Acute coronary syndrome (ACS) refers to the spectrum of clinical presentations ranging from ST-segment elevation

myocardial infarction (STEMI) to non–ST-segment elevation myocardial infarction (NSTEMI) to unstable angina. These types
are named according to the appearance of the electrocardiogram (ECG/EKG). There can be some variation as to which forms of
MI are classified under acute coronary syndrome. ACS should be distinguished from stable angina, which develops during
exertion and resolves at rest. In contrast with stable angina, unstable angina occurs suddenly, often at rest or with minimal
exertion, or at lesser degrees of exertion than the individual's previous angina. Killip classification is a system used in individuals
with an acute myocardial infarction (heart attack), in order to risk stratify them. Individuals with a low Killip class are less likely
to die within the first 30 days after their myocardial infarction than individuals with a high Killip class. Though ACS is usually
associated with coronary thrombosis, it can also be associated with cocaine use. Cardiac chest pain can also be precipitated
by anemia, bradycardia, or tachycardia. In terms of pathology, acute coronary syndrome is almost always associated with rupture
of an atherosclerotic plaque and partial or complete thrombosis of the infarct-related artery.

If the ECG does not show typical changes, the term "non-ST segment elevation ACS" is applied. The patient may still

have suffered a "non-ST elevation MI" (NSTEMI). The accepted management of unstable angina and acute coronary syndrome is

therefore empirical treatment with aspirin, heparin (usually a low-molecular weight heparin such as enoxaparin) andclopidogrel,

with intravenous glyceryl trinitrate and opioids if the pain persists.

A blood test is generally performed for cardiac troponins twelve hours after onset of the pain. If this is

positive, coronary angiography is typically performed on an urgent basis, as this is highly predictive of a heart attack in the near-

future. If the troponin is negative, a treadmill exercise test or a thallium scintigram may be requested.

Cocaine associated ACS should be managed in a manner similar to other patients with acute coronary syndrome

except beta blockers should not be used and benzodiazepines should be administered early.[16]

a. CURRENT TRENDS
b. REASON FOR CHOOSING SUCH CASE
One of the difficult parts in doing a case study is choosing what case is to present. We had agreed that we will choose
patient with ACS. Though we were not able to handle the patient personally during our duty we had the chance to
established rapport with the patient and his relatives by joining our classmate in doing his NPI, in that way we had
established the “trust” we need from them which makes easy for us to relate with them suitably and ask certain questions
that we need in order to conduct and study this case. Another thing is we find the patient and his relatives very kind with
our previous visit which make our interaction smooth. Most importantly, the term Acute Coronary Syndrome (ACS) is not
accustomed to us that much. With that thought alone, we want to further enhance our knowledge about the disease such as to
ensure appropriate evaluation of the etiology, reassess and address the course the illness takes in its progression. Also, to
have an experience in handling and providing humanitarian health services to a patient who has it and provide any
intervention or treatment indicated based on the specific etiology and the course it follows in that specific patient. With that
scenario, it is not only the knowledge that was enhanced but also our skills as a future registered health care practitioners.

c. STATISTIC OF DISEASE
 A conservative estimate for the number of discharges with ACS from hospitals in 2006 is 733,000. Of these, an
estimated 401,000 are male and 332,000 are female. This estimate is derived by adding the first-listed inpatient hospital
discharges for MI (647,000) to those for Unstable Angina (86,000).

http://www.americanheart.org/downloadable/heart/1265665152970DS-
3241%20HeartStrokeUpdate_2010.pdf
a. OBJECTIVES
1. After the completion of the case study, the nurse-researcher shall have:
General Objective:
Acquired deeper knowledge and understanding of the development of
acute coronary syndrome in relation to the risk factors presented by the
patient, discuss management and treatment and provide better nursing care
and preventive measures through the utilization of the nursing process.

Specific objectives:
1. Determined the non-modifiable and modifiable risk factors presented by
the patient that have contributed to the development of acute coronary
syndrome.
2. Identified clinical manifestations presented by the patient, which resulted
from the disease process of Acute coronary disease, related diagnostic
findings on the development of Acute coronary disease. Discussed the
disease process, treatment and management of the disease;
3. Identified nursing problems and formulate a comprehensive plan of care
for the patient with Acute coronary disease utilizing the nursing process;
4. Educated the significant others of the patient on the prevention of
complications and fostered optimal level of functioning physically,
physiologically and psychologically; and
5. Given recommendations to all in general and to the health care providers
on proper education and health teachings on the prevention of Acute
coronary disease and its complications.
6.
2. During the course of the study, the patient and the significant others shall
have:
General objectives:
 Acquired knowledge on the risk factors that have contributed to the
development of Acute coronary disease and gained positive understanding
and compliance on the treatment, management and care rendered by the
health care team.

Specific objectives:
1. Built a trusting relationship with the nurse researcher as well as with the
other health care providers;
2. Gained knowledge on the disease condition, its risk factors and possible
complications;
3. Received best possible care, having a feeling of security, comfort, and
good prognosis of the disease condition;
4. Demonstrated compliance on treatment and management; and
5. Demonstrated independence on self-care and home management upon
discharge and during follow-up home visits.

NURSING ASSESSMENT
a. PERSONAL DATA
Demographic data
Mr. Killips, a Filipin0, is now 73 years of age and was born on the 26 th
day of December 1936. Mr. Killips is the youngest child of the three siblings
of Mommy A and Daddy B. Together with his family; they presently reside in
2076 Texas st. Villasol Angeles City. They are all affiliated in the Roman
Catholic Church. He works as a farmer in Mindoro from the year 1952 until
1960. at the same year he went to tarlac and worked as a driver until 1965.
From1965-1996 he worked as a maintenance doing plumbing, mail man and
electrician in Maharaja Hotel located in Friendship, and went to Cuba for 3
years working as maintenance in a company. He was admitted in Angeles
University Foundation Medical Center last 2008 because of chest pain. He
was admitted for reasons of: Chest pain and DOB.

Socio-economic and Cultural factor

He is currently living with his wife and his son. They earn at least
10,000 a month because they have 5 rooms which are being rented. He is
 also receiving a pension of P3,500.00 pesos per month, and remittance from
his children that range from P2,000-P3,000.00 in addition to the cost of their
daily living. They are all Filipino citizen and Roman Catholic.
In times of illness, he consults to the herbolarios before going to the
hospital. They also practice taking OTC medicines like paracetamols to
relieve pain and fever.

Environmental factors
Mr. Killips home is made of concrete. They are being supplied by
electricity and water by their district suppliers. Their house has a gate which
serves as their protection against harm. Their garbage is disposed in a sack
and usually collected by the garbage collectors.
b. PERTINENT FAMILY HISTORY
(SEE THE DIAGRAM)
c. HISTORY OF PAST ILLNESS

d. HISTORY OF PRESENT ILLNESS

During his years working in Cuba as one of the
Maintenance personnel of a company, we was hospitalized in Miami
Hospital due to chest pain, he was then given a drug indicated for
his hypertension. A year after his come back in our country he was
again hospitalized in Angeles University Foundation Medical Center
because we experienced chest pain, dizziness and headache, drug
given to him was anti hypertensive. In year 2008, he was again
hospitalized in AUFMC because of chest pain, dizziness and nape
pain. In the year 2009 he was confined in Amando P. Garcia Hospital
because of dysuria. Presently the patient was admitted in Angeles
University Foundation Medical Center because of DOB and chest
pain.

e. PHYSICAL EXAMINATION
A. December 9, 2010
1. Vital Signs
T= 37.1° C
PR= 86 bpm
RR= 21 cpm
BP= 150/90 mmHg
2. Head
> With normal cephalic configuration
> No tenderness, swelling and lesion noted
> No edema present
3. Hair and Scalp
> Hair grayish in color
> With no presence of dandruffs
> Thin stranded hair
4. Skin
> Good skin turgor
> Dry skin????????????????????????????????????????????????????????
> No presence of edema
> Normal skin color
> No scars noted
> With bruise noted on right hand??????????????????????????????????
5. Eyes
 > Eyebrows and eye lashes are evenly distributed
> Eyelashes are long and curved outward
> No presence of edema over lacrimal gland
> Pink conjunctiva

6. Ears and hearing

> Symmetrical in size and shape
> Not tender, pinna coils after it is folded
> With good hearing condition
7. Nose
> Symmetric, no lesions, uniform in color, not tender
> Air moves freely through the nares
> Nasal septum intact
> No nasal discharges
8. Lips
a. Outer Lips
> No presence of sores
> Pink colored lips
> Symmetrical contour

b. Inner Lip
> Absence of lesions

9. Mouth
a. Teeth and Gums
> Normal buccal mucosa
> teeth?????????????????????????????????????????????????
> (+) gag reflex

b. Tongue
> No lesions, moves freely

10. Neck and neck muscles

> Trachea is midline position
> No usual mass upon palpation
> Muscles are equal in size and head centered
> No lesions noted

11. Chest and lungs

> Unequal size of chest
> (-) rales on both lung fields
> No tenderness, pain or unusual mass upon palpation

12. Abdomen
> soft, flabby and non tender abdomen
> No pain when pressure is given

13. Extremities
a. upper extremities
> wrinkled skin
 > uniform in color
> Equal in size
> no lesions noted
> with bruise on right hand
b. lower extremities
> wrinkled skin
.>uniform in color
> with enlarged knee on both side
> no lesion noted

14. Nail
> Pinkish nail beds
> With good capillary refill test

15. Urogenital
> with FC attached??????????????????????????????????????????

15. General Apperance:

Patient feels weak and restless.?????????????????????????????????????????

Neurological Assessment

Cranial Nerve Normal Findings Actual Findings

1. Olfactory Client must be able to Client was able to identify
Type: Sensory identify the scent of the scent of alcohol when
Fxn: Sense of smell alcohol when asked to ask to smell it.
smell it.
2. Optic Client must see the Client could able to see
Type: Sensory ballpen or penlight clearly the ball pen or penlight at
Fxn: Sense of vision and at a given distance. a given distance.
visual fields
3. Oculomotor Eyes must follow the The client’s eyes were
Type: Motor direction of the able to follow the
Fxn: Pupil constriction and movement of the movement of the penlight.
raising of eyelid penlight;
In lightly dimmed
environment, the pupils of
the eyes will dilate but
upon the introduction of
light, pupils will constrict.
4. Trochlear The eye must follow the The client was able to
Type: Motor movement of a ballpen in follow the ballpen with her
Fxn: Downward inward different directions with eyes without moving her
eye movement coordination. head.
5. Trigeminal The client elicited blinking The client elicited blinking
Type: Sensory and Motor reflex upon touching the reflex upon touching the
Fxn: Jaw movements, cornea with the use of cornea.
chewing and mastication cotton.
6. Abducens Client must be able to The client was able to
Type: Motor follow the index finger of follow the index finger of
Fxn: Lateral movements the examiner. the examiner
of the eyes
7. Facial Client must be able to The client was able to
Type: Motor and Sensory raise eyebrows, show raise eyebrows, show
Fxn: Movement of teeth and puff out cheeks. teeth and puffed out her
muscles of the face and cheeks.
sense of taste on the
anterior two-thirds of the
tongue
8. Acoustic Client must be able to The client was able to
(Vestibulocochlear) hear a snap of the finger. hear the snap of the
Type: Sensory finger.
Fxn: Sense of hearing
9. Glossopharyngeal Must be able to swallow The client was able to
Type: Motor and Sensory foods that were chewed. swallow foods that were
Fxn: Pharyngeal chewed.
movements and
swallowing
Sense of taste on the
posterior one-third of the
tongue
10. Vagus Must be able to speak The client was able to
Type: Motor clearly. speak clearly.
Fxn: Swallowing and
speaking
11. Accessory The client must able to The client was not able to
Type: Motor elevate her shoulders elevate her shoulders
Fxn: Movement of against resistance against resistance.
shoulder muscles
12. Hypoglossal The client must able to The client was able to
Type: Motor move her tongue side to move her tongue side to
Fxn: Movement of tongue side and protrude her side and protrude her
and strength of the tongue. tongue.
tongue

III. ANATOMY AND PHYSIOLOGY

Circulatory System

All animals must exchange materials with their environment, including nutrients
and wastes, O2, CO2, etc., thus need a system that will do this. The more complex the
organism, the more complex this system must be. Arthropods, like insects and spiders,
have an open circulatory system, in which the blood is pumped forward by the heart, but
then flows through the body cavity, directly bathing the internal organs. Vertebrates, like
humans, have a closed circulatory system in which the blood stays in the circulatory
system as it circulates, and chemicals are exchanged by diffusion. Our system is also
called our cardiovascular system, and is composed of our heart plus our arteries and
veins. In a person’s heart, the atria (plural of atrium) receive blood from the veins and
the ventricles send blood to the arteries. As the arteries become more finely divided,
they are called arterioles. The finest divisions of our vascular system are called
capillaries. As the vessels get larger again, the smallest are called venules which join
and enlarge to form veins. Note that the distinction between arteries and veins is by
direction of blood flow, not oxygen content. Veins carry blood toward the heart and
arteries carry it away from the heart. Because of this, not all arteries carry oxygenated
blood. The two major exceptions, in which arteries are carrying deoxygenated blood are
the pulmonary artery which carries deoxygenated blood from the heart to the lungs (to
pick up oxygen there) and the umbilical arteries which carry deoxygenated blood away
from the baby’s body to the placenta (to pick up oxygen there). We have double
circulation: we have a separate pulmonary circuit to the lungs and a systemic circuit to
the body.

This illustration is orientated as thought you were looking at this heart in another person
standing in front of you. The path of blood flow in a human, then, is as follows:

1. The superior (a) and inferior (b) vena cava are the main veins that receive blood
from the body. The superior vena cava drains the head and arms, and the inferior
vena cava drains the lower body.
2. The right atrium receives blood from the body via the vena cavae. The atria are
on the top in the heart.
3. The blood then passes through the right atrioventricular valve, which is forced
shut when the ventricles contract, preventing blood from reentering the atrium.
4. The blood goes into the right ventricle (note that it has a thinner wall; it only
pumps to lungs). The ventricles are on the bottom of the heart.
5. The right semilunar valve marks the beginning of the artery. Again, it is supposed
to close to prevent blood from flowing back into the ventricle.
6. The pulmonary artery or pulmonary trunk is the main artery taking deoxygenated
blood to the lungs.
7. Blood goes to the right and left lungs, where capillaries are in close contact with
the thin-walled alveoli so the blood can release CO2 and pick up O2.
8. From the lungs, the pulmonary vein carries oxygenated blood back into the heart.
 9. The left atrium receives oxygenated blood from the lungs.
10. The blood passes through the left atrioventricular valve.
11. The blood enters the left ventricle. Note the thickened wall; the left ventricle must
pump blood throughout the whole body.
12. The blood passes through the left semilunar valve at the beginning of the aorta.
13. The aorta is the main artery to the body. One of the first arteries to branch off is
the coronary artery, which supplies blood to the heart muscle itself so it can
pump. The coronary artery goes around the heart like a crown. A blockage of the
coronary artery or one of its branches is very serious because this can cause
portions of the heart to die if they don’t get nutrients and oxygen. This is a
coronary heart attack. From the capillaries in the heart muscle, the blood flows
back through the coronary vein, which lies on top of the artery.
14. The aorta divides into arteries to distribute blood to the body.
15. Small arteries are called arterioles.
16. The smallest vessels are the capillaries.
17. These join again to form venules, the smallest of the veins.
18. These, in turn, join to form the larger veins, which carry the blood back to the
superior and inferior vena cava.

The atrioventricular and semilunar valves prevent backflow as the heart contracts.
Defects in any of these that allow some blood to leak backwards cause distinctive
sounds through a stethoscope, thus are called heart murmurs.

The sinoatrial node controls the heart beat. This natural pacemaker is located in the
upper wall of the right atrium, and is composed of muscle tissue that sends electrical
impulses to the rest of both atria to contract. The impulse then spreads to the ventricles,
causing them to contract. The heart cycle involves three phases:

1. The atria contract and force blood into the ventricles. If the atria don’t contract,
this is called atrial fibrillation and pooled blood in the atria can begin to clot.
When the atria start beating normally again, these clots may be sent throughout
the person’s system. If one of these clots lodges in an arteriole somewhere, it
could cause a stroke, heart attack, or similar problem. As blood is pushed into
the ventricles, when the A-V valves close, the ventricular walls vibrate a little
casuing the first sound of the heart beat, the “lubb” sound.
2. The ventricles contract and force blood into the arteries. This is called systole
and the systolic blood pressure (BP) is the higher of the two numbers, when the
heart is actively contracting and putting pressure on the blood. When the
semilunar valves snap shut, this causes the second sound of the heart beat, the
“dup.”
3. The heart relaxes and blood flows into the atria and ventricles. This is called
diastole. The diastolic BP is the lower of the two numbers, when the heart is
relaxed, and so, is a measure of how much pressure the arteries, themselves,
are putting on the blood. Clogged arteries are less elastic, so the blood is under
more pressure, thus more likely to cause the arteries to burst.

The rate of contraction is the heart rate. A baby’s heart starts beating when it is about
four weeks old (the mother’s period is two weeks late, and she’s just beginning to
suspect she might be pregnant). A newborn’s heart rate is around 135 to 140 beats per
minute (bpm). By age 15 to 30, the rate decreases to about 65-75 bpm, then speeds up
slightly as the person ages. The pulse is a wave of contraction of the artery walls (which
roughly corresponds to the heart rate) as blood is forced into the arteries. Pulse is
usually measured using the radial artery (the one along the radius). To find your pulse,
rest your right arm in the palm of your left hand. Curl the fingers of your left hand up
around the thumb side of your right wrist. Place several fingers of your left hand along
and just to the outside (thumb side) of the tendon that runs along your wrist. With gentle
pressure, you should be able to feel your pulse.

Blood pressure is maximum during

systole, when the heart is pushing, and
minimum during diastole, when the heart
is relaxed. In a living person, the blood
pressure doesn’t go to zero because the
thick, elastic artery walls exert pressure
on the blood. A sphygmomanometer is the
instrument used to determine BP. The
artery used to determine BP is the
brachial artery, which runs down the
upper arm, splitting into the radial and
ulnar arteries near the elbow. The cuff of
the sphygmomanometer is wrapped
around the arm just above the elbow and
pumped up to block off blood flow (the
pressure exerted by the cuff is higher than
the systolic pressure). The pressure in the
cuff is gradually decreased, and when it
equals the person’s systolic pressure, the
heart can force blood under the cuff, and
a sound is heard as the pulses of blood
surge under the cuff. As the pressure in the cuff is lowered, when it equals the diastolic
pressure, blood can flow freely, so the sound disappears (not enough pressure is
exerted by cuff to restrict blood flow). Thus, by listening for the first sound, and when the
sound becomes faint, while watching the pressure indicator on the
sphygomomanometer, it is possible to determine someone’s blood pressure. Typically,
when you go to the doctor’s office, one of the first things that is done to you is that
someone (a nurse?) takes your blood pressure. I have frequently had the experience
that when I ask what the results were, I initially get the answer “It’s OK.” Here’s a tip:
you, not they, are in charge of your health. The only way you can educate yourself to
how your body works is to keep re-asking the question until you get a real answer. You
need to know the actual numbers to be able to evaluate if things have changed or are
good or bad. Be persistent and eventually they’ll tell you what your BP is.
(clipart edited from Corel Presentations 8)

A neonate’s BP is around 80/45 mm Hg meaning that the systolic pressure is equivalent

to air pressure that will support a column of mercury 80 millimeters high in a barometer,
and the diastolic is equivalent to the air pressure that
will support a column of mercury 45 millimeters high.
For adults in their 20s, 120/80 mm Hg is considered
average for a male and 115/75 mm Hg for a female,
thus the accepted average is said to be 120/80 mm
Hg. With age, the arteries become less elastic (due in part to undesirable lipid deposits
in their walls), so the BP rises. Hypertension is when the BP is too high. There are two
ways this could happen: either the systolic pressure is greater than 145 to 160 mm Hg
and/or the diastolic is greater than 90 to 100. Major contributing factors include the
amounts of salt, cholesterol (and other lipids), and sugar in one’s diet and the amount of
exercise the person gets. Frequently, diuretics are prescribed to try to remove water
from the person’s blood, thus lowering the blood volume and hopefully thereby, the BP.
However, many diuretics also remove potassium (and other beneficial minerals?) from
the person’s system, and if serum potassium levels are not carefully monitored and go to
low, this could cause a heart attack!

A thrombus is a blood clot (platelets and fibrin) which forms within a vessel and blocks
the blood flow. These can result from surgery or from conditions like atrial fibrillation. An
embolus is a moving thrombus which may “get stuck” somewhere. If thrombi or emboli
lodge in an artery supplying blood to the heart, this can cause a coronary embolism or
heart attack or myocardial infarction. If one of these becomes lodged in an artery in the
lungs, it is also a life-threatening pulmonary embolism, and if in the brain, a cerebral (or
cerebellar) embolism or stroke or cerebrovascular accident (CVA).

A hemorrhage is bleeding, especially profuse, and can be severe if internal.

A hematoma is a local swelling or tumor filled with blood; a bruise, especially a large
one. Sometimes, if the injury is extensive, it can calcify as it heals, leading to a hard
lump (which may need to be surgically removed).

Hemorrhoids are dilated or varicose veins in the anal area. Typically, these are caused
not enough fiber in diet causing the feces to be very hard so the person has to strain to
pass them. Increasing the amount of fiber in one’s diet can help prevent hemorrhoids
and possibly aid in healing mild cases. Because vitamin C is necessary for collagen
synthesis, it is necessary for strong capillary walls (one of the first signs of a vitamin C
deficiency is easy bruising), so that and the bioflavonoid rutin (found in buckwheat) have
proven useful for strengthening blood vessels and preventing/treating hemorrhoids and
other varicose veins.

Edema is an accumulation of fluid (plasma) within tissues and/or the lymph system.
There are many possible causes of edema from injury, to too much salt, to improperly
functioning kidneys, to lack of exercise, to female hormonal changes, to a number of
other possible causes. If in doubt, see a doctor.

Much like a heat pump for your house or your refrigerator coils, your cardiovascular
system is also involved in countercurrent heating/cooling of your body. Arteries and
veins lying near each other in your extremities, but flowing in opposite directions can
absorb heat from each other as needed. When your core temperature is too high, the
arteries carry heat to the extremities to be dissipated. As the blood returns via the veins,
any excess heat still in the blood is transferred to the arterial blood and sent to the
extremities, again. When your core temperature is too low, as the blood flows out in the
arteries to nourish the extremities, its heat is transferred to the venous blood and sent
back into the body to keep it warm.
In Raynaud’s Phenomenon, when the person (more common in women than men) gets
cold, spasms in the tiny arteriole muscles cause the circulation in portions of the fingers
or toes to completely “turn off,” and that portion of the finger/toe turns completely white.
As the person warms up and circulation is restored, initially these areas of the
fingers/toes will be cyanotic (blue), then will be flushed and red, before returning to
normal. The Merck Manual suggests that there may be a relationship between migraine
headaches and Raynaud’s. Diagnosis is confirmed by testing the blood pressure in not
only the brachial artery, but also the radial and ulnar arteries, and using tiny cuffs made
of Velcro® and aquarium tubing, each finger, both when the person is comfortably warm
and when the person’s hands have been soaking in ice water. People with Raynaud’s
need to make sure to wear warm mittens and heavy socks in winter weather, and since
much heat is lost from our heads, wearing a scarf or hat can actually help to keep the
person’s whole body warm and lessen the chances of a Raynaud’s episode in the
fingers/toes!

Hardening of the arteries is also called arteriosclerosis, a generic term for a number of
diseases in which the artery walls become thickened and lose elasticity. One special
form of this is atherosclerosis which is a build-up of lipids on the inside of blood vessels.
Major risk factors for atherosclerosis include hypertension, elevated serum lipids,
elevated LDL (low-density lipoproteins, the bad guys) and lowered HDL (high-density
lipoproteins, the good guys), smoking, diabetes, obesity, male sex, and family history.
Female hormones offer protection against accumulation of arterial plaque, so usually,
premenopausal women do not have as many problems with this as men do. However,
after menopause, lipids will start to accumulate. I once hear a statistic that the average
55-year-old woman has a build-up equivalent to the average 18-year-old man.