PHILIPPINE CHRISTIAN UNIVERSITY

Mary Johnston College of Nursing

415 Morga St., Tondo Manila

In Partial Fulfillment of the requirements

In the Medicine Ward Duty

Case study

On

Unstable Angina

Submitted by:

Ms. Cayas, Jennylyn

Ms. Moleta, Hazel Joyce

BSN-III, RLE Group 2

Submitted to:

Ms. Ma. Nicoleta M. Dizon

I. ABSTRACT, IDENTIFICATION and INTRODUCTION

Unstable angina generally represents a condition more serious than chronic stable angina pectoris. The terms unstable indicates that the patient is in a changing situation, which may be a prelude to an acute myocardial or a return to more stable pattern. ( by E.P Dutton, HEARTBOOK, The American Association, USA, New York)

Chest pain is the most common symptom of cardiovascular disease. Angina pains, while possibly severe, are usually temporary, occurring after physical exertion, during emotion stress, or after heavy meals. The last few decades have witnessed remarkable advances in the understanding of coronary heart disease, and yet the disease still presents a very great challenge to the medical profession.The purpose of this study is to gain knowledge and to increase our competency in assessment especially in cardiovascular part and also in rendering nursing care that are appropriate based on the clients case.

In our case, a 69 year old, a lawyer is brought to the Mary Johnston Hospital due to loss of consciousness. He has been diagnosed to have hypertensive cardiovascular disease. His initial BP: 160/100mmHg. The patient has a type two diabetes. He is fond of eating high fat and high salt foods, smoker and alcoholic drinker. He had also hypertensive history within the family. Problem that was identified were the ff: chest pain, having productive cough, activity intolerance, electrolyte imbalances and diet modification.II. CASE REPORT

Demographic Data

Name: Santos, E. A.

Age: 69 years old

Birthday: September 23, 1942

Gender: Male

Status: Widow

Religion: Roman Catholic

Nationality: Filipino

Nursing History

History of Present Illness

The client was seeing in the comfort room by his relatives with loss of consciousness but can still respond by nodding. He experienced pain in the chest. He was immediately brought to hospital. His BP was 160/100 mmHg and known to have HCVD. He was known to have CAP. He was then admitted to Medical ICU for 11 days and then transferred to Medicine Ward.

Past Medical History

The client is Diabetic but he doesnt know since when. He was admitted to MICU last April or May because of the same condition. The client has Insomnia.

Family History

The clients Siblings are Hypertensive.

Personal-Social History

- Retired Lawyer but still accepting easy to handle cases.

- Smoker 30packs/year

- Alcoholic Drinker 2L/day

Gordons Functional Health Pattern

Health Perception

Ok naman ako, gusto ko na nga umuwi as stated by patient

Nutrition-Metabolic

Di siya mahilig sa gulay, kadalasan mga baboy as stated by son

Di siya kumakain ng Isda, pero nkain siya ng satdinas as stated by son

Tuwing kumakain lang siya nainom ng tubig, di siya mahilig as stated by son

Nainom siya ng kape sa umaga as stated by son

Elimination

Araw-araw naman siya dumudumi as stated by son

Wala naman siyang sinasabi na masakit ang pag-ihi niya as stated by son

With Foley Catheter connected to CDU

Activity-Rest

Madalas lang siya sa bahay, mahilig manuod ng T.V. as stated by son

Mahilig yan magbasabasa ng Dyaryo -as stated by son

Sleep-Rest

May Insomnia siya eh, di siya nakakatulog kapag di siya nakakainom ng alak as stated by son

Pampatulog na niya ang alak as stated by son

Cognitive Perceptual

Di malabo mata niya, sa dyaryo nga nababasa niya pa eh as stated by son

Ok din naman pandinig niya as stated by son

Self-Perception

Ok lang ako, magaling na ko as stated by son

Roles and Relationship

Sa bahay tatlo lang kami magkakasama, siya, ako at yung kapatid ko na isa as stated by son

Sexuality-Reproductive

Tatlo kaming anak lahat yung isa iba yung nanay as stated by son

Si mama namatay dahil sa stroke as stated by son

Coping Stress Tolerance

Naiistress kapag di nakakainom as stated by patient

Dapat makainom ako ng alak as stated by patient

Values and Belief

Di na nagsisimba yan si papa, sa bahay lang palagi as stated by son

Di naman nakakalimot magdasal yan as stated by son

Physical Examination

Head

Normocephalic

No lesion

No mass

Hair

Grayish in color

Dry hair

Eyes

Symmetrical

Dry eyes noted

Pinkish conjunctivae

Ears

No lesion

Symmetrical

No discharge

Nose

Nasal septum Intact

No mucus

Mouth

Incomplete set of teeth

Dry lips

Pinkish oral mucosa

Chest

Use of respiratory muscle

No lesion

No mass noted

Abdomen

Soft and flabby

No lesion

No mass

Skin

Dry and sagging skin

Fair complexion

Extremities

Symmetrical

Complete set of fingers and toes

Can do ROM but with assistance Laboratory/Diagnostics (from oldest to latest)

February 25, 2012

Na

137 mmol/L

135-145normal

K

2.3 mmol/L

3.6-5.0

low

March 02, 2012

Na

133.9 mmol/L

135-145low

K

3.55 mmol/L

3.6-5.0

low

Interpretation

The client has a low sodium and potassium. The client is taking a medication of diuretics and the Na and K was been excreted. This indicates that there is an inadequate Na and K in the body. As a nurse, encourage the client to eat foods rich in sodium and potassium like seafood, banana and potatoes.

ECG

February 23, 2012

Interpretation- Atrial Tachycardia, Normal Axis, Left Atrial Abnormality

February 25, 2012

Interpretation- Atrial Tachycardia, Normal Axis, Poor R wave progression.

Drug Study

1. Furosemide

Loop diuretics

Inhibits sodium and chloride reabsorption at the proximal tubules, distal tubules and ascending loop of henle leading to excretion of water together with Na, Cl and K. Diuretic, Anti-hypertensive.

This is given because the client has a Foley catheter and his output was being measured. The fluids in the body must be secreted to prevent fluid excess in the body that can cause hypertension and the worst is heart congestion.

2. Clopidogrel

Anti-coagulant, Anti-platelets

Blocks ADP receptors, which prevents fibrinogen binding at the site and thereby reduce the possibility of platelet and aggregation.

The client is hypertensive and known to have Diabetes Mellitus. This drug is given to prevent thrombus or clot formation in the vessels because patients with hypertension and DM have the higher risk to have it.

3. Enoxaparine

Anti-coagulant

Stimulates both Alpha and Beta receptors within sympathetic nervous system that relaxes bronchial smooth muscle.

The client is hypertensive and known to have Diabetes Mellitus. This drug is given to prevent thrombus or clot formation in the vessels because patients with hypertension and DM have the higher risk to have it.

4. Amiodarone

Anti-arrhythmics

Blocks sodium channels at rapid pacing frequencies, prolonging myocardial cell action potential and refractory period.

This drug is given to normalize the heart rhythm because the client experienced increased in heart contraction.

5. Pantoprazole

Proton pump inhibitor

Inhibits both basal and stimulated gastric acid secretion by suppressing the final step in acid production, through the inhibition of proton pump by binding to and inhibiting hydrogen-potassium adenosine-triphospate the enzyme system located at the secretory surface of the gastric parietal cell.

This drug contributes in the action of clopidogrel. It is also given because the client eats in little amount, this is given to prevent the increase in acid production that can cause ulceration.

6. Kalium durule

Supplements for hypokalemia

The client has a decrease in Potassium. This is given to supply the inadequacy of potassium in the body.

III. DISCUSSIONLiteratureFindingsClaimEvidence

Scott Wright, R. et al. (2011). Guidelines for the management of patients with unstable angina/ non ST elevation myocardial infarction. http://circ.ahajournals.org/content/ 123/18/2022.full#sec-7 Clopidogrel in combination with ASA has been shown to reduce recurrent coronary events in post hospitalized ACS.

Proton pump inhibitor medications have been found to interfere with the metabolism of clopidogrel.

Diabetes as well as the often concurrent comorbidity of CKD, is not only a high-risk factor but also benefits from an invasive approach.1. There are drugs that can prevent having thrombus or plaque formation. Data from a number of observational studies have demonstrated an association between an increased risk of adverse cardiovascular events and the presence of 1 of the nonfunctioning allelesand are well delineated in the ACCF/AHA Clopidogrel Clinical Alert (Scott Wright, R. et al. 2011).

Two novel findings have emerged from this analysis. First, in contrast to the studies, clopidogrel had the same relative benefit across all of the risk strata. The relative benefit was 20% in the low-risk, intermediate-risk, and high-risk patients. It is worth noting that because the baseline risk is higher, the absolute benefit is greatest in the highest-risk patients. The second novel finding of this analysis is that there was a statistically significant benefit of clopidogrel plus aspirin over aspirin alone in the low-risk patients. (Cannon, C. P. 2005)

Antithrombotic therapy is designed to stop platelet aggregation and interfere with the coagulation process. (Matura, L. A. et al. 2003)

Rabin, E. & Bullard, M. (1999). Chest pain observation units for patients with unstable angina. http://www.cjem-online.ca/v1/n1/ p39 An Emergency Department Chest Pain Unit is safe, effective and economical means of providing appropriate care to patients with unstable angina at intermediate risk for cardiovascular events.

2. There are diseases that can be a risk factor of unstable angina. Diabetes is another characteristic associated with high risk for adverse outcomes after UA/NSTEMI. (Scott Wright, R. et al. 2011)

The observational data with regard to patients with mild to severe CKD also support the recognition that CKD is an underappreciated high-risk characteristic in the UA/NSTEMI population (Scott Wright, R. et al. 2011)

Out of all patients 35.8% were female, 30% were diabetics (Duration 13.4 8.7 years), 42% were smoker and 91% were hypertensive (Abbasi, M. et el. 2006)

Three-vessel disease was diagnosed in 42% of diabetic and 31% of nondiabetic patients. In a multivariate analysis including the extent of CAD, diabetes remained a strong independent predictor of the combined end point. (Norhammar, A. et al. 2004)

Data were collected on 1046 ACS patients of whom 170 (16%) had a prior diagnosis of DM. Based on the rate of recruitment and the population covered in the study, about 21,000 patients with DM will be admitted with non-ST elevation ACS each year in the UK. (Bakhai, A. et al. 2005)

Calcified plaques in the DM group were significantly greater than those in the non-DM group (42.9% vs. 23.1%;p=0.03). (Feng, T. et al. 2010)

Collet, J. P. et al. (2002). Enoxaparin in unstable angina patients who would have been excluded from randomized pivotal trials. http://www.sciencedirect.com/ science/article/pii/ S0735109702026645 Enoxaparin with dose adjustment to creatinine clearance provides adequate anti-Xa and no excess of bleeding.

3. There are ways to reduce mortality in patient with ACS. The ISIS-2 trial, the second study of infarct survival, indicated an ASA dose of 160mg chewedon arrival to the ED as soon as a diagnosis of ACS is suspectedor made decreases mortality rate. (Matura, L. A. et al. 2003)

He Clopidogrel has shown a 34% reduction in cardiovascular death or recurrent MI when the patient is given a loading dose of 300mg and then 75mg orally daily. (Matura, L. A. et al. 2003)

Although patients with a higher risk score had an increased rate of death or MI within 42 days and 365 days (p < 0.001) in both management strategies, early invasive management for patients in the high and very high risk categories was associated with a lower rate of death or MI within 42 days compared with conservative management. (Solomon, D. H. et al. 2001)

In only one study found a statistically significant beneficial association between PA and hospital mortality. After combining the data found a significant reduction in the probability of hospital death in patients with PAD (odds ratio= 0.61, confidence interval 95%, from 0.48 to 0.78, P