GENERAL OBJECTIVES: After 2-3 hours of lecture discussion the BSN 3F students will be able to develop positive attitude

and acquire basic knowledge and skills on how to take good care of the patient with Acute Coronary Syndrome: Non-ST Elevation Myocardial Infarction and understanding the goal of the treatment of this kind of condition.
SPECIFIC OBJECTIVES CONTENT METHODOLO GY TIME ALLOTMEN T RESOURCE S EVALUATION

Specifically, they will be able to:

I.INTRODUCTION: Globally. it is anticipated that both morbidity and mortality rates from heart disease will double between 1990 and 2020. As a matter of fact, the prevalence of heart attack according to WHO for may 2009-2010, 7.5 million people suffers myocardial infarction worldwide annually. 12,460 cases of M.I. are recorded last 2009 here in the Philippines. Traditional studies of the epidemiology of myocardial infarction have focused on infarction and have seldom reported on the clinical entity of acute coronary syndromes, with or without biomarker elevation. Part of the reason for this resides in the need for a standardized definition in epidemiology and the relative ease of standardizing the definition of myocardial infarction, contrasting with the more challenging task of defining acute coronary syndromes from an epidemiological point of view particularly in forms without biomarker elevation and with transient or absent electrocardiographic changes. Thus, over the years, epidemiological studies did not account for a large segment of the burden of non-fatal coronary disease, namely acute coronary syndromes, that do not meet validated infarction criteria. The redefinition of myocardial infarction has underscored this important issue, thereby challenging epidemiologists to incorporate acute coronary syndromes in the surveillance of coronary disease. Indeed, studies that have evaluated the implications of the redefinition of myocardial infarctions illustrate that reliance on one biomarker or the other will alter the categorization between types of acute coronary syndromes. Advocates of the widespread use of troponin have argued that acute coronary syndromes represent a continuum of disease, a concept quite familiar to clinicians, and that any increase in cardiac biomarkers have prognostic implications. However, while the implications of the shift across types of acute coronary syndromes may arguably be rather modest from a clinical and pathophysiological point of view, the

After 3 hours of lecture-discussion, the students of BSN III-F was able to

consequences of a diagnosis of myocardial infarction for employment, health insurance, evaluation of health care delivery, epidemiology and public health are enormous. For this reason, operational definitions of acute coronary syndromes have been proposed that include a purposeful effort to categorize such events while also specifically identifying myocardial infarctions that would have met criteria using the previous enzymatic biomarkers. This approach would enable health care providers to relate the newly defined myocardial infarctions to the previous classification. Thus, as the new myocardial infarction criteria generate continued reflection and discussion, more data on their clinical and epidemiological implications are clearly needed. This underscores the need to broaden the approach to coronary disease surveillance to include acute coronary syndromes rather than focusing primarily on myocardial infarction as traditionally defined. This is critical to understanding the trends that will be measured over the next decade marked by the change in biomarkers and to accurately evaluate the burden of heart disease. Unstable angina (UA), acute non-ST elevation myocardial infarction (NSTEMI), and acute ST elevation myocardial infarction (STEMI) are the three presentations of acute coronary syndromes (ACS). The first step in the management of patients ACS is prompt recognition, since the beneficial effects of therapy are greatest when performed soon after hospital presentation. For patients presenting to the emergency department with chest pain suspicious for an ACS, the diagnosis of myocardial infarction can be confirmed by the ECG and serum cardiac biomarker elevation; the history is relied upon heavily to make the diagnosis of unstable angina. Once the diagnosis of either UA or an acute NSTEMI is made, the acute management of the patient involves the simultaneous achievement of several goals:
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Relief of ischemic pain Assessment of the patient's hemodynamic status and correction of abnormalities. Hypertension and tachycardia, both of which will markedly increase myocardial oxygen consumption requirements, may be managed with beta blockers and intravenous nitroglycerin. Estimation of risk Choice of a management strategy, ie, an early invasive strategy (with angiography and intent for revascularization with PCI or CABG as defined by the anatomy) versus a conservative strategy with medical therapy. Initiation of antithrombotic therapy (including antiplatelet and anticoagulant therapies) to prevent further thrombosis of or embolism from an ulcerated plaque Beta blocker therapy to prevent recurrent ischemia and lifethreatening ventricular arrhythmias

The acute management goals should be followed by the administration of different drugs that may improve the long-term prognosis Some of these therapies include:

Long-term antiplatelet therapy to reduce the risk of recurrent coronary artery thrombosis or, with PCI, coronary artery stent thrombosis Statins Long-term oral anticoagulation in the presence of left ventricular thrombus or chronic atrial fibrillation to prevent embolization Possible use of an angiotensin converting enzyme (ACE) inhibitor in patients at increased risk

We chose this case because in this condition health care team are needed for the proper interventions given to the patient mainly with the pharmacological therapy and most especially the nurses are expected to do a critical nursing care and management. As student nurse it is our responsibility to study this
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case in order for us to have a good and strong foundation towards caring a patient who has been diagnosed with Acute Coronary Syndrome. 1.Know the patients General Data II.GENERAL DATA Name: E. L. S. Address: San Agustin Heights, Tisa Labangon, Cebu City Age: 47 years old Sex: Male Civil Status: Married Birthdate: December 12, 1962 Birth place: Manila City Nationality: Filipino Religion: Roman Catholic Occupation: Businessman Weight: 68.5 kg Height: 165 cm Hospital Number: 070022379714 Room Number: A-503 Date of Admission: September 19, 2010 Time of Admission: 5:21 PM How Admitted: Emergency Room Attending Physicians: Dr. Pilberito Tumabang Chin Dr. Alfredo Solis Simon Diagnosis: Acute Coronary Syndrome: Non-ST elevation Myocardial Infarction

III A. HEALTH HISTORY A.1. BIOLOGICAL DATA

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2. Assess patients Health Status and Physical Assessment

A case of E. L. S., 47years old, male, residing at San Agustin Heights, Tisa Labangon, Cebu City, a Filipino citizen, Roman Catholic, with 1 brother and 1 sister, he is the eldest child of the family. He was born on December 12, 1962 in Manila City. Both his parents and his 2 siblings are doctors. He is a mechanical engineer in profession graduated at Cebu Institute of Technology as well as a businessman. A.2 REASON FOR SEEKING CONSULTATION He was admitted because he felt onset of pain left arm radiating to his chest associated with numbness and loss of strength for 3 consecutive days. The pain is not relieved with rest and mefenamic acid. The pain lasts for 1 to 5 minutes with a pain score of 8 out of 10, being 10 as worst pain and 0 as none. A.3 CURRENT HEALTH STATUS Few months PTA, patient experienced tolerable chest pain and was relieved by rest. A night PTA, patient had onset of chest pain with generalized weakness and numbness on his left upper extremities, he took Mefenamic acid and pain was relieved and was able to sleep. Morning PTA, while patient was driving, chest pain recurred but was tolerable as claimed, until 6 hours prior to admission, chest pain was increased in intensity with feeling of heaviness, with the pain score of 8/10. Persistence of condition prompted the admission. He was diagnosed of hypertension last January 2009. A.4 PAST HEALTH HISTORY Patient was fully immunized, non-diabetic and non-asthmatic. He is allergic to crustaceans and no known allergy to drugs. He was admitted to Cebu Doctors Hospital due to a motor vehicular accident, 20years ago. He was diagnosed hypertensive January last year. He drinks alcoholic beverages occasionally and smokes 20 pack per year. His family has a history of heart problems and hypertension.
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A.5 FAMILY HISTORY (Refer to Appendix A pp. 22) A.6 GORDONS FUNCTIONAL HEALTH PATTERN

Health Perception- Health Management Pattern Before admission, the patient rates his health at 8 out of 10, being 10 as the healthiest and 0 as death. He tends to self medicate with a double dose of ascorbic acid if patient is not in good health condition such as fever or headache. He is not engaging in any form of weight control or exercise program. As a form of exercise, he cleans his cars every morning. He is completely immunized. He has no medication being maintained. During admission, patient still rates his health at 8 out 10 which for him means normal. He takes all the prescribed medications and proper diet as ordered by the physician and trying his best to stop smoking. Nutritional-Metabolic Pattern Before admission, there is no specific diet followed by the patient, he stated that his favorite food is Lechon Baboy & eggs. He eats rice every meal. He will just take foods that are being offered in their cafeteria such as adobong baboy, fried fish, humba and etc. He drinks more water usually 1L/day than carbonated drinks. No nausea and vomiting experience. During admission, he reported to have changed in weight for the past 6 months. He has no experienced of nausea and vomiting. Patient follows the proper diet of Full Low Salt Low Fat Low Cholesterol Diet.

Elimination Pattern Before admission, patient has no problem of urination and defecation. He urinates yellowish to amber colored urine more than 5x a day and defecates soft to semi-solid feces at least once a day. During admission, the patient has no changes in elimination pattern. Reported to defecate at least once a day and sometimes urinates 2 to 3 times at dawn. Activity-Exercise Pattern Before admission, patient usually wakes up around 6am in the morning, cleans his cars and drinks coffee. At 9am, he eats his breakfast with rice, eggs and etc. He will drive his father from home to the hospital and manage his food business with his wife. He will eat his lunch together with his wife at around 12 noon. He eats his dinner around 6pm with his father and wife and waited for his father to end his work around 8pm and drive back to their house. He watches television and do some paper works regarding their business and sleep around 12 midnight. During admission, the patient is advised to have a complete bed rest with toilet privileges and may ambulate along the room and hallway. Sleep-Rest Pattern Before admission, patient tends to sleep around 12 midnight and wakes up around 6am.He has no sleep pattern disturbance experienced. During admission, he tends to sleep around 9pm and wakes up around 6 am. He reported to have a sleep awakening due to urinary urgency and interruptions due to clinical procedures such as taking the vital signs. Cognitive-Perceptual Pattern
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Patient uses glasses upon reading, with a good hearing sensation, able to read and write. He speaks English, Tagalong and Bisaya. No speech pattern disturbance. Patient is oriented to time, person and place. During admission, patient is able to report feeling of pain and numbness on his chest. No experienced of vertigo or any other complaints. Self-Perception Pattern Before admission, patient is aware about their family history of heart diseases and complications brought by smoking but still smoke 1 pack of cigarettes per day. During admission, patient promised to stop smoking and will comply to the giving medication as a maintenance. Role-Relationship Pattern Patient is married but has no children. He and his wife lives together with his parents. He stated that mostly his wife does make decision in terms of their business and other family matters. He is a college graduate with a degree of B.S. Mechanical Engineering. Family genogram (refer to Appendix A pp.) Sexuality Reproductive Pattern He admitted that he had his first sex with his wife before they got married at the age of 20. They had taken medication that can increase their sexual hormones. They do not practice using any contraceptive methods. Coping-Stress Management Before admission, to relieve his stressful day he smokes. He stated that
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his long term stressor is about the condition of his father because his father has a heart problem. During admission, even though he is stressed, he tends not to smoke. To cope with stress during admission, he would walk around the vicinity or request his nephews and nieces to come and visit him in the hospital. Value-Belief System Before admission, patient and his wife are active members in their church. They attend masses every Sunday at the Alliance of Two Hearts around 7am. He believes in miracles. During admission, he prays every night before he go to sleep.

A.7 PSYCHOSOCIAL PROFILE A case of E. L. S., 47years old, male, residing at San Agustin Heights, Tisa Labangon, Cebu City, a Filipino citizen, Roman Catholic, with 1 brother and 1 sister, he is the eldest child of the family. Both his parents and his 2 siblings are doctors. He is very close to his father, nephews, and nieces. He is a mechanical engineer in profession graduated at Cebu Institute of Technology as well as a businessman. There is no gap between him and his workers. He relates harmoniously to the community in general. He smokes 1 pack a day. He drinks alcoholic beverages occasionally. He is married for 25 years but has no child. He cope up stress through smoking.

III B. PHYSICAL EXAMINATION General Observation: General Observation:

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 Received patient lying on bed, coherent, afebrile, conscious and

oriented to time, person and place, with IVF of D50.33% Sodium Chloride 500cc @ 10cc/hr, infusing well on his left arm to consumed and shift to heplock. Patient is neat and clean.
The patient is very cooperative, answers questions attentively,able to

ambulate without any assistance, able to perform self-care fully, patient is not pale, not weak and afebrile.
Patients environment is clean and conducive to health. With the following vital signs:

T- 36.5 oC PR- 82 bpm RR- 20 cpm BP- 120/90 mmHg II. Intergumentary System Patients skin color is brown and there is uniformity in color.It has normal skin turgor. His hair is short and black in color. Itis evenly distributed. There are no presence of infestation. There are no dandruff noted in his scalp. His nails are pinkish in color. Capillary refill returns at least 1-2 seconds. Skin is relatively dry with minimal amount of perspiration. No edema present on all extremities. Cold and clammy skin is noted. No lesions and bleeding on the all skin parts.

III. Head, Face, Neck Assessment HEAD: - Patients head is oval in shape and symmetrical to the body. Patient is noted to have scar in the forehead. No lumps, lesions. masses and no
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tenderness upon palpation. FACE: - The face is symmetrical and proportionate to the body. The eyes are laterally proportionate to the face. The nose is located at the midline. The buccal parts are not tender upon palpation. No presence of freckles or pimples inspected. Facial expressions are evident. Patient is able to raise the eyebrows, wrinkle the forehead, smile, show the teeth and frown. NECK: - Neck is symmetrical. No visible masses, no visible distention of the jugular veins noted. Patient can perform range of motion of the neck without pain. Carotid pulse is present. Thyroid was felt when the patient swallows. There are no bruit sounds heard. No palpable lymph nodes palpated. IV. Eye Assessment - Patient is using eyeglasses for reading newspapers. He can read without eyeglasses at a distance of 3-4 feet. His eyelids blink at the same time. Sclera is white in color. Bulbar and palpebral conjunctiva are clear without any signs of inflammation such as redness. The eyebrows are evenly distributed. The patient able to follow the 6 cardinal fields of gaze accordingly. The pupils are round, equal in size and is reactive to light and accommodation such as patients eyes is able to focus on objects that are close and faraway. V. Ear Assessment - The ears were proportional and equal. It was free from signs of tenderness, redness or presence of masses. The patient was able to hear equally with both ears and can repeat correctly when told to do so. The mastoid processes are nontender and no swelling or redness noted. VI. Nose and Sinuses Assessment -The patients nose is symmetrical and located in the medial line of the face. During palpation there were no pain, tenderness, swelling and deformity.
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Sinuses are not inflamed and resonant sound was heard during percussion. No nasal polyps were noted during inspection. VII. Mouth Assessment - The lips were pink but dry, symmetrical, without lesions. The oral mucosa is moist and free from lesions. The gums were pink in color and moist with clearly defined margins at each tooth. Patient has no dentures. The tongue is pink and free from lesions. No mouth ulcers or oral thrush noted. VIII. Cardiovascular Assessment -There are no palpitations and pulses are palpable. Patients heart produces S1 and S2 sounds upon auscultation. The chest expands equally. No chest indrawing and any deformities noted. Heart rate is regular in rhythm that ranges from 69-95 beats per minute. His blood pressure ranges 110/70-170/90 mmHg. Chest pain is noted that is not relieved with rest. IX. Respiratory Assessment -Chest walls are symmetrical. There were no masses or scars that indicate trauma or surgery. There are no presence of wheezing or crackle sounds auscultated. The respiration ranges from 18-25cpm. X. Abdomen Assessment Abdomen is protrude and no scars, lesions or rashes noted. Abdomen moves up during inspiration and moves down during expiration. His waist line measures 36 cm. There are no masses or tenderness when palpated. Bowel sounds are present upon auscultation.

XI. Musculoskeletal Assessment Patient is ambulatory. There are no presence of deformities. No inflammation noted in his muscles and joints. No masses and tenderness during palpation.
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XII. Neurologic Assessment Cranial nerve I olfactory -Able to identify smell and distinguish certain smell. Cranial nerve II optic Could identify and distinguish objects from the other such as pt. able to identify circle from oval by their shapes. 3. Discuss the Anatomy and Physiology of the Cardiovascular System Cranial nerve III oculomotor Can follow objects in the six cardinal positions of gaze. Both eyes moves together at the same time. Cranial nerve IV trochlear Can move the eyes up and down. Cranial nerve V trigeminal Can masticate and feel sensation in the face and scalp. Cranial nerve VI- abducent Can move the eyes up and down. Cranial nerve VII facial Can move frown and smile. Cranial nerve VIII vestibucochlear Could hear and identify sounds and have a good sense of balance. Cranial nerve IX glossopharyngeal Can swallow without difficulty and can identify certain taste. Cranial nerve X vagus
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 Gag reflex is present and can communicate well. Cranial nerve XI- accessory - Can move head and neck in a complete range of motion. Cranial nerve XII hypoglossal - Can move the tongue up, down, left and right. IV. ANATOMY AND PHYSIOLOGY OF CARDIOVASCULAR SYSTEM IMAGE OF THE HEART (Refer to Appendix B pp.23) The 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 drain 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
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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. THE HEART Heart is a hollow muscular organ that pumps blood through the body. The heart, blood, and blood vessels make up the circulatory system, which is responsible for distributing oxygen and nutrients to the body and carrying away carbon dioxide and other waste products. The heart is the circulatory system's power supply. It must beat ceaselessly because the body's tissuesespecially the brain and the heart itself-depend on a constant supply of oxygen and nutrients delivered by the flowing blood. If the heart stops pumping blood for more than a few minutes, death will result. The human heart is shaped like an upside-down pear and is located slightly to the left of center inside the chest cavity. About the size of a closed fist, the heart is made primarily of muscle tissue that contracts rhythmically to propel blood to all parts of the body. This rhythmic contraction begins in the developing embryo about three weeks after conception and continues throughout an individual's life. The muscle rests only for a fraction of a second between beats. Over a typical life span of 76 years, the heart will beat nearly 2.8 billion times and move 169 million liters (179 million quarts) of
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blood. STRUCTURE OF THE HEART The human heart has four chambers. The upper two chambers, the right and left atria, are receiving chambers for blood. The atria are sometimes known as auricles. They collect blood that pours in from veins, blood vessels that return blood to the heart. The heart's lower two chambers, the right and left ventricles, are the powerful pumping chambers. The ventricles propel blood into arteries, blood vessels that carry blood away from the heart.A wall of tissue separates the right and left sides of the heart. Each side pumps blood through a different circuit of blood vessels: The right side of the heart pumps oxygen-poor blood to the lungs, while the left side of the heart pumps oxygen-rich blood to the body. Blood returning from a trip around the body has given up most of its oxygen and picked up carbon dioxide in the body's tissues. This oxygen-poor blood feeds into two large veins, the superior vena cava and inferior vena cava, which empty into the right atrium of the heart. The right atrium conducts blood to the right ventricle, and the right ventricle pumps blood into the pulmonary artery. The pulmonary artery carries the blood to the lungs, where it picks up a fresh supply of oxygen and eliminates carbon dioxide. The blood that is oxygen-rich returns to the heart through the pulmonary veins, which empty into the left atrium. Blood passes from the left atrium into the left ventricle, from where it is pumped out of the heart into the aorta, the body's largest artery. Smaller arteries that branch off the aorta distribute blood to various parts of the body. A. THE HEART VALVES Four valves within the heart prevent blood from flowing backward in the heart. The valves open easily in the direction of blood flow, but when blood pushes against the valves in the opposite direction, the valves close. Two valves, known as atrioventricular valves, are located between the atria and
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ventricles. The right atrioventricular valve is formed from three flaps of tissue and is called the tricuspid valve. The left atrioventricular valve has two flaps and is called the bicuspid or mitral valve. The other two heart valves are located between the ventricles and arteries. They are called semilunar valves because they each consist of three half-moon-shaped flaps of tissue. The right semilunar valve, between the right ventricle and pulmonary artery, is also called the pulmonary valve. The left semilunar valve, between the left ventricle and aorta, is also called the aortic valve. B. THE MYOCARDIUM Muscle tissue, known as myocardium or cardiac muscle, wraps around a scaffolding of tough connective tissue to form the walls of the heart's chambers. The atria, the receiving chambers of the heart, have relatively thin walls compared to the ventricles, the pumping chambers. The left ventricle has the thickest walls-nearly 1 cm (0.5 in) thick in an adult-because it must work the hardest to propel blood to the farthest reaches of the body. C. THE PERICARDIUM A tough, double-layered sac known as the pericardium surrounds the heart. The inner layer of the pericardium, known as the epicardium, rests directly on top of the heart muscle. The outer layer of the pericardium attaches to the breastbone and other structures in the chest cavity and helps hold the heart in place. Between the two layers of the pericardium is a thin space filled with a watery fluid that helps prevent these layers from rubbing against each other when the heart beats. D. THE ENDOCARDIUM The inner surfaces of the heart's chambers are lined with a thin sheet of shiny, white tissue known as the endocardium. The same type of tissue, more broadly referred to as endothelium, also lines the body's blood vessels,
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forming one continuous lining throughout the circulatory system. This lining helps blood flow smoothly and prevents blood clots from forming inside the circulatory system. E. THE CORONARY ARTERIES The heart is nourished not by the blood passing through its chambers but by a specialized network of blood vessels. Known as the coronary arteries, these blood vessels encircle the heart like a crown. About 5 percent of the blood pumped to the body enters the coronary arteries, which branch from the aorta just above where it emerges from the left ventricle. Three main coronary arteries-the right, the left circumflex, and the left anterior descending-nourish different regions of the heart muscle. From these three arteries arise smaller branches that enter the muscular walls of the heart to provide a constant supply of oxygen and nutrients. Veins running through the heart muscle converge to form a large channel called the coronary sinus, which returns blood to the right atrium. FUNCTION OF THE HEART The heart's duties are much broader than simply pumping blood continuously throughout life. The heart must also respond to changes in the body's demand for oxygen. The heart works very differently during sleep, for example, than in the middle of a 5-km (3-mi) run. Moreover, the heart and the rest of the circulatory system can respond almost instantaneously to shifting situationswhen a person stands up or lies down, for example, or when a person is faced with a potentially dangerous situation THE CARDIAC CYCLE Although the right and left halves of the heart are separate, they both contract in unison, producing a single heartbeat. The sequence of events from the beginning of one heartbeat to the beginning of the next is called the cardiac
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cycle. The cardiac cycle has two phases: diastole, when the heart's chambers are relaxed, and systole, when the chambers contract to move blood. During the systolic phase, the atria contract first, followed by contraction of the ventricles. This sequential contraction ensures efficient movement of blood from atria to ventricles and then into the arteries. If the atria and ventricles contracted simultaneously, the heart would not be able to move as much blood with each beat. During diastole, both atria and ventricles are relaxed, and the atrioventricular valves are open. Blood pours from the veins into the atria, and from there into the ventricles. In fact, most of the blood that enters the ventricles simply pours in during diastole. Systole then begins as the atria contract to complete the filling of the ventricles. Next, the ventricles contract, forcing blood out through the semilunar valves and into the arteries, and the atrioventricular valves close to prevent blood from flowing back into the atria. As pressure rises in the arteries, the semilunar valves snap shut to prevent blood from flowing back into the ventricles. Diastole then begins again as the heart muscle relaxes-the atria first, followed by the ventricles-and blood begins to pour into the heart once more. A health-care professional uses an instrument known as a stethoscope to detect internal body sounds, including the sounds produced by the heart as it is beating. The characteristic heartbeat sounds are made by the valves in the heart-not by the contraction of the heart muscle itself. The sound comes from the leaflets of the valves slapping together. The closing of the atrioventricular valves, just before the ventricles contract, makes the first heart sound. The second heart sound is made when the semilunar valves snap closed. The first heart sound is generally longer and lower than the second, producing a heartbeat that sounds like lub-dup, lub-dup, lub-dup. Blood pressure, the pressure exerted on the walls of blood vessels by the flowing blood, also varies during different phases of the cardiac cycle. Blood pressure in the arteries is higher during systole, when the ventricles are
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4. Trace the Pathophysiology of the disease condition 5. Discuss the Theoretical Framework of the disease condition.

contracting, and lower during diastole, as the blood ejected during systole moves into the body's capillaries. Blood pressure is measured in millimeters (mm) of mercury using a sphygmomanometer, an instrument that consists of a pressure-recording device and an inflatable cuff that is usually placed around the upper arm. Normal blood pressure in an adult is less than 120 mm of mercury during systole, and less than 80 mm of mercury during diastole. Blood pressure is usually noted as a ratio of systolic pressure to diastolic pressure-for example, 120/80. A person's blood pressure may increase for a short time during moments of stress or strong emotions. However, a prolonged or constant elevation of blood pressure, a condition known as hypertension, can increase a person's risk for heart attack, stroke, heart and kidney failure, and other health problems.

V. CONCEPTUAL FRAMEWORK OF THE DISEASE CONDITION (Refer to Appendix C pp.24-25)

VI. THEORITICAL FRAMEWORK OF THE DISEASE CONDITION RISK FACTORS OF M.I INCLUDE: Old Age As we get older, Blood vessels tend to be sclerotic (Hardened). High blood pressure Blood vessels tend to adapt to the high pressure by hardening its wall. High blood cholesterol, especially LDL; builds up in blood vessels walls, thereby forming plaque.
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 Cigarette smoking Cigarette smoke is known to be a vasoconstrictor. Lack of physical mobility Circulation is not optimized, thereby increasing risk of plaque formation Diabetes Mellitus Increase in blood sugar level causes a viscous blood, making the heart pump harder without in turn increase B.P. Family history of chest pain, heart disease, and stroke Heart disease is hereditary disease. M.I. may be due to a rupture of an atheromatous plaque. Because this is interpreted by the body as an inflammation/wound, thrombus form in the area, causing an occlusion, thereby decreasing blood and oxygen supply. If oxygen demand is increased, M.I. may develop in relation to the low oxygen supply. Vasospasm (Hardening of vessels) may also cause M.I. M.I. starts off as an ischemia (insufficient tissue oxygenation) cause by a blockage in the blood vessels. Decreasing in oxygen supply causes the cells to undergo anaerobic respiration. Lactic acid is formed because of this kind of respiration. Build-up of lactic acid causes the pain felt by the patient who is having M.I. Delayed of failure to treat the ischemia results in the death of the heart tissue. Because of the lack of oxygen, the heart compensates by beating faster (Tachycardia). As a result, the heart muscles hypertrophy. However, the enlarged heart muscle does not function as well as normal muscles do (they have decreased tonicity and therefore decreased contractility). Overtime, this may result in left ventricular hypertrophy. Because of this, Blood backflows into the lungs w/c results in edema and pulmonary congestion. Because of the infracted (dead) tissue in the heart, cardiac output is reduced and B.P. is decreased. Once the B.P. goes down, the baroreceptors in the blood vessels, which controls the B.P, Activates the S.N.S which cause
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6. Elaborate clinical management of the patient

vasoconstriction, thereby increasing B.P. Blood Flow is also decreased in the different organ systems such as:

RESPI: -

S.O.B DYPNEA TACHYPNEA

GI: - INDIGESTION SKIN: - COOL - NAUSEA - CLAMMY - VOMITING - DIAPHORETIC - PALE

NEURO: - ANXIETY REDUCED L.O.C. - LETHARGY - LIGHTHEADNESS When blood flow to the kidney is reduced. It is interpreted a hypovolemia. This is why the kidney activates the R-A-A System by releasing renin cause the conversion of angiotensinogen I the liver to angiotensin I. an substance. Angiotensin-coverting enzyme (ACE) in the lungs converts angiotensin I to its active form, Angiotensin II. This substance causes vasoconstriction, thereby increasing B.P and afterload. Alsi, Angiotensin II stimulates the release of aldosterone from the adrenal cortex. Aldosterone cause 2 things: Sodium and H2O retention and ADH stimulation. Both Function causes the increase in fluid volume. Cardiac workload is increased, leading to hypertrophy. This may eventually lead to left ventricular failure.

VII. CLINICAL MANAGEMENT A. MEDICAL MANAGEMENT

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7. Explain Nursing management of the patient

(Refer to Appendix D pp.26-71) B. LABORATORY AND DIAGNOSTIC EXAMINATIONS (Refer to Appendix E pp. 72-74) C. TREATMENT AND PROCEDURES Vital Signs taking- closely monitored because this serves as a baseline data of the patient and will indicate whether the patients condition is progressing or reclining. It is a routine taking of the patients temperature,pulse rate , respiration and blood pressure.

8. Elaborate recommendations and conclusion

Monitoring intake and output monitor the function of organ i.e kidney and liver. Health Teaching- this is to provide information to the patient about her condition and the need for her to take her medication and so that she will also take it.
Chest X-Ray- are used to diagnose many conditions involving the

chest wall, bones of the thorax, and structures contained within the thoracic cavity including the lungs, heart, and great vessels. Pneumonia and congestive heart failure are very commonly diagnosed by chest radiograph. Chest radiographs are used to screen for jobrelated lung disease in industries such as mining where workers are exposed to dust.
ECG 12 Leads- works mostly by detecting and amplifying the tiny

electrical changes on the skin that are caused when the heart muscle "depolarises" during each heart beat. At rest, each heart muscle cell has a charge across its outer wall, or cell membrane. Reducing this charge towards zero is called de-polarisation, which activates the
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mechanisms in the cell that cause it to contract.

2D ECHO- is a sonogram of the heart, it uses standard ultrasound

techniques to image two-dimensional slices of the heart. This allows assessment of cardiac valve areas and function, any abnormal communications between the left and right side of the heart, any leaking of blood through the valves (valvular regurgitation), and calculation of the cardiac output as well as the ejection fraction
HGT Monitoring- to know their blood glucose level at any time and

helps prevent the immediate and potentially serious consequences of very high or very low blood glucose. Monitoring also enables tighter blood glucose control, which decreases the long-term risks of diabetic complications.
URINALYSIS- is an array of tests performed on urine and one of the

most common methods of medical diagnosis.

D. DIET The patient is under a diet of Full Low Salt Low Fat Low Cholesterol Diet. To control and/or decrease levels of cholesterol in the blood and decrease blood pressure and fluid retention. VIII. NURSING MANAGEMENT A. NURSING CARE PLAN (Refer to Appendix F. pp.75-78) B. DISCHARGE PLAN
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(Refer to Appendix G. pp. 79-81) IX. RECOMMENDATIONS & CONCLUSION To be a nurse, we must have the three requirements which include knowledge, attitude and skills. This study will help us to improve for the best way to render care for our patients and to our future patients and also gaining their trust. We must be careful in dealing with patients with Myocardial Infarction and we must see to it that we can prevent further complications as the cardiovascular system serves to be one of the most delicate and major systems in our body. We recommend to the student nurses to be more patient and understanding. To apply what they have learned about the cardiovascular system not only in the hospital area but to their everyday life. This study imparts knowledge and information on how to promote health to our patients with myocardial defects. We, as a nurse, play a role not just to promote health but to educate our patients. We are also teachers. We are the ones who teach the patients on the best way to take care for their self. Thus, we need sufficient knowledge about the condition of myocardial infarction and its impact on the patients life. This will help us to be more skillful in rendering care to our patient. It will help us become better nurses through the experiences we encountered. We should always be advance in searching for knowledge about health. Simple research like reading magazines, books, surfing the internet and going to seminars are some ways to upgrade nursing research.

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APPENDIX A FAMILY HISTORY:

patient

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LEGENDS: Mother Father Brother Sister LUNG CANCERDIABETICGrandfather -Grandmother CADHPN-

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APPENDIX B

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ANATOMY OF THE HEART

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