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Case Study On Acute Coronary Syndrome

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Question:

Discuss about the Case Study on Acute Coronary Syndrome.
 
 

Answer:

Introduction

Acute Coronary Syndrome refers to different conditions with common Pathophysiology, which may be referred to as heart attack, thrombosis in the coronary artery, or unstable angina. ACS leads to the death of part of heart tissues or may render a section of the heart non-functional, if it is not treated within a short time(Carney 2013). This case study explains the role of the nurse in assessment treatment and assessment of an ACS case, presenting with signs and symptoms that are characteristic of an individual suffering an ACS. Andrew Tailor who is a 48-year-old individual, a high school physical education teacher discharged from the orthopedic ward due to a left knee reconstruction the previous 3 days apparently manifests with ACS symptoms on his date of discharge.  As a nurse, I notice that he is distracted and even looks pale. Further signs and symptoms that make me suspect that he could be suffering a heart attack. The signs and symptoms that he presents with include central chest pain, uncomfortable chest tightness since morning, diaphoresis, and cool peripheries, respiratory rate at18, the heart is 115/60 and his SpO2 at a 97% on room air. This report includes details of my initial assessment and management of Andrew Tailor. Further details include how I would use the PQRST mnemonic to conduct a systematic assessment of Andrew’s chest pain, five nursing priorities for that I could provide to as a registered nurse, including the rationale explaining how each of the priorities can address and/or is related to ACS Pathophysiology.

Systematic Assessment of Andrews Chest Pain Using the PQRST mnemonic

As a Registered Nurse, I will asses Andrews pain using the PQRST mnemonic.  I will then document the responses, in order to provide the right medication procedures. Even so, since the symptoms imply a possible heart attack, I will do so, in a very short period as I call the ambulance.

Provocation

In the first step, I will ask for the provocation of the pain, which Andrew feels in the chest. Ciaramelli et al(2015), indicates that the patient should indicate the activity they were engaging in when they started feeling the chest pain in order to find leads to the condition. In this regard, I will seek for information on what activity makes the pain go or worsen.  In responding to these first two questions, the patient would most likely be able to answer the third question, on what activity can trigger the chest pain, the discomfort in the chest and the shortness of breath. Since Andrew had been in the orthopedic ward for the previous three days, I will seek for information as on which particular position of sitting, sleeping, or standing causes much of the pain in the chest. In this case, I will also seek for information on what makes the pain go or which position that Andrew takes in order to see the pain disappear. The patient should also provide information on whether changing positions or resting helps relieve pain.  If bending, lying on bed, or walking aggravates Andrews’s pain, then I will also note this in the diagnosis.

Quality/Quantity

In this regard, I will ask Tailor to explain further on the discomfort he feels. I will provide the patient with different terms with which he can describe his chest pain. These include terms such as sharp, dull, slight, and extensive pain. In this, I will classify the condition as angina or un-angina. Angina in this case is a sharp pain that persist for long and tends to be radial.

Region/Radiation

While Tailor has already indicated that his pain is at the central part of the chest, I will seek answers on whether the pain radiates or not. This is because excessive and radiating chest pain could imply the probability of myocardial ischemia.  As a sports person he might sustained other internal injuries, not diagnosed before at the orthopedic section of the health facility. The patient should explain how the pain travels or whether it is localized to the chest alone(Heradstveit & Heltne 2014). Further, I will ask Tailor to indicate whether the pain started from somewhere else before moving to the central part of the chest as indicated in his brief after his discharge.

 

Severity Scale

In this case, I will ask the patient to indicate the pain severity on a scale of between 0 and 10, where zero means no pain while 10 implies worst pain that Andrew Tailor has ever felt in his life. I will also let him to explain whether he thinks he can carry out physical activities with such pain.  He needs to indicate how bad the chest pain is at its worst level according to Al-Ziarjawey (2015). For instance, if it forces him to sit, lie down or even slow his movements. Further, the patient should indicate how long one episode of his chest pain lasts.

Timing

In this case, I will seek to understand and document the time the specific time the pain started apart from his general responses after being discharged. Since Tailor indicates that the pain had started the morning he has discharged, then, he should be able indicate how long it lasted after he felt it for the first time.  According to Heradstveit & Heltne (2014), the patient should also indicate how often the pain occurs and what he was doing in the morning when he first experienced the central chest pain.  At this point, I will ask Andrew to state other additional signs and symptoms that he experiences a part from diaphoresis, sweating and cooling of his legs and the hands, the shortness in breath and the feeling of a congested chest.

The first five nursing priorities for Andrew

The following are the first five nursing priorities for a case of Acute Coronary Syndrome conditions.

Immediate ECG and transportation of patient to the emergency department-ECG determination will help me to note the electrical functioning of the heart and at the same time understand the blood flow behavior in the heart muscles.

Administration of 324 mg Aspirin, beta-blockers, and morphine-Aspirin and beta-blockers can use alternatively to induce reperfusion and to prevent myocardial infarction in the patient. Morphine on the other hand will work as a pain reliever since the pain seems to be stressing the patient.

Immediate Starting of the Patient on Oxygen and Monitoring his condition- Since Andrew’s SpO2 is 97%, it is necessary that he be put on Oxygen through the nasal cannula, before taking him to the emergency department. This will help replenish the oxygen levels back above 98% in order to reduce both diaphoresis and cooling of the peripheries due to lack reduced blood flow to these regions.

Administration of Cardiac Markers-Cardiac markers like the Troponin hormone induces heart muscle contraction and thus helps trigger reperfusion. It will also stabilize the heart rate and thus prevent myocardial infarction.

 


Administration of Anticoagulants-Anticoagulants such as UFH will prevent blood coagulation in the body. However, since the patient recently underwent knee reconstruction, I will use fondapiranux, a coagulant that has lesser coagulation effect, to prevent bleeding at the wound.

 


Rationale of the Management Strategies for ACS

Immediate ECG and transportation of patient to the emergency department

The first measure I should take is to use the electrocardiogram (ECG), to assess the patient’s heart muscular and electrical functioning. Being a two-stage pump that is electrical, it is necessary to measure the myocardial electrical activity in the first five minutes, since it is an important documentation to be used by a receiving physician at the emergency department(Pengo 2009). This device will help in providing evidence on the blood flow to the myocardium, through the coronary artery particularly. Noting that he has an acute coronary syndrome and thus could suffer from myocardial infarction and possible life-threatening ischemia attack, I would call for an ambulance and transport him to the emergency department. I will provide the receiving physician at the Emergency department with my report. From Pathophysiology of ACS, it is clear that any delays could lead to myocardial infarction and the death of muscle cells(Pengo 2009).  Further occlusion of the coronary artery due to coagulated blood, and even that occurs in a short while, could lead to heart failure and death(Lv 2013).  Studies indicate that heart related diseases are among the life-threatening conditions today (Reshma 2014). Therefore, fast medical attention of Tailor Andrew is necessary, to prevent further myocardial infarction and blood coagulation.

 


Administration of Aspirin, beta blockers and morphine

The first move of a nurse is always to stabilize the patient before administering other treatment measures. Therefore, I would immediately give him 324 mg of Aspirin while he is being moved to the Emergency Department, if he indicates that he is never allergic to the drug. Aspirin works as an anticoagulant and if administered along with morphine, the patient stabilizes as the pain also is relieved, reducing the paleness, diaphoresis, and stress(Lv 2013).  If the patient indicates that he is allergic to aspirin, I will administer P2Y12 inhibitors alone and inform the receiving physician of the same, in order to continue the administration indefinitely(Funk  & Duvernoy 2015).  There is need to administer beta-blockers as they reduce mortality of the myocardium, readmission, and the re-infarction in cases of coronary artery syndrome. According to the Centers for Medicare and Medicaid Services (CMS) in John & Bhatt (2004), there is need to administer the beta-blockers also in cases of Acute Myocardial Infarction in patients.

Immediate Starting of the Patient on Oxygen and Monitoring

Since Andrew’s SpO2 is 97%, it is necessary that he be put on Oxygen through the nasal cannula, as soon as Tailor arrives at the emergency department. From the Pathophysiology of ACS, it is clear that there is less oxygen within the hemoglobin in the red blood cells (Schamroth 2012). Heart muscles require oxygen for aerobic respiration in order to obtain the energy necessary to pump blood in the Left ventricle, to the rest of the body(Reshma 2014). Occluded coronary artery means that lesser blood and oxygen reach some parts of the heart muscles, leading to death in a short while.  Starting the patient with oxygen also helps him relieve the angina due to the contraction and expansion of the rib cage to breath. It is probable that Andrew could be undergoing a Myocardial Infarction. This simply refers to a heart attack, caused by coronary thrombosis or occlusion(Funk  & Duvernoy 2015).  This may involve the blocking of either one or several coronary arteries. In cases where the blockage covers a vast area o the heart, then there are high chances of death, as oxygen and ATP do not reach these cells(Reshma 2014). If there is no death, it is probable that there will be heart tissue necrosis and scarring. Other blood vessels can still take over to supply blood to these damaged areas if care is immediately provided.

Administration of Cardiac Markers

There is an urgent need to administer Troponin, which is a hormone that will induce cardiac muscle contraction in order to trigger normal heartbeat.  While there are different types of Troponin hormone, Troponin I and/or T, are very sensitive (Ramaraj et al 2010). Administering these two needs to be done carefully and specifically for particular myocardial injuries. However, different health institutions are currently adopting more novel highly sensitive Troponin I assay. Therefore, there is need to measure and monitor the patient’s Troponin levels on arrival and after a set period(Funk  & Duvernoy 2015).  The lower the level of Troponin in the heart muscles, the lesser the heart muscles contract and the lesser the blood the left ventricle is able to push into the aorta and eventually into the arteries, including the heart’s own coronary artery.  In case there is occlusion within these arteries, it is likely that some cell tissues of the heart muscles will begin to die off.  From the Pathophysiology of ACS, it is clear that death of heart muscles is an irreversible procedure and thus, there is need to provide Troponin, where the pulse rate is lower than expected (John & Bhatt 2004). Since Andrew Tailor has just been discharged from the orthopedic department due to knee injury, there is need to also carry out an x-ray procedure to ascertain any internal fracturing and bleeding that could have arisen from a possible fall, which also led to his injury.

Administration of Anticoagulants

Apparently, Andrew requires primary percutanous coronary intervention. Therefore, anticoagulants are necessary to prevent occlusion of the coronary artery and other vessels on the myocardium(Colby 2008). In this case, intravenous unfractionated heparin (UFH) to be started on him in order to have a maintained clotting levels that are therapeutic. However, having been discharged from a knee injury, it is most likely that using UFH could retrigger bleeding at the wound. Thus, the levels of UFH should be maintained at a proper level, or alternatively, bivalirudin should be used, in this case where bleeding is possible (Journal Of Interventional Cardiology 2006). Also instead of using UFH, nurses should administer the Xa inhibitor known as fondapiranux, which is a recommended alternative, as an anticoagulant. Studies indicate that early administration of aspirin, bivalirudin, or the other coagulants prevents acute myocardial infarction in high-risk patients (The Pharmaceutical Journal 2015).  This could be the case for Andrew, having complained of pain since he woke up in the morning. Another critical anticoagulant is Enoxaparin, which reduces the death of heart muscles with a 20% more than UFH(Colby 2008). It is however clear that Fondapiranux is effective up to the 180th day, but it could lead to catheter thrombosis. Therefore, it should be supplemented with other anticoagulants that are appropriate in cases of percutaneous coronary intervention. Pathophysiology of ACS indicates that sedimentation rate of a patient’s red blood cells are usually higher especially after the occurrence of myocardial infarction(Carney 2013).  In this case, there is need for anti-coagulants as described above. This is because the biggest risk once a heart attack occurs includes arrhythmias and a cardiac standstill leading instant death in several cases.

In conclusion this report presents a case study on how as a registered nurse, I ought to assess and provide immediate management of an individual with Acute Coronary Artery.  Thus, the report consist of the PQRST mnemonic which I  used to conduct a chest pain assessment of Andrew Tailor, a patient who had presented with signs and symptoms of acute coronary syndrome.  The procedure includes provocation, quality, and/or quantity of pain, the radiation of the pain, the severity, and lastly the timing.  The report also details five different strategies that I used to initially manage the condition of Andrew Tailor, as a registered nurse. These include the taking of ECG measures, movement of patient to the emergency department, administration of Aspirin and beta-blockers and morphine to stabilize blood flow and relieve pain, starting the patient on oxygen, anticoagulants, and hormone Troponin, to trigger electrical and structural functioning of the heart. Lastly, the report provides the relationship between the above interventional approaches and the Pathophysiology of Acute Coronary Syndrome. Further, the report includes several textual references from researchers and publications that have ventured into explaining Acute Coronary Syndrome among other heart disease conditions.

 

References

Carney, E. (2013). Acute coronary syndromes: Management of acute coronary syndrome—renal outcomes. Nat Rev Nephrol, 9(9), 492-492. https://dx.doi.org/10.1038/nrneph.2013.137

Colby, S. (2008). Improving management of Acute Coronary Syndrome in the rural Emergency Department. Australasian Emergency Nursing Journal, 11(4), 209. https://dx.doi.org/10.1016/j.aenj.2008.09.042

Pengo, V. (2009). Prasugrel for the treatment of patients with acute coronary syndrome. VHRM, 321. https://dx.doi.org/10.2147/vhrm.s3428

RAMARAJ, R., MOVAHED, M., & HASHEMZADEH, M. (2010). Novel Antiplatelet Agent Ticagrelor in the Management of Acute Coronary Syndrome. Journal Of Interventional Cardiology, 24(3), 199-207. https://dx.doi.org/10.1111/j.1540-8183.2010.00613.x

Schamroth, C. (2012). Management of acute coronary syndrome in South Africa : insights from the ACCESS (Acute Coronary Events - a Multinational Survey of Current Management Strategies) registry : cardiovascular topics. Cardiovascular Journal Of Africa, 23(7), 365-370. https://dx.doi.org/10.5830/cvja-2012-017

TCT Annual Meeting: Acute Coronary Syndrome-Management. (2006). Journal Of Interventional Cardiology, 19(2), 189-190. https://dx.doi.org/10.1111/j.1540-8183.2006.130_4.x

Acute coronary syndrome guideline. (2015). The Pharmaceutical Journal. https://dx.doi.org/10.1211/pj.2015.20069059

Funk, A. & Duvernoy, C. (2015). Acute Coronary Syndrome: Current Diagnosis and Management in Women. Current Cardiovascular Risk Reports, 9(8). https://dx.doi.org/10.1007/s12170-015-0468-z

Lv, S. (2013). Prevalence and management of hypertension in patients with acute coronary syndrome vary with gender: Observations from the Chinese registry of acute coronary events (CRACE). Molecular Medicine Reports. https://dx.doi.org/10.3892/mmr.2013.1461

Reshma Kureemun, P. (2014). Acute Coronary Syndrome and Pheochromocytoma Management: About Two Cases. Analgesia & Resuscitation : Current Research, 03(04). https://dx.doi.org/10.4172/2324-903x.1000127

AL-Ziarjawey, H. (2015). Heart Rate Monitoring and PQRST Detection Based on Graphical User Interface with Matlab. International Journal Of Information And Electronics Engineering. https://dx.doi.org/10.7763/ijiee.2015.v5.550

Ciaramelli, E., Neri, F., Marini, L., & Braghittoni, D. (2015). Improving memory following prefrontal cortex damage with the PQRST method. Front. Behav. Neurosci., 9. https://dx.doi.org/10.3389/fnbeh.2015.00211

Heradstveit, B. & Heltne, J. (2014). PQRST – A unique aide-memoire for capnography interpretation during cardiac arrest. Resuscitation, 85(11), 1619-1620. https://dx.doi.org/10.1016/j.resuscitation.2014.07.008

John, J. & Bhatt, D. (2004). Management of Acute Coronary Syndrome in Diabetes Mellitus. Herz, 29(5). https://dx.doi.org/10.1007/s00059-004-2614-0

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