amount of

creatinine present

is the blood and/or

urine

130.8 58-

120mmol/L

The client is dehydrated. His

urine is tea-colored. Pain is

felt when urinating but there

is no presence of blood.


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Sodium (Na) DO: 09-17-

2013

DS: 09-18-

2013

Measures the level

of Na is the blood

146.6 135145

mmol/L

Client is in good hydration

status

Potassium (K) DO: 09-17-

2013

DS: 09-18-

2013

Measures the

amount of K

present is the

blood

4.23 3.555

mmol/L

Clients K level is within

normal range

Urinalysis DO: 09-17-

2013

DS: 09-18-

2013

Urinalysis can

reveal diseases

that have gone

unnoticed because

they do not

produce striking

signs and

symptoms

Determination of

Color Normal

Patient has lightyellow color

urine.

Yellow Yellow to

amber in

color

Transparency

There is presence of

suspended particles in theurine such as normal urine

crystals and mucus because

of inflammation of the

gallbladder.


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urine composition

and possible

abnormal

components (e.g.

protein or glucose)

or infection

Turbid Clear

Specific Gravity

Normal

This means that the

patient has normal

hydration status AEB

patient didnt manifest

signs of dehydration

such as poor skin turgor,

etc.


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1.013 1.0101.025

Sugar

Normal

There is absence of sugar in the urine

which means that the patient is notindicative of diabetes.


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Negative Negative

Microscopic Findings

Pus

Cells

The patient has mild inflammation of the

gallbladder and mild infection.

0-1 /hpf 0-1/hpf

RBCThe patient has mild inflammation of the

gallbladder and mild infection.


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12 (Negative or

Rare)

Epithelial

Cells

Normal

This indicates that the patient is not

indicative of inflammation in the bladder

and present of epithelial cells represent

possible contamination of the specimen

with skin bacteria

Few Rare

BacteriaBacteria in urine are unusual, but few

bacteria can due to contamination

Few None


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Electrocardiogram

There is an Elevated ST Segment which means independent of changes in ventricular activation and that

may be the result of global or segmental pathologic processes that affect ventricular repolarization and has Occasional

Pulmonary Vascular Resistance.


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7. ANATOMY AND PHYSIOLOGY

The heart is located in the chest between the lungs behind the sternum and

above the diaphragm. It is surrounded by the pericardium. Its size is about that of a fist,

and its weight is about 250-300 g. Its center is located about 1.5 cm to the left of themidsagittal plane. Located above the heart are the great vessels: the superior and

inferior vena cava, the pulmonary artery and vein, as well as the aorta. The aortic arch

lies behind the heart. The esophagus and the spine lie further behind the heart.

(Williams and Warwick, 1989).

The walls of the heart are composed of cardiac muscle, called myocardium. It

also has striations similar to skeletal muscle. It consists of four compartments: the right

and left atria and ventricles. The heart is oriented so that the anterior aspect is the right

ventricle while the posterior aspect shows the left atrium. The atria form one unit and


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the ventricles another. This has special importance to the electric function of the heart,

which will be discussed later. The left ventricular free wall and the septum are much

thicker than the right ventricular wall. This is logical since the left ventricle pumps blood

to the systemic circulation, where the pressure is considerably higher than for the

pulmonary circulation, which arises from right ventricular outflow. The cardiac muscle

fibers are oriented spirally and are divided into four groups: Two groups of fibers wind

around the outside of both ventricles. Beneath these fibers a third group winds around

both ventricles. Beneath these fibers a fourth group winds only around the left ventricle.

The fact that cardiac muscle cells are oriented more tangentially than radially,

and that the resistivity of the muscle is lower in the direction of the fiber has importance

in electrocardiography and magneto cardiography. The heart has four valves. Between

the right atrium and ventricle lies the tricuspid valve, and between the left atrium and

ventricle is the mitral valve. The pulmonary valve lies between the right ventricle and the

pulmonary artery, while the aortic valve lies in the outflow tract of the left ventricle

(controlling flow to the aorta). The blood returns from the systemic circulation to the right

atrium and from there goes through the tricuspid valve to the right ventricle. It is ejected

from the right ventricle through the pulmonary valve to the lungs. Oxygenated blood

returns from the lungs to the left atrium and from there through the mitral valve to the

left ventricle. Finally blood is pumped through the aortic valve to the aorta and the

systemic circulation.


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In the heart muscle cell, or myocyte, electric activation takes place by means of

the same mechanism as in the nerve cell - that is, from the inflow of sodium ions across

the cell membrane. The amplitude of the action potential is also similar, being about 100

mV for both nerve and muscle. The duration of the cardiac muscle impulse is, however,

two orders of magnitude longer than that in either nerve cell or skeletal muscle. A

plateau phase follows cardiac depolarization, and thereafter repolarization takes place.

As in the nerve cell, repolarization is a consequence of the outflow of potassium

ions. (Netter, 1971).Associated with the electric activation of cardiac muscle cell is its

mechanical contraction, which occurs a little later. For the sake of comparison, Figure

6.5 illustrates the electric activity and mechanical contraction of frog sartorius muscle,

frog cardiac muscle, and smooth muscle from the rat uterus (Ruch and Patton, 1982).

An important distinction between cardiac muscle tissue and skeletal muscle is

that in cardiac muscle, activation can propagate from one cell to another in any

direction. As a result, the activation wavefronts are of rather complex shape. The only

exception is the boundary between the atria and ventricles, which the activation wave

normally cannot cross except along a special conduction system, since a non-

conducting barrier of fibrous tissue is present. Located in the right atrium at the superior

vena cava is the sinus node (sinoatrial or SA node) which consists of specialized

muscle cells. The sinoatrial node in humans is in the shape of a crescent and is about

15 mm long and 5 mm wide (see Figure 6.6). The SA nodal cells are self-excitatory,

pacemaker cells. They generate an action potential at the rate of about 70 per minute.

From the sinus node, activation propagates throughout the atria, but cannot propagate

directly across the boundary between atria and ventricles, as noted above. The

atrioventricular node (AV node) is located at the boundary between the atria and

ventricles; it has an intrinsic frequency of about 50 pulses/min. However, if the AV node

is triggered with a higher pulse frequency, it follows this higher frequency. In a normal

heart, the AV node provides the only conducting path from the atria to the ventricles.

Thus, under normal conditions, the latter can be excited only by pulses that

propagate through it. Propagation from the AV node to the ventricles is provided by a

specialized conduction system. Proximally, this system is composed of a common


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bundle, called the bundle of His (named after German physician Wilhelm His, Jr., 1863-

1934). More distally, it separates into two bundle branches propagating along each side

of the septum, constituting the right and left bundle branches. (The left bundle

subsequently divides into an anterior and posterior branch.) Even more distally the

bundles ramify into Purkinje fibers (named after Jan Evangelista Purkinje (Czech; 1787-

1869)) that diverge to the inner sides of the ventricular walls. Propagation along the

conduction system takes place at a relatively high speed once it is within the ventricular

region, but prior to this (through the AV node) the velocity is extremely slow. From the

inner side of the ventricular wall, the many activation sites cause the formation of a

wavefront which propagates through the ventricular mass toward the outer wall. This

process results from cell-to-cell activation. After each ventricular muscle region has

depolarized, repolarization occurs. Repolarization is not a propagating phenomenon,

and because the duration of the action impulse is much shorter at the epicardium (the

outer side of the cardiac muscle) than at the endocardium (the inner side of the cardiac

muscle), the termination of activity appears as if it were propagating from epicardium

toward the endocardium.


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8. THE PATIENT AND HIS ILLNESS

a. PATHOPHYSIOLOGY (BOOK-CENTERED)

Schematic Diagram

Non-modifiable Factors:

Age (older adults)

Gender (male and menopause

women)

Hereditary(Including Race)

Modifiable Factors:

Smoking

Physical Inactivity

Obesity

Diabetes

Stress

Homocysteine Levels

Inflammatory Response

Menopause

Thrombus formation

Activation latelet

M ocardial ischemia Anaerobic metabolism

Lactic Acid Production

Acidosis

Prolonged unrelieved

ischemia

Change in the condition of the plaque in the coronary artery

An ina


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Myocardial cell death

Altered re olarizationRelease of lysosomal

enz mes

Conduction system

disorder

Heart Contractility

SNS Stimulation LV Function

Elevated ST segment

Elevated Cardiac

Biomarkers

D srh thmias

Decreased COIncreased

Afterload

Increased

Oxygen Demand

Tach cardia Increased

Preload

Increased

CVP and

PCWP

VasoconstrictionTach nea


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b. Synthesis of the disease

b.1. Definition of the disease

Coronary artery disease develops when your coronary arteries the major

blood vessels that supply your heart with blood, oxygen and nutrients become

damaged or diseased. Cholesterol-containing deposits (plaque) on your arteries are

usually to blame for coronary artery disease. When plaques build up, they narrow your

coronary arteries, causing your heart to receive less blood.

Eventually, the decreased blood flow may cause chest pain (angina), shortness

of breath, or other coronary artery disease signs and symptoms. A complete blockage

can cause a heart attack. Because coronary artery disease often develops over

decades, it can go virtually unnoticed until you have a heart attack. But there's plenty

you can do to prevent and treat coronary artery disease. Start by committing to a

healthy lifestyle.

Coronary artery disease is a narrowing or blockage of the arteries and vessels

that provide oxygen and nutrients to the heart. It is caused by atherosclerosis, an

accumulation of fatty materials on the inner linings of arteries. The resulting blockage

restricts blood flow to the heart. When the blood flow is completely cut off, the result is a

heart attack.

Coronary artery disease, also called coronary heart disease or heart disease, is

the leading cause of death for both men and women in the United States. According to

the American Heart Association, deaths from coronary artery disease have declined

some since about 1990, but more than 40,000 people still died from the disease in

2000. About 13 million Americans have active symptoms of coronary artery disease.

Coronary artery disease occurs when the coronary arteries become partially

blocked or clogged. This blockage limits the flow of blood from the coronary arteries,

which are the major arteries supplying oxygen-rich blood to the heart. The coronary

arteries expand when the heart is working harder and needs more oxygen. Arteries

expand, for example, when a person is climbing stairs, exercising, or having sex. If the


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arteries are unable to expand, the heart is deprived of oxygen (myocardial ischemia).

When the blockage is limited, chest pain or pressure, called angina, may occur. When

the blockage cuts off the flow of blood, the result is heart attack (myocardial infarction or

heart muscle death).

Healthy coronary arteries are clean, smooth, and slick. The artery walls are

flexible and can expand to let more blood through when the heart needs to work harder.

The disease process in arteries is thought to begin with an injury to the linings and walls

of the arteries. This injury makes them susceptible to atherosclerosis and blood clots

(thrombosis).

b.2. Nonmodifiable

HEREDITARY (INCLUDING RACE)

Children whose parents had heart disease are at higher risk for coronary artery

disease. This increased risk is related to genetic predisposition to hypertension,

elevated lipid levels, diabetes and obesity, all of which increase the risk f coronary

artery disease.

For people 35 to 74 years of age, the age adjusted death rate from coronary artery

disease for African American women is 72% higher than that for white women and

Native Americans. The prevalence of coronary is lowest among Mexican American

AGE

Age influences both the risk and the severity of coronary artery disease.

Symptomatic coronary artery disease appears predominantly in people older than 40

years of age and 4 of 5 people who die of coronary artery disease are age 65 years or

older. Angina and Myocardial Infarction, however, can occur in a persons 30s and even

in ones 20s. at older ages, women who have heart attacks are twice as likely as to die

from the heart attack.


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GENDER

Coronary artery disease is the number one killer of both men and women. In 1999

mortality from coronary artery disease was almost equal for men and women. Although

men are at higher risk for heart attacks at younger ages, the risk for women increasessignificantly at menopause, so that coronary artery disease rates in women after

menopause are two to three times that of women the same age before menopause.

Women who take oral contraceptives and who smoke or have high blood pressure are

at greater risk for coronary artery disease. Women with an early menopause are also at

higher risk than are women with a normal or late menopause.Two lifestyle changes

during the past 2 decades may be responsible for the increased incidence of coronary

artery disease among women. More women (many with full responsibility for the

household and children) have entered the work force, and more women have begun to

smoke tobacco at an earlier age.

Modifiable

SMOKING

Both active smoking and passive smoking have been strongly implicated as a risk

factor in the development of coronary artery disease. Currently 23% of men and 18% of

women are smokers. The prevalence of smoking is higher in people with 11 years of

education or less. Smoking triples the risk of heart attack in women and doubles the risk

of heart attack in men. It also doubles the risk of dying from a heart attack and may

quadruple the risk of sudden death. Nonsmokers who are exposed to second hand

tobacco smoke at home or work may also have a higher death rate from coronary artery

disease. The risk of coronary artery disease is decreased by 50% 1 year after smokers

quit. The risk is further reduced to that of nonsmokers within 5 to 10 years after smoking

cessation.Tar, nicotine, and carbon monoxide contribute to the damage. Tar contains

hydrocarbons and other carcinogenic substances. Nicotine increases the release of

epinephrine and norepinephrine, which results in peripheral vasoconstriction, elevated

blood pressure and heart rate, greater oxygen consumption, and increased likelihood of

dysrhythmias. In addition, nicotine activates platelets and stimulates smooth muscle cell


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proliferation in the arterial walls. Carbon monoxide reduces the amount of blood

available to the intima of the vessel wall and increases the permeability of the

endothelium.

PHYSICAL INACTIVITY

In the United States about 25% of adults report no leisure time physical activity,

even though regular aerobic exercise is important in preventing heart and blood vessel

disease. There is an inverse relationship between exercise and the risk of coronary

artery disease. Those who exercise reduce their risk of coronary artery disease

because they have (1) higher HDL levels; (2) lower LDL cholesterol, triglyceride and

blood glucose levels; (3) greater insulin sensitivity; (4) lower blood pressure; and (5)

lower body mass index. The AHA recommends 30 to 60 minutes of physical activity on

most days of the week.

OBESITY

Obesity places an extra burden on the heart, requiring the muscle to work harder to

pump enough blood to support added tissue mass. In addition obesity increases the risk

for coronary artery disease because it is often associated with elevated serum

cholesterol and triglyceride levels, high blood pressure, and diabetes. The prevalence of

obesity has increased to 30% in the years 1999 to 2002 compared to 22% from 1988 to

1994. Since 1993 the prevalence of those who are obese increased to 61%. Distribution

of body fat is also important. A waist measurement is a way to estimate fat. For men a

highrisk waistline measurement is more than 40 inches and for women a high risk

waist measurement is more than 35 inches. Body mass index is another measure to

estimate body fat. A BMI from 18.5 to 24.9 is considered healthy. Extreme obesity, or a

BMI greater than 40, is estimated to occur in 4.9% of the population. People can lower

their heart disease risk by losing as little as 10 to 20 pounds. An altering pattern of

weight gain and weight loss, however, is associated with an increased risk for coronary

artery disease.


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DIABETES

Since 1990 the prevalence of people diagnosed with diabetes increased by 61%. In

addition, the prevalence of diabetes has increased by 8% since 2000 to 2001.

Contributing to these statistics is the increased frequency of obesity and sedentarylifestyles. A fasting blood glucose level of more than 126 mg/dl or a routine blood

glucose level of 180 mg/dl and glucosuria signals the presence of diabetes and

represents an increased risk for coronary artery disease. Clients with diabetes have a

two to four fold higher prevalence, incidence, and mortality from all forms of

coronary artery disease.

STRESS

A persons response to stress may contribute to the development of coronary artery

disease. Some researchers have reported a relationship between coronary artery

disease risk and stress levels, health behaviors, and socioeconomic status. Stress

response appears to increase coronary artery disease risk through its effect on major

risk factors. For example, some people respond to stress by overeating or by starting or

increasing smoking. Stress is also associated with elevated blood pressure. Although

stress is unavoidable in modern life, an excessive response to stress can be a health

hazard. Significant stressors include major changes in residence, occupation, or

socioeconomic status.

HOMOCYSTEINE LEVELS

Researchers have reported that elevated levels of plasma Homocysteine (an amino

acid produced by the body) are associated with an increased risk of coronary artery

disease. Scientists do not know whether homocysteine directly or indirectly increases

coronary artery disease risk, however, because homocysteine levels are related to renalfunction, smoking, fibrinogen, and C reactive protein (CRP). Elevated homocysteine

levels can be reduced by treatment with folic acid, vitamin B6, and vitamin B12. Experts

currently recommend that homocysteine levels be measured in people with a history of

premature coronary artery disease, stroke, or both in the absence of other risk factors.


41/109


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after stopping the stressful activity. In some people, especially women, this pain

may be fleeting or sharp and noticed in the abdomen, back or arm.

Shortness of breath. If your heart can't pump enough blood to meet your body's

needs, you may develop shortness of breath or extreme fatigue with exertion.

Heart attack. If a coronary artery becomes completely blocked, you may have a

heart attack. The classic signs and symptoms of a heart attack include crushing

pressure in your chest and pain in your shoulder or arm, sometimes with

shortness of breath and sweating. Women are somewhat more likely than men

are to experience less typical signs and symptoms of a heart attack, including

nausea and back or jaw pain. Sometimes a heart attack occurs without any

apparent signs or symptoms.


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PATHOPHYSIOLOGY (CLIENTCENTERED)

Schematic Diagram

Non-modifiable Factors:

Age (older adults)

Gender (male)

Hereditary

Modifiable Factors:

Physical Inactivity

Stress

High fat diet

Alcohol drinking

Thrombus formation

Activation latelet

M ocardial ischemia Anaerobic metabolism

Lactic Acid Production

Acidosis

Prolonged unrelieved ischemia

Change in the condition of the plaque in the coronary artery

An ina

M ocardial cell death

Altered repolarization Release of lysosomal enzymesConduction

system disorder

Heart Contractilit

SNS Stimulation LV Function

Elevated ST

segment D srh thmias

September 18, 2013

he patient has

ccasional PVC.

On

Septem

18, 2

the pa

verbalizdifficulty

breathin


44/109

NONMODIFIABLE FACTORS (CLIENTCENTERED)

HEREDITARY

Children whose parents had heart disease are at higher risk for coronary artery

disease. This increased risk is related to genetic predisposition to hypertension,

elevated lipid levels, diabetes and obesity, all of which increase the risk f coronary

artery disease.

AGE

Age influences both the risk and the severity of coronary artery disease.

Symptomatic coronary artery disease appears predominantly in people older than 40

years of age and 4 of 5 people who die of coronary artery disease are age 65 years or

older.

GENDER

Coronary artery disease is the number one killer of both men and women. In 1999

mortality from coronary artery disease was almost equal for men and women. Men are

at higher risk for heart attacks at younger ages.

Decreased

CO

Increased

Oxygen Demand

Tachypnea

September 18, 201

The patie

manifested palenes

of skin, conjunctiva

body weakness an

dry mucou

membrane. Rale

and crackles wer

also heard durin

auscultation.

September 18, 2013

The patient manifested

increased respiratory rate

of 31cpm


45/109

MODIFIABLE FACTORS

PHYSICAL INACTIVITY

In the United States about 25% of adults report no leisure time physical activity,

even though regular aerobic exercise is important in preventing heart and blood vessel

disease. There is an inverse relationship between exercise and the risk of coronary

artery disease. Those who exercise reduce their risk of coronary artery disease

because they have (1) higher HDL levels; (2) lower LDL cholesterol, triglyceride and

blood glucose levels; (3) greater insulin sensitivity; (4) lower blood pressure; and (5)

lower body mass index. The AHA recommends 30 to 60 minutes of physical activity on

most days of the week.

STRESS

A persons response to stress may contribute to the development of coronary artery

disease. Some researchers have reported a relationship between coronary artery

disease risk and stress levels, health behaviors, and socioeconomic status. Stress

response appears to increase coronary artery disease risk through its effect on major

risk factors. For example, some people respond to stress by overeating or by starting or

increasing smoking. Stress is also associated with elevated blood pressure. Although

stress is unavoidable in modern life, an excessive response to stress can be a health

hazard. Significant stressors include major changes in residence, occupation, or

socioeconomic status.

HIGH FAT DIET

The vessels that bring blood to the heart are called the coronary arteries. They are

like narrow tubes. A fatty substance called plaque (say this: plak) can build up in these

arteries and make them narrow, so less blood gets to the heart. A diet high in saturated

fat greatly increases your risk of heart disease. Saturated fat increases your LDL

cholesterol. LDL cholesterol is bad cholesterol.

SIGNS AND SYMPTOMS


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Pain and discomfort are the main symptoms of angina. Angina often is described

as pressure, squeezing, burning, or tightness in the chest. The pain or discomfort

usually starts behind the breastbone. Pain from angina also can occur in the

arms, shoulders, neck, jaw, throat, or back. The pain may feel like indigestion.

(September 18, 2013)

Difficulty of breathing due to tightness of chest brought about interruption in the

artery.

Pallor manifested on September 18, 2013 due to poor perfusion, poor venous

return and decreased oxygen level in the blood.

Restlessness manifested on September 18, 2013 caused by loss of oxygen and

nutrients to the myocardial tissue because of inadequate coronary blood flow.


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PLANNING (NURSING CARE PLAN)

Problem#1: Ineffective airway clearance related to retained secretions due to decreased cardiac output

Assessment Diagnosis Scientific

Explanation

Objective Nursing

Intervention

Rationale Expected

Outcome

S=

O=The patient

may manifest:

-restlessness

-Increased RR

-dyspnea

-cyanosis

-excessive

sputum

-rales

-crackles

-fatigue

Ineffectiveairway

clearance

related to

retained

secretions

When mucussecretion and

mucus

clearance are

not in

balance,

excessive

airway mucus

can cause

serious

problems.

This condition

is called

impaired

airway

clearance.

Short term:

After 2-3

hours of

nursing

interventions

, the patient

will verbalize

understandin

g of disease

process.

Long term:

After two

days of

nursing

interventions

1. assesspatients

condition

2. monitor

and record vital

signs.

3. encourage

deep breathing

exercises

4. elevate headof bed and

change position

every 2 hours

5. encourage

hydration

6. balance

1. todetermine

possible

problems

2. for

baseline data

3. To maximize

effort

4. to decrease

pressure in thediaphragm and

enhance

ventilation

5. to loosen

secretion

6. to reduce

Short term:

The patient shall

have verbalized

understanding of

disease process.

Long term:

The patient shall

have maintained


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Excess, often

sticky mucus

may

accumulate in

the airways inconditions as

varied as

cystic fibrosis,

cerebral

palsy, and

chronic

obstructive

pulmonary

disease

bronchiectasi

s. Retained

secretions

are a

universal

problem in

people with

the patient

will maintain

airway

patency

rest periods with

activities

7. position head

appropriate for

condition

8. Instruct

patient the

importance of

ambulation

fatigue

7. to maintain

open airway

8. help maintain

adequate lung

expansion

airway patency


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carbon

dioxide.

Although

underlying

causes are

diverse,

consequence

s are the

same:

vulnerable

individuals

are caught up

in the vicious

cycle of

recurrent,

ever-worsening

episodes of

inflammation,

pulmonary

infection,

increased


51/109

production of

excess

mucus, and

airway

obstruction,

lung damage,

and

respiratory

failure.


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Problem#2: Decreased Cardiac Output related to Increased Vascular Resistance

ASSESSMENT DIAGNOSIS SCIENTIFIC

EXPLANATION

OBJECTIVE NURSING

INTERVENTIONS

RATIONALE EXPECTED

OUTCOME

S-

O-The patientmay manifest:

-Restlessness

-Increased BP

-Cold clammy

skin

-Decreased

peripheral

pulses

-Dyspnea

Decreased

cardiac

output r/t

increased

vascular

resistance

CAD causes

narrowing of

blood vessels.

This condition

leads to intense

pressure exerted

on the walls of the

blood vessels.

The bodys

compensatory

mechanism is to

increase theworkload of the

heart and thus the

patient has

decreased

cardiac output

Short term:

After 2-3 hoursof nursing

interventions,

the patient will

verbalize

understanding

of disease

process.

Long term:

After two days

of nursing

interventions

the patient will

participate in

activities to

decrease in the

1. Assess patients

condition

2. Monitor and

record vital

signs

3. Encourage

patient toverbalize

concerns

4. Encourage

patient to

change position

1. To

determine

possible

problems

2. To obtain

baseline

data

3. To make

client

express his

feelings

4. To improve

venous

return

Short term:

The patientshall have

verbalized

understanding

of disease

process.

Long term:

The patient

shall have

participated in

activities to

decrease in

the hearts

workload


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Problem#3: Ineffective Tissue Perfusion related to decreased cardiac output

ASSESSMENT NURSING

DIAGNOSIS

SCIENTIFIC

EXPLANATION

PLANNING INTERVENTIONS EXPECTED

OUTCOME

S-

O- The patient

manifested the

following:

-Shortness of

breath

-Fatigue

- The patient

may manifest:

-Pallor

Ineffective tissue

perfusion related to

decreased cardiac

output secondary

to Coronary Artery

Disease

During a chest

pain, vessels of

the heart, such as

the coronary

arteries, can

become occluded

with intravascular

plaques. The

heart does not

absorb blood

through the

myocardial wall.Instead, blood is

pumped through

the heart's own

vasculature

during the

relaxation

Short term:

After 3 hours of

nursing

interventions, the

patient will be

able to

demonstrate

behaviors on

how to have

effective airways.

Long term:

After 1- 2 days of

nursing

interventions, the

1. Established

therapeutic

relationship.

2. Assessed pt.s

condition.

3. Monitored and

recorded vital

signs.

4. Performed

morning care

5. Noted color

andtemperature of

the skin.

6. Monitored

peripheral

pulse.

7. Provided a

Short term:

The pt. shall have

demonstrated

behaviors on how

to have effective

airways.

Long term:

The patient shall

be free from

shortness of

breath.


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-Cool

temperature

-Decrease

pulse

-Decrease

urine output

(diastole) period

between heart

beats. An

occlusion of a

blood vessel is

known by the

clinical

designation

"thrombus." If a

cardiac plaque

breaks off from

one vessel and

becomes lodged

in another vessel,

the tissue-fed

oxygen-rich bloodis inadequately

perfused.

patient will be

able to

demonstrate

adequate tissue

perfusion as

evidenced by

palpable

peripheral

pulses, warm

and dry skin,

adequate urinary

output, and the

absence of

respiratory

distress.

warmth

environment.

8. Encouraged

active rom.

9. Monitored

urine output.


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Problem#4: Acute Pain

ASSESSMENT NURSING

DIAGNOSIS

SCIENTIFIC

EXPLANATION

PLANNING INTERVENTIONS EXPECTED

OUTCOME

S-

O- The patientmanifested:

-Pain scale of 8/10

-Increase

respiratory rate

-Chest pain

-The patient may

manifest:

Acute Pain Coronary artery

disease (CAD) is

caused by a

narrowing of the

arteries that

supply the heart

muscle with

blood. When the

arteries narrow,

blood flow is

reduced. The

reduced bloodflow causes the

heart muscle to

receive less

oxygen than it

needs to function

properly. When

Short Term:

After 3 hours of

Nursing

Interventions,

the patient,

pain scale will

decrease from

8 to 6.

Long term:

After 2 days of

Nursing

Interventions,

the patient will

demonstrate

behavior of

1. Established

therapeutic

relationship

2. Assessed

pt.s

condition.

3. Monitored

and recorded

vital signs

4. Assessed

pains location

andintensity/seve

rity arising

with.

5. Provided

diversional

activities like

Short term:

The patient shallhave identified

and used

techniques to

enhance activity

intolerance.

Long term:

The patient shall

have participated

willingly in

necessary

activities.


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-Restlessness

-Irritability

- (+) guarded

behavior

-(+) facial grimaces

-Crying

-v/s change

-Diaphoresis

-Sleep disturbance

ischemia occurs

patients typically

develop angina or

chest pain

originating from

the heart. It has

been described as

chest pain or

discomfort that

has a squeezing

or pressure-like

quality, usually felt

behind the

breastbone

(sternum), but

sometimes felt inthe shoulders,

arms, neck, jaws,

or back.

being relieved

from pain and

will be free

from the

complications

of the

condition.

having

conversation

w/ the

patient.

6. Stressed to

patient the

importance of

providing

adequate rest

period to the

patient.

7. Administered

meds as

ordered.


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Problem#5: Fatigue related to Poor Physical Condition

ASSESSMENT DIAGNOSIS SCIENTIFIC

EXPLANATION

OBJECTIVE NURSING

INTERVENTIONS

RATIONALE EXPECTED

OUTCOME

S-The patient

may verbalize

overwhelming

lack of energy

O-The patient

may manifest:

-Lethargy or

drowsiness

-Disinterest in

surroundings

-Decreased

performance

Fatigue

related to poor

physical

condition

Fatigue is an

overwhelming

sense of

exhaustion

resulting to

decreased

capacity to

perform activities

at the usual level.

This is due to the

patients poor

physical conditionbrought about by

the disease

condition.

Short term:

After 2 hoursof nursing

interventions

, the patient

will be able

to verbalize

understandin

g of

condition

and

causative

factors.

Long term:

After 3 days

of nursing

interventions

, the patient

1. Monitor and

record vital

signs

2. Determine

ability to

participate in

activities

3. Establish

realistic activity

goals with client

1. To obtain

baseline

data

2. To

enhance

commitme

nt to

promoting

optimal

outcomes

3. To

maximize

participatio

n

Short term:

The patientshall have

verbalized

understanding

of condition

and causative

factors.

Long term:

The patient

shall have

performed

ADLs and

participate in

desired

activities/level

of activity.


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-Listlessness

-Compromised

concentration

-Introspection

will be able

to perform

ADLs and

participate in

desired

activities/lev

el of activity.

4. Plan care to

allow

individually

adequate rest

periods,

schedule

activities for

periods when

client has the

most energy

5. Provide

environment

conducive to

health

4. To

encourage

patients

cooperatio

n

5. To

maintain/in

crease

strengthand

muscle

tone and to

enhance

sense of

well-being.


60/109

6. Give medication

as ordered

6. To lessen

fatigue

Problem#6: Activity intolerance related to imbalance oxygen supply and demand

Assessment Diagnosis Scientific

Explanation

Objective Nursing

Intervention

Rationale Expected

Outcome

S=

O=The patient

may manifest:

-restlessness

-Increased RR

-cold clammy

skin

-decreased

peripheral

Activity

intolerance

related to

imbalance

oxygen

supply and

demand

Coronary artery

disease results

from the

interruption of

blood supply to

a part of the

heart, causing

heart cells to

die. Typical

symptoms

Short term:

After 2-3

hours of

nursing

interventions,

the patient will

verbalize

understanding

of disease

1. assess

patients

condition

2. monitor and

record vital

signs

3. encourage

patient to

verbalize

1. to determine

possible

problems

2. for baseline

data

3. to make client

express his

feelings

4. to improve

Short term:

The patient shall

have verbalized

understanding of

disease process.


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pulses

-pallor

-cyanosis

-fatigue

include sudden

chest pain

(typically

radiating to the

left arm or left

side of the

neck),

shortness of

breath, nausea,

vomiting,

palpitations,

sweating, and

anxiety.

Women may

experience

fewer typicalsymptoms than

men, most

commonly

shortness of

breath,

weakness, a

process.

Long term:

After two days

of nursing

interventions

the patient will

be able to

maintain her

breathing

pattern as

evidenced by:

vital signs

within the

normal range

concerns

4. encourage

patient to

change

position

every two

hours

5. encourage

patient to do

relaxation

techniques

6. Encourage

patient to

engage in

diversional

activities

such as

chatting with

family and

friends.

7. reinforced

venous return

5. to reduce

stress

6. to divert

attention and

help patient

lessen

experienced

pain and

anxiety

7. to prevent

further

complications

of the disease

8. to prevent

overexertion

9. to reduce

fatigue

10. to conserve

energy

Long term:

The patient shall

have maintained

her breathing

pattern as

evidenced by: vital

signs within the

normal range


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feeling of

indigestion, and

fatigue resulting

in

musculoskeletal

impairment

and/or pain,

cognitive

impairment and

anxiety,

metabolic

abnormalities.

low salt and

low fat diet

8. adjust

activities

9. balance rest

periods with

activities

10. increase

activity levels

gradually


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C. IMPLEMENTATION

1. MEDICAL MANAGEMENT

a. IVFs, NGT feeding, Nebulization, TPN, Oxygen therapy, etc

Medical

Management/Treatment

Date Ordered

Date PerformedDate Changed

General Description Indication

OrPurposes

Clients Response to

Treatment

D5W 500ccx KVO Date ordered:

09/17/2013

Date performed:

09/17/2013

D5W is initially infused,

it is an isotonic

solution, but when the

dextrose is

metabolized, the

solution actually

becomes hypotonic,a

solution where

osmotic pressure

causes fluid to shift

into cells.

Lactated Ringers and

5% Dextrose, is

indicated to Mr.

Corona D. Sease as

a source of water and

calories or as an

alkalinizing agent.

Mr. Corona D. Sease

was able to maintain

good hydration status

as evidenced by good

skin turgor and moist

oral mucous

membrane.


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Nursing Responsibilities

Prior

Verify the Doctors order

Prepare all the equipment needed

Do not administer unless solution is clear and container is undamaged.

Properly label the IV fluid.

Explain the purpose of the procedure and what to expect

During

Provide patient's safety

Locate for a good vein

Apply antiseptic to the puncture site

Check if it is the correct type of IV fluid

After

Secure the IV tubing

Discard unused portion

Regulate the IV fluid as prescribed

Document the procedure


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Medical

Management/

Treatment

Date Ordered

Date Performed

Date Changed

General Description Indication

Or

Purposes

Clients Response to

Treatment

O2 Inhalationregulated at 2-3 LPM

Date ordered:09/17/2013

Date performed:

09/17/2013

Inhalation of oxygenaimed at restoring

toward normal any

physiologic alterations

of gas exchange in the

cardiopulmonary

system, as by the use

of a respirator, nasal

catheter, tent,

chamber, or mask.

O2 Inhalation, isindicated to Mr.

Corona D. Sease as

a source of

supplementary

oxygen.

Mr. Corona D. Seasewas able to maintain

normal respiratory

breathing pattern.


Prior

Verify the Doctors order

Prepare all the equipment needed


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During

Provide patient's safety

Place properly on patients nose

Regulate at 2-3LPM as ordered

After

Document and record


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b. Drugs

1. Aspirin

Name of

Drug; Genericname; Brand

name

Date

Ordered/Date Taken

Date

Changed

Route, Dosageand Frequency

General Action,

Mechanism ofAction

Indication or

Purposes

Clients

Response tothe Medication

with Actual

Side Effect

Generic name:

Aspirin

(acetylsalicylic

acid)

Brand Name:

Asaphent

Date ordered:

08/17/2013

Date taken:

08/17/2013

PO, 80 mg 1 tab , OD General action:

NSAID;

Anti-platelet

aggregation

Mechanism of

action:

Inhibits

prostaglandin

synthesis,

resulting in anti-

inflammatory

Indicated for

Mr. Corona

D. Sease for

treatment of

mild to

moderate

pain;

reduction of

risk of death

or unstable

angina

pectoris, or

Mr. Corona D.

Sease

responded well

in the drug as

evidenced by

normal platelet

count.


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Nursing responsibilities

Prior

Verify the doctor's order

Give necessary information to the patient

Obtain a history of previous use and reactions to medication.

During

Administer medication as ordered

Verify/check the medication again

activity, and

platelet

aggregation

inhibition;

reduces fever by

acting on the

brain's heat-

regulating center

to promote

vasodilation and

sweating.

recurrent

transient

ischemia

attacks

(TIAs).


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After

Monitor fungal/bacterial super infection

Monitor sodium level


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2. Clopidogrel

Name of drug;

Generic Name;

Brand Name

Date ordered/

Date Taken/

Date Changed

Route, Dosage

and Frequency

General Action,

Mechanism of

Action

Indication or

Purposes

Clients

Response to

the medication

with Actual

Side Effect

Generic name:

Clopidogrel

Brand name:

Plavix

Date ordered:

09/17/2013

Date taken:

09/17/2013

PO, 75mg/tab, 1 tab

OD

General action:

Inhibits platelet

aggregation by

blocking AD

Preceptors on

platelets ,preventing

clumping of platelets

Mechanism of

action:

It was found to inhibit

prostaglandin

synthesis and to

complete for binding

It was indicated

for Mr. Corona D.

Sease for

prevention of

thrombosis along

with Aspirin and

to prevent

vascular

ischemic events.

Mr. Corona D

Sease

responded we

in the drug a

evidenced b

normal platele

count.


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Prior

Check the doctors order three times and verify the patient

Check the label of the drug, its name and its expiration date.

Explain the importance of compliance in medication regimen

Final Case Study - CAD

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