INTRODUCTION

“An ounce of prevention is worth a pound of cure”

-Henry de Bracton

You have likely heard this before, it is a very striking quote in a sense that, if
prevention really does the job why come up with lots of cure, right? Maybe this would
answer that question. Prevention is a smart thing to do, no doubt about it. By merely
doing things cautiously, we would avoid things that may harm us and could even save
us from a much serious condition. Being careful does not mean being suspicious, as
humans we are trying to stray away from factors that may cost our living and we often
realize the importance of something when we already lose it. Along with, it is sad to
think that, we have all the means to salvage ourselves from these things that could take
away our riches or worst, our life but we could not breakaway from these things that
causes disease.

It is so ironic that in this day of high-tech, complex, and costly medical

procedures and treatments we are still not be able to control diseases that continuously
disturb people’s lives. As the saying goes prevention is better than cure, we cannot take
things back to its normal state, it is better to avoid things that may break the equilibrium
of our body system than availing cures that would not bring back what has been taken.
To think about it, it is devastating to realize that in the presence of innovations and
advancements we cannot return what was already gone.

Coronary artery disease can present as a chronic coronary syndrome which is

stable or as acute coronary syndromes with unstable patterns. From the clinical
standpoint, acute coronary syndromes can be subdivided into two subsets: ST elevation
myocardial infarction (STEMI) and Non ST elevation acute coronary syndromes which
can be subdivided into: Non-ST elevation myocardial infarction (NSTEMI) and unstable
angina. STEMI and NSTEMI, as well as unstable angina can present with identical

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clinical pictures and reflect a spectrum of severity.
Acute ST elevation MI is caused by relatively prolonged coronary occlusion, a non ST
elevation acute coronary syndrome may represent transient coronary occlusion and
reperfusion leading to myocardial cellular injury and the appearance of markers of
myocardial necrosis. Manifestations of myonecrosis may progress to other heart
conditions such as heart failure. (Retrieved at:
http://www.ceulectures.org/learning/lecture_view.asp?seminarID=acs_nstemi)

The sub-types of acute coronary syndrome include unstable angina (UA, not associated
with heart muscle damage), and two forms of myocardial infarction (MI, heart attack), in
which heart muscle is damaged. These types are named according to the appearance
of the electrocardiogram (ECG/EKG) as non-ST segment elevation myocardial
infarction (NSTEMI) and ST segment elevation myocardial infarction (STEMI). There
can be some variations as to which forms of MI are classified under acute coronary
syndrome.

ACS should be distinguished from stable angina, which develops during exertion
and resolves at rest. In contrast with stable angina, unstable angina occurs suddenly,
often at rest or with minimal exertion, or at lesser degrees of exertion than the
individual's previous angina (crescendo angina). New onset angina is also considered
unstable angina, since it suggests a new problem in a coronary artery.

Though ACS is usually associated with coronary thrombosis, it can also be

associated with cocaine use. Cardiac chest pain can also be precipitated by anemia,
bradycardia (excessively slow heart rate) or tachycardia (excessively fast heart rate).

Myocardial infarction (MI) or acute myocardial infarction (AMI), commonly known

as a heart attack is the interruption of blood supply to part of the heart, causing some
heart cells to die. This is most commonly due to occlusion (blockage) of a coronary
artery following the rupture of a vulnerable atherosclerotic plaque, which is an unstable
collection of lipids (fatty acids) and white blood cells (especially macrophages) in the

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wall of an artery. The resulting ischemia (restriction in blood supply) and oxygen
shortage, if left untreated for a sufficient period of time, can cause damage or death
(infarction) of heart muscle tissue (myocardium). According to Beaglehole, heart attacks
are the leading cause of death for both men and women all over the world. Important
risk factors are previous cardiovascular disease (such as angina, a previous heart
attack or stroke), older age (especially men over 40 and women over 50), tobacco
smoking, high blood levels of certain lipids (triglycerides, low-density lipoprotein or "bad
cholesterol") and low levels of high density lipoprotein (HDL, "good cholesterol"),
diabetes, high blood pressure, obesity, chronic kidney disease, heart failure, excessive
alcohol consumption, the abuse of certain drugs (such as cocaine and
methamphetamine), and chronic high stress levels (O'Meara ES, et al. , 2006).

Classical symptoms of acute myocardial infarction include sudden chest pain

(typically radiating to the left arm or left side of the neck), shortness of breath, nausea,
vomiting, palpitations, sweating, and anxiety (often described as a sense of impending
doom). Women may experience fewer typical symptoms than men, most commonly
shortness of breath, weakness, a feeling of indigestion, and fatigue (Ishikawa T et al.,
March 2006). Approximately one quarter of all myocardial infarctions are silent, without
chest pain or other symptoms.

A heart attack is a medical emergency, and people experiencing chest pain are
advised to alert their emergency medical services because prompt protection with an
external defibrillator can save one's life from primary ventricular fibrillation which occurs
unexpectedly in 10% of all myocardial infarctions especially during the first hours of
symptoms. Contemporary treatment of many myocardial infarctions can result in
survival and even good outcomes. While it is true that certain less amenable cases are
very massive and rapidly fatal "widowmakers", it is also true that in small attacks with
limited damage and optimal treatment the heart muscle can be salvaged.

In the United States, ischemic heart disease is the most prevalent cardiovascular
disorders affecting approximately 213 persons out of 100, 000 populations. Estimates
by the Center for Disease Control indicate that if complications of coronary artery

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disease are controlled, it would be possible to increase life expectancy by 7 years.
(retrieved at: US Center for Disease Control www.cdc.gov)

While in Asia, specifically Malaysia, Acute coronary syndrome is the leading

cause of death. Presently, acute coronary syndrome dominates the statistics in causes
of mortality worldwide. According to a study conducted in Malaysia entitled Acute
Coronary Syndrome (ACS) Registry - Leading the Charge for National Cardiovascular
Disease (NCVD) Database it shows that the strongest determinants of mortality is
basically the Killip class and the age of the patient. And the leading treatments of choice
are antithrombotic such as Clopidogrel, and the use of Percutaneous Coronary
Intervention such as stenting.
(Retrieved at: http://www.acrm.org.my/ncvd/documents/publications/acsRegistry.pdf)

Diabetes mellitus type 2 or type 2 diabetes (formerly called non-insulin-

dependent diabetes mellitus (NIDDM), or adult-onset diabetes) is a disorder that is
characterized by high blood glucose in the context of insulin resistance and relative
insulin deficiency. While it is often initially managed by increasing exercise and dietary
modification, medications are typically needed as the disease progresses. There are an
estimated 23.6 million people in the U.S. (7.8% of the population) with diabetes with
17.9 million being diagnosed, 90% of whom are type 2. With prevalence rates doubling
between 1990 and 2005, CDC has characterized the increase as an epidemic.

Traditionally considered a disease of adults, type 2 diabetes is increasingly

diagnosed in children in parallel to rising obesity rates due to alterations in dietary
patterns as well as in life styles during childhood.

Unlike type 1 diabetes, there is very little tendency toward ketoacidosis in type 2
diabetes, though it is not unknown. One effect that can occur is nonketonic
hyperglycemia which also is quite dangerous, though it must be treated very differently.
Complex and multifactorial metabolic changes very often lead to damage and function
impairment of many organs, most importantly the cardiovascular system in both types.
This leads to substantially increased morbidity and mortality in both type 1 and type 2

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patients, but the two have quite different origins and treatments despite the similarity in
complications.

Community-acquired pneumonia (CAP) is a disease in which individuals who

have not recently been hospitalized develop an infection of the lungs (pneumonia). CAP
is a common illness and can affect people of all ages. CAP often causes problems like
difficulty in breathing, fever, chest pains, and a cough. CAP occurs because the areas
of the lung which absorb oxygen (alveoli) from the atmosphere become filled with fluid
and cannot work effectively.

CAP occurs throughout the world and is a leading cause of illness and death.
Causes of CAP include bacteria, viruses, fungi, and parasites. CAP can be diagnosed
by symptoms and physical examination alone, though x-rays, examination of the
sputum, and other tests are often used. Individuals with CAP sometimes require
treatment in a hospital. CAP is primarily treated with antibiotic medication. Some forms
of CAP can be prevented by vaccination.

It is the researcher’s utmost priority and duty as a nurse to be equipped with

sufficient knowledge to be able to efficiently render care to his patients; an in – depth
study of a client’s health problem or a case study is one of the most efficient way to
satisfy such responsibility. And to efficiently share a body of knowledge to the nursing
field, criteria are being determined by the researchers in choosing the case that will be
used for presentation. The first criteria identified is the complexity of the disease
condition, the increasing mortality rate in line with the disease condition – the trend of
mortality rate regarding Acute Coronary Syndrome increases through time and still one
of the leading cause of mortality worldwide, therefore studying the disease process and
management would increase the chances of survival by being familiar to the disease
and it’s treatment, and the little known knowledge regarding the condition made the
researchers chose such case for presentation.

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Objectives

This case study represents a holistic picture of the patient’s health care problem
that requires a more in- depth analysis with what the patient had experienced. This will
also provide a new opportunity for the researchers to examine the relationship of
associated factors with the phenomena of the study.

A. Nurse – centered
a. After the conduct of the study, the nurse shall be able to:
1. To ensure appropriate evaluation of the etiology.
2. Reassess and address the course of the illness takes in its
progression.
3. Respond to the disease condition through appropriate nursing
interventions.
4. Evaluate the client’s response to medical management.
5. Promote rehabilitation and prevention of relapses through
effective health teachings.

B. Patient – centered
a. To promote optimum level of functioning, prevent further relapses, and
development of complications through:
1. Thorough assessment of the clinical manifestations.
2. Proper problem identification.
3. Promotion of clients’ active participation through consensual
identification of proper interventions to address identified problems.
4. Promotion of independence through appropriate health teachings.
5. Evaluation of the client’s response to nursing interventions and the
needs in providing reinforcements from the nursing interventions
provided.