Introduction

A heart beat signifies life, from the day it starts to beat in the womb, till it stops, and where death conquers
us. The heart beats not only to one tune but it also responds to the tune of emotions and physical stress. As some of
us may have also experience moments of joy or sorrow and the heart may feel pain or pleasure.

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

Coronary arteries are blood vessels on the heart. They are smooth and elastic, allowing blood to flow freely.
Before your teen years, fat can start to deposit in the blood vessel walls. As you get older, the fat builds up. This
causes injury to your blood vessel walls. In an attempt to heal itself, the fatty tissues release chemicals that promote
the process of healing but make the inner walls of the blood vessel sticky. Then, other substances, such as
inflammatory cells, proteins, and calcium that travel in your bloodstream start sticking to the inside of the vessel
walls. The fat and other substances combine to form a material called plaque, which can narrow the flow of blood in
the artery (atherosclerosis). Over time, the inside of the arteries develop plaques of different sizes.

Eventually, a narrowed coronary artery may develop new blood vessels that go around the blockage to get
blood to the heart. However, during times of increased exertion or stress, the new arteries may not be able to supply
enough oxygen-rich blood to the heart muscle.

In other cases, the blood clot may totally block the blood supply to the heart muscle, causing what is called
an acute coronary syndrome. This is actually a name given to three serious conditions: Unstable angina, Non-ST
segment elevation myocardial infarction (NSTEMI) or non-Q-wave MI, ST segment elevation myocardial infarction
(STEMI) or Q-wave MI.

The most common symptom is of coronary artery disease is angina or simply chest pain. Angina can be
described as a discomfort, heaviness, pressure, aching, burning, numbness, fullness, squeezing or painful feeling.
Other symptoms that can occur with coronary artery disease include shortness of breath, palpitations, tachycardia,
weakness or dizziness, nausea, sweating.
DEMOGRAPIC DATA:

Name: Bartolata, Bobby A.

Age: 53 years old

Civil Status:Married

Race/Nationality: Filipino

Religion:Catholic

Educational Background: College Graduate

Address: Taguig City

Admission Diagnosis: Acute Coronary Syndrome- Non ST Elevated Myocardial Infarction

Date Admitted: October 14, 2019

Time Admitted:

Discharge Date: not yet discharged

Height:

Weight:

BMI:
Information Source and Source of Information:

The information presented in this study is gathered through the Nurse-Patient

interaction, some data came from the NOD and the chart of the patient.

Chief Complaint:

Prior to admission, the client complained of chest pain not relieved by resting or after
taking HPN medications.

History of Present Illness

 Chest pain
 Difficulty of breathing
 Shortness of breath
 (+) HPN

Past Medical History:

 Physical Assessment

General Survey

General Appearance: The client was received on bed, awake, cooperative and coherent on
moderate high back rest, hooked with good patency of IVF PNSS 500cc/hr KVO at left hand
with side drip of Isoket drip 10cc/hr and ongoing oxygen thru nasal cannula at 2 lpm. Has a
Glasgow Coma Scale of 15.

The patient has a mesomorph body type which is muscular and he has broad bone
structures rather than thin or curvy.

Vital Signs (taken October 16, 2018 -7am)

Vital Signs Results

Blood Pressure 120/80 mmHg

Temperature 36 °C

Pulse Rate 96 beats/min

Respirations 21 breaths/min

SpO2 99%

Physical Examination

Type of
Area of Assessment Results
Assessment Used

Head Inspection The client’s head was proportionate to the body size. There
were no tenderness and wounds in the scalp. The client’s
hair was evenly distributed.

Eyes Inspection & The client has a blurring vision. No edema or lesions on
palpation eyelids were apparent. Eyelids color was the same as
surrounding skin color. Eyelashes were present. Anicteric
sclerae, has a palpebral conjunction. Pupils were round
and equal sized, Eyes were properly aligned. The patient
also wears eyeglasses.
Ears Inspection The ears of the client and facial skin were the same color.
No inflammation, lesions, or nodules were apparent.
There’s no visible discharge from the auditory canal though
cerumen noted. External meatus was apparent. No redness
or swelling was noted. The alignments of the pinnas were
symmetrical and they were elastic and recoil when folded.

Palpation No masses or tenderness on the auricle was detectable

during manipulation. Mastoid process seen no sign of
tenderness.

Nose Inspection The client had a nasal cannula on his nose. His nose was
symmetrical and lesion free, with no deviation of the
septum or discharge. No nasal flaring was apparent. Nasal
mucosa was pinkish red, with no visible lesions and no
purulent drainage

Palpation Sinuses were seen no sign of tenderness

Mouth Inspection The client had moist oral mucosa with symmetric facial
structures.

Inspection Client’s skin was slightly dry and he has a brown

complexion. Nails are short and clean. The skin was slightly
Skin and Nails cold to touch.

Palpation The client’s capillary refill is within 3 secs. No edema and

swelling noted.

Neck Inspection There was no presence of vein distention. Skin was intact
and symmetrical.

Palpation There was no swelling in the lymph nodes.

Inspection There was shallow chest expansion. His chests were

symmetric and aligned.

Percussion Dullness was heard upon percussion.

Thorax & Heart
Palpation No tender spots and bulges in the chest were detectable.

Auscultations No crackles or wheezes noted on both sides of his lungs

upon assessment. His Cardiac rate was 96 beats/minute
with regular rhythm. There were no murmurs heard.

Inspection The client’s abdomen was symmetric and skin was same to
other body parts.
 Percussion Flatness was heard upon percussion

Abdomen Palpation The patient doesn’t have a board-like abdomen.

Auscultation Presence of borborygmy sound was noted.

Inspection No presence of edema was noted. There were no gross

deformities that were apparent. Body parts were
Extremities symmetrical and the client’s body was aligned. No
swellings were noted. The client was able to move his
body and had shown no muscle weakness.

Palpation The client had no edema or swelling noted

Genitalia Inspection The client was on diaper.

Neurologic Inspection & The patient is active, cooperative and coherent. Follows
status Palpation verbal commands and shows no sign of muscle weakness
or any confusion.

Glasgow Coma Scale:

Eye Response (4) spontaneous

Verbal Response (5) oriented

Motor Response (6) obeys command

Anatomy and Physiology

CARDIOVASCULAR SYSTEM

o The cardiovascular system can be thought of as the transport system of the body. This
system has three main components: the heart, the blood vessel and the blood itself.

o The heart is the system's pump and the blood vessels are like the delivery routes. Blood
can be thought of as a fluid which contains the oxygen and nutrients the body needs and
carries the wastes which need to be removed.

o The heart is the pump responsible for maintaining adequate circulation of oxygenated
blood around the vascular network of the body.

o It is a four-chamber pump, with the right side receiving deoxygenated blood from the
body at low pressure and pumping it to the lungs (the pulmonary circulation) and the left
 side receiving oxygenated blood from the lungs and pumping it at high pressure around
the body (the systemic circulation).

Function and Location of the Heart

o The heart's job is to pump blood around the body. The heart is located in between the
two lungs. It lies left of the middle of the chest.

Structure of the Heart

o The heart is a muscle about the size of a fist, and is roughly cone-shaped. It is about
12cm long, 9cm across the broadest point and about 6cm thick. The pericardium is a
fibrous covering which wraps around the whole heart. It holds the heart in place but
allows it to move as it beats. The wall of the heart itself is made up of a special type of
muscle called cardiac muscle.

Chambers of the Heart

 The heart has two sides, the right side and the left side. The heart has four chambers.
The left and right side each have two chambers, a top chamber and a bottom chamber.
The two top chambers are known as the left and right atria(singular: atrium). The atria
receive blood from different sources. The left atrium receives blood from the lungs and
the right atrium receives blood from the rest of the body. The bottom two chambers are
known as the left and right ventricles. The ventricles pump blood out to different parts of
 the body. The right ventricle pumps blood to the lungs while the left ventricle pumps out
blood to the rest of the body. The ventricles have much thicker walls than the atria which
allow them to perform more work by pumping out blood to the whole body.

Blood Vessels

 Blood Vessels are tubes which carry blood. Veins are blood vessels which carry blood
from the body back to the heart. Arteries are blood vessels which carry blood from the
heart to the body. There are also microscopic blood vessels which connect arteries and
veins together called capillaries. There are a few main blood vessels which connect to
different chambers of the heart. The aorta is the largest artery in our body. The left
ventricle pumps blood into the aorta which then carries it to the rest of the body through
smaller arteries. The pulmonary trunk is the large artery which the right ventricle pumps
into. It splits into pulmonary arteries which take the blood to the lungs. The pulmonary
veins take blood from the lungs to the left atrium. All the other veins in our body drain
into the inferior vena cava (IVC) or the superior. These two large veins then take the
blood from the rest of the body into the right atrium.

Valves

 Valves are fibrous flaps of tissue found between the heart chambers and in the blood
vessels. They are rather like gates which prevent blood from flowing in the wrong
direction. They are found in a number of places. Valves between the atria and ventricles
are known as the right and left atrioventricular valves, otherwise known as the tricuspid
and mitral valves respectively. Valves between the ventricles and the great arteries are
known as the semilunar valves. The aortic valve is found at the base of the aorta, while
the pulmonary valve is found the base of the pulmonary trunk. There are also many
valves found in veins throughout the body. However, there are no valves found in any of
the other arteries besides the aorta and pulmonary trunk.

Cardiovascular System

 The cardiovascular system refers to the heart, blood vessels and the blood. Blood
contains oxygen and other nutrients which your body needs to survive. The body takes
these essential nutrients from the blood. At the same time, the body dumps waste
products like carbon dioxide, back into the blood, so they can be removed.

 The main function of the cardiovascular system is therefore to maintain blood flow to all
parts of the body, to allow it to survive. Veins deliver used blood from the body back to
the heart. Blood in the veins is low in oxygen (as it has been taken out by the body) and
high in carbon dioxide (as the body has unloaded it back into the blood). All the veins
drain into the superior and inferior vena cava which then drains into the right atrium.

 The right atrium pumps blood into the right ventricle. Then the right ventricle pumps
blood to the pulmonary trunk, through the pulmonary arteries and into the lungs. In the
lungs the blood picks up oxygen that we breathe in and gets rid of carbon dioxide, which
we breathe out. The blood is becomes rich in oxygen which the body can use.
  From the lungs, blood drains into the left atrium and is then pumped into the left
ventricle. The left ventricle then pumps this oxygen-rich blood out into the aorta which
then distributes it to the rest of the body through other arteries. The main arteries which
branch off the aorta and take blood to specific parts of the body are:

 Carotid arteries, which take blood to the neck and head

 Coronary arteries, which provide blood supply to the heart itself

 Hepatic artery, which takes blood to the liver with branches going to the stomach

 Mesenteric artery, which takes blood to the intestines

 Renal arteries, which takes blood to the kidneys

 Femoral arteries, which take blood to the legs

 The body is then able to use the oxygen in the blood to carry out its normal functions.
This blood will again return back to the heart through the veins and the cycle continues.

Cardiac Cycle

 The cardiac cycle is the sequence of events that occurs in one complete beat of
the heart. The pumping phase of the cycle, also known as systole, occurs when heart
muscle contracts.

 The filling phase, which is known as diastole, occurs when heart muscle relaxes. At the
beginning of the cardiac cycle, both atria and ventricles are in diastole. During this time,
all the chambers of the heart are relaxed and receive blood. The atrioventricular valves
are open.
  Atrial systole follows this phase. During atrial systole, the left and right atria contract at
the same time and push blood into the left and right ventricles, respectively. The next
phase is ventricular systole. During ventricular systole, the left and right ventricles
contract at the same time and pump blood into the aorta and pulmonary trunk,
respectively. In ventricular systole, the atria are relaxed and receive blood.

 The atrioventricular valves close immediately after ventricular systole begins to stop
blood going back into the atria. However, the semilunar valves are open during this
phase to allow the blood to flow into the aorta and pulmonary trunk. Following this
phase, the ventricles relax that is ventricular diastole occurs. The semilunar valves close
to stop the blood from flowing back into the ventricles from the aorta and pulmonary
trunk. The atria and ventricles once again are in diastole together and the cycle begins
again.

Components of the Heartbeat

 The adult heart beats around 70 to 80 times a minute at rest. When you listen to your
heart with a stethoscope you can hear your heart beat.

 The sound is usually described as "lubb-dupp". The "lubb" also known as the first heart
sound, is caused by the closure of the atrioventricular valves. The "dupp" sound is due
to the closure of the semilunar valves when the ventricles relax (at the beginning of
ventricular diastole).

 Abnormal heart sounds are known as murmurs. Murmurs may indicate a problem with
the heart valves, but many types of murmur are no cause for concern.
Laboratory and Diagnostic Examination

1. Complete Blood Count Date of Results: October 14, 2018

Blood Hematology Normal Values

Components Results

hemoglobin 140 135-180 g/l

Hematocrit 0.43 0.40-0.54

Red blood cell 4.19 4.50-6.00X10^12/L

Platelet 172 150.00-400.00 X10^9/L

White blood cell 9.8 4.5-11.0

MCV 102 80-100fl

MCH 33.3 27-33 pg

MCHC 32.7 31-36 g/dL

RDW-CV 10.1 11-16%

RDW-SP 37 37-54 fl

Interpretation:

Based on the obtained values of the laboratory results, the red blood cell is lower than the
normal range this may indicate that there is not enough blood circulating in the blood and the
increase in MCV and MCH means that there is an increase in the hemoglobin per RBC due to
compensation effect of the body for the decrease in rbc and RDW-CV represents the variation
of rbc in volume distribution or size.

2. Blood Chemistry

Date of Results: October 14, 2018

Test Results Normal Values

BUN 4.74 2.50-7.14
Creatinine 110 46-110
Sodium 135mmol/L 137-145 mmol/L
Potassium 3.8mmol/L 3.6-5.1 mmol/L
Interpretation:

The result of the sodium test is lower than normal values. Decrease in sodium level was
due to hypoxia and ischemia, which increase the permeability of sarcolemma to sodium

3. Troponin Result

Test Result Normal Value

Troponin I 0.35 ug/l (+) < 0.1 ug/l

Interpretation:

The troponin result obtained shows a higher than its normal value, which indicates that the client
has a damage or injury to the heart muscle, thus, specifically proved that he was suffering from
a myocardial infarction.

4. CPK-MB Result

Test Result Normal Value

CPK-MB 302.8 u/l 0-24 u/l

Interpretation:

Indication of myocardial injury and a useful diagnosis for NSTEMI.

Treatment and Management

Patient was admitted to ICU

Was hooked to oxygen, pulse oximeter and cardiac monitor
Oxygen via nasal cannula 2 lpm
The ordered diet is low salt low fat with SAP
Ordered to have IVF of D5W 500 cc to run for 10cc/hr
Diagnostic tests done: ecg, NA, K, BUN, Crea, CXR PA view, Trop I,
urinalysis, PT PTT and 2D echo with Doppler utz
Medications ordered and given:
Aspirin 80 mg tab PO OD
Clopidogrel 75 mg 1 tab PO OD
Atorvastatin 40 mg 1 tab PO OD
Lactulose 30 cc PO ODHS
Omeprazole 40 mg TIV OD
Froxaparin 0.4 cc SC BID
Captoril 25 mg ¼ tab PO BID
ISMN 60 g ½ PO BID
ISDN 5.0 mg 1 tab PO PRN for chest pain
Morphine 3 mg TIV for chest pain

Isoket drip + PNSS 90cc to run for 10cc

Maintain patient in moderate high back rest