HEARTnew

NCML04N Curative and Rehabilitive Nursing Care Management (Part II)
Xerlen O. Makalintal July 21, 2008 1

2005-10041 Joannes Paulus T Hernandez
BSHB,BSN, RN
Re-defining Acute Coronary Syndrome In The Perspectives Of Adult Health

Nuirsing:
A Case Review Of Nursing Care Modeling, The St. James Hospital
Xerlen O. Makalintal BSN 4-8

Lyceum-St.Cabrini College of Allied Medicine
ACKNOWLEDGEMENT

BSHB,BSN, RN
I would like to extend my deepest gratitude first and foremost to our

Almighty God who gave me the strength and wisdom to be able to do
and finish this work. I do believe that through the guidance and
power of our good God, nothing is impossible. Faith and belief is the
key to be able to see what is right and stay on the positive side that
with God, all things can be
done.
Second, to all my loved ones who gave me their full support, may it
be emotionally, spiritually and financially. They served as my source
of vigor. They are the strongest person whom I lean on in times of
confusion and troubles, they never left me behind.
To all my friends and classmates who have been there in times of

needs and extended their help in the most they can.
And lastly to my beloved one who never stopped in supporting me

and giving me a lot of reasons to be inspired in everything I do.
Thank you for all the inspiring thoughts from all the people around
me if without them I would not be able to take all the risk.
Thank you again to the trust you bestowed upon me!

BSHB,BSN, RN

BSHB,BSN, RN

BSHB,BSN, RN

BSHB,BSN, RN

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II. Anatomy and Physiology
⇒ An adult's heart is approximately 5 inches in size and is larger than an

adult's fist. In men, the average weight of the heart is 10 to 12 ounces
and in women, the average weight is 8 to 10 ounces.
⇒ It works as a pump to send oxygen-rich blood through all parts of your body.
Blood contains oxygen and nutrients that every cell in your body needs to survive.
The oxygen-rich blood travels throughout the arteries and vessels, nourishing the
body so that it can function properly.
The essential functions of the heart are:
1. 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 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
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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 semi lunar 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 semi lunar 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.
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
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 about 120 mm of
mercury during systole, and about 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.
2. Generation of the Heartbeat

Unlike most muscles, which rely on nerve impulses to cause them to contract,
heart muscle can contract of its own accord. Certain heart muscle cells have
the ability to contract spontaneously, and these cells generate electrical
signals that spread to the rest of the heart and cause it to contract with a
regular, steady beat. The heartbeat begins with a small group of specialized
muscle cells located in the upper right-hand corner of the right atrium. This
area is known as the sinoatrial (SA) node. Cells in the SA node generate their
electrical signals more frequently than cells elsewhere in the heart, so the
electrical signals generated by the SA node synchronize the electrical signals
traveling to the rest of the heart. For this reason, the SA node is also known
as the heart’s pacemaker.

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Impulses generated by the SA node spread rapidly throughout the atria, so

that all the muscle cells of the atria contract virtually in unison. Electrical
impulses cannot be conducted through the partition between the atria and
ventricles, which is primarily made of fibrous connective tissue rather than
muscle cells. The impulses from the SA node are carried across this
connective tissue partition by a small bridge of muscle called the
atrioventricular conduction system. The first part of this system is a group of
cells at the lower margin of the right atrium, known as the atrioventricular
(AV) node. Cells in the AV node conduct impulses relatively slowly,
introducing a delay of about two-tenths of a second before an impulse
reaches the ventricles. This delay allows time for the blood in the atria to
empty into the ventricles before the ventricles begin contracting.
After making its way through the AV node, an impulse passes along a group
of muscle fibers called the bundle of His, which span the connective tissue
wall separating the atria from the ventricles. Once on the other side of that
wall, the impulse spreads rapidly among the muscle cells that make up the
ventricles. The impulse travels to all parts of the ventricles with the help of a
network of fast-conducting fibers called Purkinje fibers. These fibers are
necessary because the ventricular walls are so thick and massive. If the
impulse had to spread directly from one muscle cell to another, different
parts of the ventricles would not contract together, and the heart would not
pump blood efficiently. Although this complicated circuit has many steps, an
electrical impulse spreads from the SA node throughout the heart in less than
one second.
The journey of an electrical impulse around the heart can be traced by a

machine called an electrocardiograph (see Electrocardiography). This
instrument consists of a recording device attached to electrodes that are
placed at various points on a person’s skin. The recording device measures
different phases of the heartbeat and traces these patterns as peaks and
valleys in a graphic image known as an electrocardiogram (ECG, sometimes
known as EKG). Changes or abnormalities in the heartbeat or in the heart’s
rate of contraction register on the ECG, helping doctors diagnose heart
problems or identify damage from a heart attack.
3. Control of the Heart Rate
Although the SA node generates the heartbeat, nerves and certain chemicals
in the bloodstream may influence the heart rate. Impulses from nerves cause
the heart to speed up or slow down almost instantaneously (see Nervous
System). The nerves that regulate heart rate are part of the autonomic
nervous system, which directs activities of the body that are not under
conscious control. The autonomic nervous system is made up of two types of
nerves, sympathetic and parasympathetic fibers. These fibers come from the
spinal cord or brain and deliver impulses to the SA node and other parts of

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the heart. Sympathetic nerve fibers increase the heart rate. These fibers are
activated in times of stress, and they play a role in the so-called fight or flight
response that prepares humans and other animals to escape danger. In
addition to fear or physical danger, exercising or experiencing a strong
emotion can also activate sympathetic fibers and cause an increase in heart
rate. In contrast, parasympathetic nerve fibers slow the heart rate. The heart
receives impulses from both sympathetic and parasympathetic fibers
constantly. In fact, in the absence of nerve impulses the SA node would fire
about 100 times each minute—parasympathetic fibers are responsible for
slowing the heart to the normal rate of about 70 beats per minute.
4. Cardiac Output
As a measure of overall heart function doctors use cardiac output, the
amount of blood pumped by each ventricle in one minute. Cardiac output is
equal to the heart rate multiplied by the stroke volume, the amount of blood
pumped by a ventricle with each beat. Stroke volume, in turn, depends on
several factors: the rate at which blood returns to the heart through the
veins; how vigorously the heart contracts; and the pressure of blood in the
arteries, which affects how hard the heart must work to propel blood into
them. Normal cardiac output in an adult is about 3 liters per minute per
square meter of body surface.
An increase in either heart rate or stroke volume—or both—will increase

cardiac output. During exercise, sympathetic nerve fibers increase heart rate.
At the same time, stroke volume increases, primarily because venous blood
returns to the heart more quickly and the heart contracts more vigorously.
Many of the factors that increase heart rate also increase stroke volume. For
example, impulses from sympathetic nerve fibers cause the heart to contract
more vigorously as well as increasing the heart rate. The simultaneous
increase in heart rate and stroke volume enables a larger and more efficient
increase in cardiac output than if, say, heart rate alone increased during
exercise. In a healthy adult during vigorous exercise, cardiac output can
increase six-fold, to 18 liters per minute per square meter of body surface.
Coronary Arteries
Because the heart is composed primarily of cardiac muscle tissue that

continuously contracts and relaxes, it must have a constant supply of oxygen
and nutrients. The coronary arteries are the network of blood vessels that
carry oxygen- and nutrient-rich blood to the cardiac muscle tissue.
The blood leaving the left ventricle exits through the aorta, the body’s main
artery. Two coronary arteries, referred to as the "left" and "right" coronary
arteries, emerge from the beginning of the aorta, near the top of the heart.
The initial segment of the left coronary artery is called the left main coronary.
This blood vessel is approximately the width of a soda straw and is less than
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an inch long. It branches into two slightly smaller arteries: the left anterior
descending coronary artery and the left circumflex coronary artery. The left
anterior descending coronary artery is embedded in the surface of the front
side of the heart. The left circumflex coronary artery circles around the left
side of the heart and is embedded in the surface of the back of the heart.
Just like branches on a tree, the coronary arteries branch into progressively
smaller vessels. The larger vessels travel along the surface of the heart;
however, the smaller branches penetrate the heart muscle. The smallest
branches, called capillaries, are so narrow that the red blood cells must travel
in single file. In the capillaries, the red blood cells provide oxygen and
nutrients to the cardiac muscle tissue and bond with carbon dioxide and
other metabolic waste products, taking them away from the heart for
disposal through the lungs, kidneys and liver.
When cholesterol plaque accumulates to the point of blocking the flow of

blood through a coronary artery, the cardiac muscle tissue fed by the
coronary artery beyond the point of the blockage is deprived of oxygen and
nutrients. This area of cardiac muscle tissue ceases to function properly. The
condition when a coronary artery becomes blocked causing damage to the
cardiac muscle tissue it serves is called a myocardial infarction or heart
attack.
Superior Vena Cava
The superior vena cava is one of the two main veins bringing de-oxygenated
blood from the body to the heart. Veins from the head and upper body feed
into the superior vena cava, which empties into the right atrium of the heart.
Inferior Vena Cava
The inferior vena cava is one of the two main veins bringing de-oxygenated
blood from the body to the heart. Veins from the legs and lower torso feed
into the inferior vena cava, which empties into the right atrium of the heart.
Aorta
The aorta is the largest single blood vessel in the body. It is approximately
the diameter of your thumb. This vessel carries oxygen-rich blood from the
left ventricle to the various parts of the body.
Pulmonary Artery
The pulmonary artery is the vessel transporting de-oxygenated blood from

the right ventricle to the lungs. A common misconception is that all arteries
carry oxygen-rich blood. It is more appropriate to classify arteries as vessels
carrying blood away from the heart.
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Pulmonary Vein
The pulmonary vein is the vessel transporting oxygen-rich blood from the
lungs to the left atrium. A common misconception is that all veins carry de-
oxygenated blood. It is more appropriate to classify veins as vessels carrying
blood to the heart.
Right Atrium
The right atrium receives de-oxygenated blood from the body through the
superior vena cava (head and upper body) and inferior vena cava (legs and
lower torso). The sinoatrial node sends an impulse that causes the cardiac
muscle tissue of the atrium to contract in a coordinated, wave-like manner.
The tricuspid valve, which separates the right atrium from the right ventricle,
opens to allow the de-oxygenated blood collected in the right atrium to flow
into the right ventricle.
Right Ventricle
The right ventricle receives de-oxygenated blood as the right atrium

contracts. The pulmonary valve leading into the pulmonary artery is closed,
allowing the ventricle to fill with blood. Once the ve ntricles are full, they
contract. As the right ventricle contracts, the tricuspid valve closes and the
pulmonary valve opens. The closure of the tricuspid valve prevents blood
from backing into the right atrium and the opening of the pulmonary valve
allows the blood to flow into the pulmonary artery toward the lungs.
Left Atrium
The left atrium receives oxygenated blood from the lungs through the
pulmonary vein. As the contraction triggered by the sinoatrial node
progresses through the atria, the blood passes through the mitral valve into
the left ventricle.
Left Ventricle
The left ventricle receives oxygenated blood as the left atrium contracts. The
blood passes through the mitral valve into the left ventricle. The aortic valve
leading into the aorta is closed, allowing the ventricle to fill with blood. Once
the ventricles are full, they contract. As the left ventricle contracts, the mitral
valve closes and the aortic valve opens. The closure of the mitral valve
prevents blood from backing into the left atrium and the opening of the aortic
valve allows the blood to flow into the aorta and flow throughout the body.
Papillary Muscles
The papillary muscles attach to the lower portion of the interior wall of the
ventricles. They connect to the chordae tendineae, which attach to the
tricuspid valve in the right ventricle and the mitral valve in the left ventricle.
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The contraction of the papillary muscles opens these valves. When the
papillary muscles relax, the valves close.
Chordae Tendineae
The chordae tendineae are tendons linking the papillary muscles to the
tricuspid valve in the right ventricle and the mitral valve in the left ventricle.
As the papillary muscles contract and relax, the chordae tendineae transmit
the resulting increase and decrease in tension to the respective valves,
causing them to open and close. The chordae tendineae are string-like in
appearance and are sometimes referred to as "heart strings."
Tricuspid Valve
The tricuspid valve separates the right atrium from the right ventricle. It
opens to allow the de-oxygenated blood collected in the right atrium to flow
into the right ventricle. It closes as the right ventricle contracts, preventing
blood from returning to the right atrium; thereby, forcing it to exit through
the pulmonary valve into the pulmonary artery.
Mitral Value
The mitral valve separates the left atrium from the left ventricle. It opens to
allow the oxygenated blood collected in the left atrium to flow into the left
ventricle. It closes as the left ventricle contracts, preventing blood from
returning to the left atrium; thereby, forcing it to exit through the aortic valve
into the aorta.
Pulmonary Valve
The pulmonary valve separates the right ventricle from the pulmonary artery.
As the ventricles contract, it opens to allow the de-oxygenated blood
collected in the right ventricle to flow to the lungs. It closes as the ventricles
relax, preventing blood from returning to the heart.
Aortic Valve
The aortic valve separates the left ventricle from the aorta. As the ventricles
contract, it opens to allow the oxygenated blood collected in the left ventricle
to flow throughout the body. It closes as the ventricles relax, preventing
blood from returning to the heart.
a. Anatomy of the Myocardium

BSHB,BSN, RN
Myocardium
The walls of the heart itself are made up of three layers. The outer layer
(epicardium), the middle layer (myocardium) that consists of muscle
tissue which contracts with each cardiac cycle and constitutes the largest
portion of the heart wall, and the innermost layer (endocardium), which
is comprised of endothelial tissue laced with small blood vessels and
bundles of smooth muscle.
Several layers of pericardium surround the heart forming a framework of connective

tissue that serves to protect it. The fibrous pericardium is outermost and serves as
protection because of its denseness. The serous pericardium is the inner portion and
has two thin smooth layers, the parietal and visceral layers, separated by the

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pericardial space. The space contains 10-20 milliliters of fluid that acts as a lubricant
on the surfaces of the pericardium and as a cushion around the heart.
b. Histology of Myocardium
Normal Myocardium
Legend: 1 - tunica intima 2 - tunica media

3 - tunica externa 4 - internal elastic lamina
c. Histopathology

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Normal Myocardium With Myocardial Infarction
Dr. Thomas Caceci, VM8054 Veterinary Histology
III. Pathophysiology, Diagnosis and Management of the Disease
Myocardial infarction, or heart attack, occurs when the blood flow to the heart
muscles stops or is reduced sufficiently for long enough to cause cell death.
In most cases, myocardial infarction is caused by blockages in coronary
arteries by thrombosis.It is characterized by these clinical features.
1. Change in serial ECG tracings- ST-segment Elevation

2. Angina- described as a sensation of tightness, pressure, or squeezing
lasting for more than 20 minutes
3. systolic murmurs
Clinical Findings:
• More common in male

• Most frequently occurs in persons older than 45 years
• Chest pain, usually across the anterior precordium is typically
described as tightness, pressure, or squeezing
• Changes in serial ECG tracings
• Blood pressure may be elevated or decreased
• Increased respiratory rate
• Elevated jugular venous pressure and hepatojugular reflux
• A cool and pale skin
• third and fourth heart sound
• systolic murmurs
• Pericardial friction rub and rales over the lung

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• Lightheadedness with or without syncope

• Edema
• Diaphoresis
Laboratory Diagnoses:
Serum Test:
-Total CK
-CK-MB
-Myoglobulin
-Troponin T or l
Medical Therapy
Aim
Minimize myocardial damage
Prevent complications
Relief pain
1. Drug therapy – beta blocker
• Drug of choice is metiprolol

• Decrease the contractility of the heart
• Minimize myocardial damage
Thrombolytic
• Dissolve and lyse the thrombus in a coronary artery
2. Improve Oxygen Supply/Demand

• Increasing oxygen supply by increasing either arterial oxygen content or
coronary blood flow leads to an increase in tissue oxygen levels
Nursing Care Goals

• Rekief Angina
• Reducing Anxiety
• Decreasing heart’s work load
• Bed rest
• Monitor Blood Pressure
• Diet- Low fat, Low salt diet
Discharge Instructions:

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• Report signs of chest pain

• Diet restriction
• Admininstration of medications and importance of follow-up care.
Reference:
Management of patients with CVD, chapter 28-Myocardial Infarction Brunner and Suddarth’s
Medical-Surgical Nursing textbook, 11th edition,2008, Philadelphia Lippincott Williams and
wilkins, pp883-884

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IV. Pathophysiology, Diagnosis, and Management of Major Complications

BSHB,BSN, RN
V. Nursing Process
Date of Rotation: June 24-28,2008

Institution: St. James Hospital, Sta. Rosa Laguna Ward:ICU Bed#: B
Patient: (RM) Date & Time of Admission:June 23, 2008 Case#:
Medical Diagnosis: Acute Myocardial Infarction
Nursing Student: Xerlen O. Makalintal
PATIENT HISTORY:
My clinical rotation was at St. James Hospital at Ward 4. I was assigned to RM

from 06/24 to 06/25. She was on her 2nd dy of hospitalization, with diagnosis
of Acute Coronary Syndrome. She was admitted due to severe chest pain.
Rm is a 68 year old blood type A female, born on May 18, 1940, Roman
Catholic, who stands about 5’2” tall and weighs about 79 kilograms. She is
already widow with four(4) borns. She is currently residing at Cabuyao,
Laguna. She is living with her eldest daughter and family. She finished
elementary education and married at the age of 19. her first hospitalization
was 2 years ago with the same comlaint. No surgeries had been performed
since then. She has diabetes mellitus type II and hypertention. No history of
alcohol consumption and tobacco usage. No food or drug allergies, asthma,
lung, kidney disease exist in her family only hypertension. She has
maintainance medication for her hypertension and analgesics for pain.
2 months ago before her current hospitalization, she experienced a quick

squeezing and tightness on her chest after eating too much fatty foods. She
just take a rest and her medication to ease the pain.
After 2 months, month of June, RM experienced severe chest pain and

difficulty of breathing that lead her to consult health care. She was rushed
into the hospital and was admitted. ECG tracing was done and instructed Npo
for 8hrs by her physician to test for her RBS for she is known to have diabetes
mellitus.
ECG tracing 06/23/2008

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On examination his heart rate is 90 beats per minute, blood pressure is

140/100 mm Hg, he has normal heart sounds and his lungs are clear to
auscultation.
This ECG shows that this patient has an inferior wall myocardial infarction.
PATIENT ASSESSMENT:
RM is conscious a, resting in a supine position with head elevated. She appers

weak and with difficulty of breathing. She is receiving supplement of oxygen
at a rate of 4 L/min via nasal cannula. Intravenous fluid is connected through
the left metacarpal vein without signs of inflammation. She is complaining of
pain and uneasyness.
Vital signs(T- 37.8 ํC, HR- 70/min, 110/80, RR 34cpm) revealed in slight
respiratory distress(tachypnic) and slight febrile.
Functional Health Pttern Assessment
General Description

BSHB,BSN, RN
In bed, awake, complaining of difficulty of breathing. Looks weak and in pain.

Good hygiene is imposed as evidence by proper grooming and neat clothing.
Health Perception/Health Management
Verbalizes, “Nahihirapan ako,ngayon lang ako nakaramdam ng ganito kahit

naospital na ako noon.” Reveals difficulty in health status.
Nutritional-Metabolic Pattern
With appetite to eat. Prefers food brought by the relatives. Has eaten “mami”
for breakfast, sinigang na isda and half cup of rice for lunch and “mais na
gulay” for dinner in a 24 hour period.
Elimination Pattern
Reported regular pattern of elimination.
Activity-Exercise Patterns
Level 0: Full self care
Level 1: Requires use of equipment/ device
Level 2: Requires assist or supervision of another person
Level 3: Requires assist or supervision of another person
+ equipment or device
Level 4: is dependent and does not participate
NA: not applicable
Fucntional level
Feeding: 3
Grooming: 3
Dressing: 3
Bathing: 3
General Mobility: 3
Bed Mobility: 3
Toileting: 3
Sleep-Rest Pattern
Sleep is deprive at night because of difficulty of breathing.
Cognitive-Perceptual Pattern
Senses are intact and can understand verbal but with difficulty in reading
written instructions.
Self Perception- Self Concept Pattern

Values the role of being a mother and wishing for immediate recovery to
perform her normal activities.
Role- Relationship Pattern

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Close family tie exist.
Sexuality-Reproductive
No longer sexually active due to old age.
Coping-Stress Tolerance Pattern

Presence of family members provides strength and security.
Value-Belief Pattern
Believes that the Lord will guide to provide comfort and healing.
Summary
Patient is 65 years of age, with will power to cope up with her disease.
Though she is really in pain, she still try to be strong and believing that the
good Lord will provide comfort and relief from her disease.
A. Analysis of Data
Physiological Psychological Cultural Development Social

al

BSHB,BSN, RN
HEALTH
HISTORY Mrs. RM is 68 Mrs. RM Lives with
years old. It is stated that her eldest
her 2nd she never daughter
hospitalizatio felt bad with and
n. No food or her health family
drug allergies. but only with
No vices. her current
hospitalizatio
n.
PHYSICAL
Health Perception/health
EXAMINATION T- 37.8Management:
Facial Value/belief:
Height – 5’2”
PR- 70 bpm grimace Weight –
Verbalizes, “Nahihirapan
RR- 34ako,ngayon
cpm Believes79kg
that the Lord
lang ako nakaramdam ng ganito kahit
BP-110/80 will guide to provide
naospital na ako noon.” comfort and healing.
Reveals difficulty in health status.
LABORATORY
DATA
Nutritional/Metabolic: Medication/History:
With appetite to eat. With maintainance

Prefers food brought by the relatives. Medication for hypertension.
Has eaten “mami” for breakfast,
sinigang na isda and half cup of rice for lunch
and “mais na gulay” for dinner in
a 24 hour period.
Elimination: ____________________________
Physical Examination:
Reported regular pattern of elimination.
Cognitive/Perceptual:
Senses are intact and can understand

verbal but with difficulty in
reading written instructions.
Role/Relationships:
Close family tie exist.
Self-Perception/Self-Concept:
Values the role of being a mother
and wishing for immediate recovery
to perform her normal activities.
Coping/Stress: Laboratory Data:

Presence of family members
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provides strength and security.
B. Nursing Diagnoses
DIAGNOSTIC DATA CLUSTERING/ DETERMINING FORMULATING NURSING

CATEGORY GROUPING DATA STRENGTHS DIAGNOSTIC
AND HEALTH PROBLEMS STATEMENTS
Strength:

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Angina relatod to -Tachypnea Increase intake of Ineffective cardiac

Acute Coronary -(+) DOB fatty foods. tissue perfussion
Syndrome -(+) murmur
Health Problem:
Persistent chest
pain
Hypertension -elevation of Deficient knowledge

Blood pressure Strength: about acute
coronary syndrome
Sedentary Lifestyle
self-care.
Health Problem:
Heart attack
C. Nursing Diagnoses Framework

BSHB,BSN, RN
1. Ineffective cardiac tissue perfusion
Chief Medical Diagnosis:
Acute Coronary Syndrome

(Myocardial Infarction)
3. Risk for ineffective

2. Risk for imbalance
peripheral tissue
fluid volume
perfusion.
4. Ineffective airway 5. Deficient

clearance knowledge about ACS
self-care
D. Care Planning
Assessme Nursing Goal Nursing Rationale Outcom Evaluation

nt Diagnosis Orders e
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Data Stateme Criteria

nt
S= Ineffectiv Client will -Monitor For the Relieved

“Ang sakit e cardiac report v/s client to from chest
ng dibdib tissue beginnin decrease discomfort
ko parang perfusion g relief of -follow diet chest reported
kinukurot. related chest strictly discomfort by client.
” to discomfo (low fat, s. Achieved.
As reduced rt. low salt
verbalized coronary diet)
by the blood
patient. flow. -give
analgesics
for onset
O= of pain as
ordered.
-(+) DOB
-tachypnic
RR 34cpm
-
fatigability
E. Nursing Theory Application
E.1. Orem’s Theory: Self-care Deficit Theory
Major Components of the Theory Application to Client’s

Situation
Man/Person Nurse provides bed side care and
Partially Compensatory system assist the patient’s needs.
-nurse and patient share
responsibilityfor care.
Health Nurse monitors the health status of
Partially Compensatory system the patient.
-nurse and patient share
responsibilityfor care.
Environment The nurse should provide a safe and

The environment is linked to the healthy environment for the client,
individual, forming an integrated and this factor helps the patient’s
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interactive system. condition to get better.
Nursing Taking into consideration that the

Is a deliberate action, function of the patient can’t take good care of
practical intelligence of nurses, and herself and needs the assistance of
action to bring about humanely health professionals.
desirable conditions in persons and
their environment.
Key Concepts Perform morning care, and be
Self-care agency, self care demands sensirive to the other needs of the
patient when it comes to her health
condition.
E.2. Orem’s Theoretical Framework
Assessment Planning
Chest pain Educate the family

members to attend
the needs to lessen
the discomfort of the
patient.
Evaluation
The Patient’s family was able to learn

how to care for the patient when
in discomfort. Patient felt comfort with the
help of her family. Implementation
Demonstrate how to care
for the patient when
feeling of
discomfort arises.
Key Conceptual Application of Orem’s Theory

BSHB,BSN, RN
INFORMATION DATA
Name of client: ___RM Age: 68

Civil Status: Widow Education Status: Elementary Graduate
Religion: Roman Catholic Ethnic Group: N/A
Number of Children: 4 Age of Children: 1st -48
2nd -41
3rd -36
4th -30
Support System_______Family and Relatives_____
Cultural Health Beliefs____None_______________
Other pertinent_____________________________
SELF-CARE REQUISITES
1. is there any universal self deficit in the following categories? (if there
is, please indicate)
1.1 Sufficient intake of air
1.2 Sufficient intake of water
1.3 Suffiecient intake of food
1.4 Satisfactory eliminative functions
1.5 Activity balanced with rest__self-care deficit,inadequate rest and

activity imbalance due to sedentary lifestyle.____
1.6 Time spent alone balanced with time spent with others
1.7 Prevention of danger to the self__self care deficit, presence of

acute disease.
1.8 Being normal__self-care deficit, presence of illness.
2. is there a developmental self-care in the following categories? (if there

is, please indicate.)

BSHB,BSN, RN
2.1 Conditions that support life processes and promote the following
specific developmental stages:
2.1.1 inter-uterine life and birth
2.1.2 neonatal life, whether born to term or prematurely, or normal or

low birth weight
2.1.3 infancy
2.1.4 childhood
2.1.5 adolescence
2.1.6 early adulthood
2.1.7 middle adulthood
2.1.8 adulthood
2.1.9 pregnancy in either childhood or adulthood
2.2 Conditions affecting human development
2.2.1 Is there a deficit in provision of care to prevent occurrence of

deleterious effects of these edverse conditions, e.g. is the
provision of adequate nutrition, rest and sleep during pregnancy?
2.2.2 Is there a deficit in provision of care to prevent or overcome

existing or potential deleterious effects of particular conditions;
particularly, in the provision of care to minimize the adverse
effects of the following conditions on human development:
• educational deprivation
• problem of social adaptation; the loss of relatives, friends, or

associates
• the loss of possessions or one’s job
• sudden changes in living conditions
• a change in status, either social or economic
• poor health, poor living conditions; or disability
• terminal illness or expected or expected death

BSHB,BSN, RN
• envoronmental hazards
3. Is there a deficit in the following six categories of health-deviation self-

care requisites? (please specify)
3.1 Seeking and securing appropriate medical assistance when

exposed to specific physical, biological agents, or environmental
conditions associated with human pathological states or when
there is evidence of genetic, physiological or psychological
conditions known to produce human pathology.
3.2 Being aware and attending to the effects and results of

pathological conditions and states including effects on
development.
3.3 Effectively carrying out medically prescribed diagnostic,

therapeutic and rehabilitive measures directed towards preventing
specific types of pathology, regulating human integrated
functioning, correcting deformities, or compensating for
disabilities.
3.4 Being aware of, and attending to or regulating the discomforts or

deleterious effects of medical care measures performed or
prescribed by physicians including their effects on development.
3.5 Modifying the self-concept to be able to accept one’s state of

health or the need for specific forms of health care; learning to live
with the effects of pathological conditions and states; the effects of
medical diagnosis and treatment measures, in a lifestyle that
promotes continued personal development.
E.2. Levine’s Theory: Four Conservation Principles of Nursing

BSHB,BSN, RN
Major Components of the Theory Application to Client’s

Situation
Man/Person Provide healthy and safe
Continually adapting to the environment
environment
Health To promote wellness for the client.

Health is the goal of conservation by
being adaptive to change
Environment Client must be in safe environment
Operational environment undetected for her organs to function well, this
natural forces perceptual will also help for her easy and fast
environment information recorded recovery
Nursing Performing bedside care, monitoring
Nursing is to take care of others v/s, reporting any abnormalities to
when they need to be taken care of. the staff nurses.
Key Concepts The client should be aware of her
Conservation of energy, structural health condition, she should know
integrity, personal and social how to use her energy properly in
integrity. her daily avtivities.

BSHB,BSN, RN
Conservation of Conservation of
Energy Structural
Integrity
Patient RM is
weak and fatigue RM Performs
based on my activities such as
observation. But practicing DBE,
is following the knowing the fact
doctor’s order. that she stays in
Using her the ICU ward she
remaining body needs to observe
energy, patient proper hygiene to
was able to prevent infection.
tolerate the pain.
Levine’s
Theory:
Four
Conservation
Principles of
Nursing
Conservation of
Personal
Conservation of
Integrity
Social Integrity
RM learned the
RM seeks medical
importance of
care with the
having a good
health
hygiene and
professionals.
self-confidence
She develops
increased. She
good relationship
also participates
with the medical
in every activity
staff.
that will help to
improve her
health
condition.

BSHB,BSN, RN
Problem concern Conservation Evaluation: Nursing Measures

of client principles Supportive or
Terapeutic
Chest pain 1. Energy Therapeutic Bed rest
(+)DOB 2. Structural Therapeutic Oxygen

integrity administration
worried about 3. Social Supportive Giving advice.

fast recovery integrity
4. Personal
integrity
E.3. Neuman’s Theory: System Model
E.4. Pender’s Theory: Health Promotion

BSHB,BSN, RN
Major Concepts Definition Application to

Client’s Situation
1. Percieved One’s opinion of Help the patient realize

BSHB,BSN, RN
Susceptibility chances of getting a that the people close to

condition her is also prone in
acquiring some infection
present. She can serve
as an health educator to
the peopla around her.
2. Percieved Severity One’s opinion of how Explain the possible

serious condition and its outcomes of each
consequences are. procedure and the
outcome of it, for the
patient to be ready.
3. Percieved benefits One’s belief in the Explain every procedure

efficacy of the advised that will be done to the
action to reduce risk or patient, explain the
seriousness of impact benefits of each
procedure to gain her
cooperation.
4. Percieved barriers One’s opinion of the Assist the patient to

tangible and perform each activity
psychological costs of and give positive
the advised action opinion regarding the
patient’s condition,
through good
communication.
5. Cues to Action Strategies to Activate Explain each procedure

“readiness” properly to gain the
patient’s cooperation
6. Self efficacy Confidence in one’s Follow the doctor’s

ability to take action advice to obtain healthy
life.
E. Logic Tree

BSHB,BSN, RN

BSHB,BSN, RN

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NCML04N Curative and Rehabilitive Nursing Care Management (Part II)

Xerlen O. Makalintal July 21, 2008 1

Re-defining Acute Coronary Syndrome In The Perspectives Of Adult Health

Xerlen O. Makalintal BSN 4-8

Xerlen O. Makalintal July 21, 2008 2

I would like to extend my deepest gratitude first and foremost to our

To all my friends and classmates who have been there in times of

And lastly to my beloved one who never stopped in supporting me

Thank you again to the trust you bestowed upon me!

Xerlen O. Makalintal July 21, 2008 3

Xerlen O. Makalintal July 21, 2008 4

Xerlen O. Makalintal July 21, 2008 5

Xerlen O. Makalintal July 21, 2008 6

Xerlen O. Makalintal July 21, 2008 7

Xerlen O. Makalintal July 21, 2008 8

II. Anatomy and Physiology

⇒ An adult's heart is approximately 5 inches in size and is larger than an

The essential functions of the heart are:

contraction of the ventricles. This sequential contraction ensures efficient

2. Generation of the Heartbeat

Xerlen O. Makalintal July 21, 2008 10

Impulses generated by the SA node spread rapidly throughout the atria, so

The journey of an electrical impulse around the heart can be traced by a

3. Control of the Heart Rate

Xerlen O. Makalintal July 21, 2008 11

An increase in either heart rate or stroke volume—or both—will increase

Because the heart is composed primarily of cardiac muscle tissue that

When cholesterol plaque accumulates to the point of blocking the flow of

Superior Vena Cava

Inferior Vena Cava

The pulmonary artery is the vessel transporting de-oxygenated blood from

The right ventricle receives de-oxygenated blood as the right atrium

a. Anatomy of the Myocardium

Xerlen O. Makalintal July 21, 2008 15

Several layers of pericardium surround the heart forming a framework of connective

Xerlen O. Makalintal July 21, 2008 16

Legend: 1 - tunica intima 2 - tunica media

Xerlen O. Makalintal July 21, 2008 17

Normal Myocardium With Myocardial Infarction

Dr. Thomas Caceci, VM8054 Veterinary Histology

III. Pathophysiology, Diagnosis and Management of the Disease

1. Change in serial ECG tracings- ST-segment Elevation

• More common in male

Xerlen O. Makalintal July 21, 2008 18

• Lightheadedness with or without syncope

1. Drug therapy – beta blocker

• Drug of choice is metiprolol

2. Improve Oxygen Supply/Demand

Nursing Care Goals

Xerlen O. Makalintal July 21, 2008 19

• Report signs of chest pain

Xerlen O. Makalintal July 21, 2008 20

IV. Pathophysiology, Diagnosis, and Management of Major Complications

Date of Rotation: June 24-28,2008

My clinical rotation was at St. James Hospital at Ward 4. I was assigned to RM

2 months ago before her current hospitalization, she experienced a quick

After 2 months, month of June, RM experienced severe chest pain and

ECG tracing 06/23/2008

Xerlen O. Makalintal July 21, 2008 22

On examination his heart rate is 90 beats per minute, blood pressure is

RM is conscious a, resting in a supine position with head elevated. She appers

Functional Health Pttern Assessment

Xerlen O. Makalintal July 21, 2008 23

In bed, awake, complaining of difficulty of breathing. Looks weak and in pain.

Support System___Family and Relatives_

Cultural Health BeliefsNone___________