NURSING CARE FOR A PATIENT WITH NSTEMI ADMITTED FOR INSERTION OF

PERCUTANEOUS CORONARY STENT A CASE STUDY

INTRODUCTION

This case study aims to apply the clinical nursing skills on a patient with myocardial infarction
admitted to a government hospital in the Kingdom of Saudi Arabia for percutaneous coronary
stent insertion. Before commencing with this study, approval from the ward managers of the
selected government hospital was acquired. Informed consent was also taken from the patient
and assured that the informations herewith will be treated with anonymity and confidentiality.

It is also important to introduce the personal details of the patient, before commencing with
the case description and explaining the disease process of myocardial infarction.

Case description

Table 1 summarizes Mr. Fouads demographic profile. He is a 41 year old male, admitted to
Coronary Care Unit on 10 August 2016 at 0037H with a specific physician diagnosis of Non-
ST Segment Elevation Myocardial Infarction (NSTEMI). He is a known diabetic, hypertensive
patient and he denies smoking addiction and had a history of Coronary Artery Disease, sudden
cardiac death.

He came to emergency room on wheelchair borne, with complaints of retrosternal

compressing type of chest pain that started around midnight and continue through out the day
intermittently with waxing and waning intensity. The pain was sudden in onset, and crescendo
over the day. It was associated with sweating, fatigue and dyspnea. He has history of long
distance travel recently (10 hours journey). He had positive Troponin I (0.094) with no acute
changes in initial electrocardiography (table 2).

Mr. Fouad was seen by Dr. Mohammed and given the author (being the attending nurse-in-
charge) order to facilitate blood investigations (table 3), 2D echocardiogram (table 4); and
prescribed some medications such as Juspirin 300mg/tablet per orem (PO) and Plavix
300mg/tablet PO (table 5). After oral intake of medications, the patient should be kept on NPO
(Nil per orem), an intravenous (IV) fluid of normal saline at 100 milliliters (mls) /hour was
started. Patient was prepared for cardiac catheterization, as a form of investigation. Attending
physicians orders were carried out immediately including securing. Mr. Fouad developed mild
chest pain at around 0230H, received IV Infusion Nitroglycerin at 5mcg/min and titrate
accordingly to BP response, maintain systolic blood pressure above 100mmHg. Discontinued
IV Infusion Nitroglycerin at 0600H.

Table 1. Demographic profile

Patient Name : FOUAD

Age : 41 years old

Gender : Male

Marital Status : Married

Nationality : Saudi Arabian

Religion : Muslim

Occupation : Businessman (Wholesale Trade)

Address : Riyadh, Kingdom Saudi Arabia

Social history : Heavy smoker (2-3 packs/day)

Height : 165 cm

Weight : 90 kg

Altered anatomy and physiology

NSTEMI is called incomplete heart attack as per Jerome E. Granato (2011) and also one type
of myocardial infarction. It is defined as a growth form of cell death without ST-segment ECG
(electrocardiography) changes and elevation. This results to an acute disturbance of blood
supply to a part of the heart and can be indicated by an elevation of cardiac markers (CK-MB
or troponin) in the blood (Granato, 2011).

ST-segment is an ECG tracing; its elevation demonstrates full thickness treachery of heart
muscle (Granato, 2011). Absence of ST-segment elevation in NSTEMI is comprehended to
implicate less than full thickness (partial thickness) damage of heart muscle according to Carol
J. Buck (2012). Hence, NSTEMI is less extreme kind of heart attack proportionate to STEMI
(ST-segment elevation myocardial infarction) in which full thickness damage of the heart
muscle develops.

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Pathophysiology

Figure 1 shows a partial closure or blockage of a major coronary artery or a complete blockage
of a minor coronary artery heretofore affected by atherosclerosis as describe by Joanne
Mozarelli et al., (2011). Atherosclerosis or stiffening of the arteries (figure 1) is a circumstances
in which plaque constructs up within the arteries. Many years are requisite to consummate an
atherosclerotic plaque. The most common mechanism of NSTEMI is rupture or erosion of an
atherosclerotic plaque that triggers platelet adhesion, activation, and aggregation, which bring
to establishment of a thrombus (figure 1) in a coronary artery.

As stated by Lina Badimon et al., (2012), normally, partial thickness damage of heart muscle
happens. Richard A. Mc Pherson et al., (2011) agreed that arterial thrombus induce disruption
of blood supply to part of the heart muscle; deep changes take place in the heart that leads to
an irreversible change and death of myocardial cells. According to Marvin R. Levy et al.,
(1992), plaque is made up of cholesterol, fatty material, cellular waste products, calcium and
fibrin (a clotting substances in the blood).

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Physical assessment and vital signs

During admission to CCU, Mr. Fouad general conditions were assessed by the author to be
fully conscious, awake, alert, communicating well and followed commands, able to move all
limbs with total GCS 14/14. On examination, Mr. Fouad is fully conscious and coherent with
initial vital signs:

BP: 122/80mmHg
Pulse Rate: 92/min
SPO2: 97% on room air
RBS: 139mmoL.

Very mild chest pain was complained by the patient. No complaint of nausea or vomiting.
Output was noted to have 600 mL urine for the first hour, while the total intake calculated was
730.6 mL within 7 hours and voided freely for 8 hours. The vital signs monitored are reflected
on the appendix. Within normal range without any signs of respiratory distress, tolerated with
oxygen support via nasal cannula and regulated at 2L/min, the Sp02 was maintained at 98%
at the end of the 8 hour shift.

Medical/Surgical plans and descriptions

Past Medical history : Retrosternal compressing type of chest pain with

dyspnea and pain unrelated to exertion.

Known diabetic and hypertensive.

Surgical Plan : Post Percutaneous Coronary Intervention to mid

right coronary artery (1 Drug-Eluting Stent).

Laboratory results

ECG (appendix 1) upon admission shows no acute changes, while the heart rhythm consistent
regular and considered normal sinus rhythm with total heart rate between 75-85 beats per
minute (appendix 1). There were no ST segment elevation seen in leads V1 and V2. This
reading was important to be noted in order for the author to validate the physicians diagnosis
of NSTEMI myocardial infarction to the patient. Small Q inferior leads noted on leads II, III,
and AVF was the primary validation of the the NSTEMI diagnosis. This means that the
myocardial infarction is old and was not an acute attack.

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The rest of the ECGs tracing shows the PR interval that was followed by a QRS and every
QRS complexes is preceded by a P wave. This means that the patient prognosis of having a
healed old myocardial infarction is high and activities of daily living can be tolerated. The LAA

(Left Atrial Abnormality) showing an mshaped (notched) and widened P wave (0.12 second)

in a "mitral" lead (I,II,aVL) were also important to note a deep negative component to the P
wave in lead V1 (P Mitrale) showing the ability of the heart muscle to tolerate an open heart
surgery. The QT/QTc interval 404/430 milliseconds were calculated in lead II and V5 before
commencing stent insertion for an open heart surgery. The QRS interval was calculated to be
80 milliseconds. This means there were no loss of heart voltage noted, and that the electrical
activity of the heart remains rhythmic. The T wave flattening in amplitude is a sign of an
electrolyte imbalance that is why serum laboratory investigation (table 2) was necessary to be
done.

Table 2. Serum laboratory investigation

Serum Normal value Result

Serial Cardiac Enzymes and Creatinine 62 - 106 70

Troponin I
CPK-MB <25 15

CPK 20 - 200 151

Troponin I < 0.028 (0.094) Positive

Electrolytes

Urea 2.78 - 8.07 3.30

Potassium 3.5 - 5.1 4.12
Creatinine 62 - 106 70
Chloride 98 - 107 70

Complete Blood Count

WBCs 4-11 9.11

NEUTROPHILS 2 - 6.9 5.31
NEUT % 37 - 80 58.20

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 LYMPHOCYTES 0.6 - 4 2.59
LYM % 10 - 50 28.40
Hemoglobin 13 - 17.4 15.0
Hematocrit 39 - 52 41.1
MCV 78 - 96 83.0
MCH 27 - 32 30.3
MCHC 29 - 37 36.5
RDW 11.6 - 15.5 11.7
Platelets 150 - 450 300
MPV 7.4 - 10.4 10.7

Lipid Profile

Cholesterol < 5.21 5.98

HDL Cholesterol 0.9 - 1.45 0.83
LDL Cholesterol < 4.12 3.90
Triglycerides < 2.0 4.5

Liver Function Test

Albumin Serum 40 - 49 40
Alkaline Phosphate 40 - 130 98
ALT/GPT < 41 30
AST/GOT < 40 26
Direct Bilirubin <5 2.60
Total Bilirubin < 21 8

Delta-Dimer 0.05 0.39

Hemoglobin A1C 4.8 - 5.9 6.96

Chest X-Ray was also indicated for clearance before surgery commences. The result shows
clear both lung fields and costophrenic angles. Normal cardiac size and shape. This is why it
is important to perform an echocardiogram (table 3) and a coronary angiogram (table 4) since
the chest x-ray is not able to identify abnormalities of the regions of the heart and its chambers.

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 Table 3. Echocardiogram

Left ventricle Regional wall motion abnormality noted in inferoposterior wall (basal
to apical). Overall normal systolic function EF: 56%.

Left atrium Normal size.

Aortic valve Structurally normal. No regurgitation or stenosis.

Mitral valve Structurally normal. No regurgitation or stenosis.

Right ventricle Dilated with good systolic function.

Right atrium Normal size.

Tricuspid valve Structurally normal. No regurgitation or stenosis.

Pulmonic valve Structurally normal. No regurgitation or stenosis.

Aortic arch Normal.

Inferior venacava Normal.

Table 4. Coronary Angiography

Left Main Stem normal

Left Anterior Descending minor atheroma mid course and mild disease distally

1st Diagonal mild tubular disease in the prox segment

Circumflex non domain a good calibre vessels with mild bifurcation mid
vessel disease

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 Right Coronary Artery dominant and critical mid vessel narrowing with further
moderate tandem lesion (culprit vessel).

Drug Study

Table 5 highlights the drugs used for this case in preparation for percutaneous coronary
stenting. However, this study will only discuss Morphine IV that was ordered for pain
management.

Morphine: Morphine 3mg IV PRN was ordered since it is an opioid or narcotic pain medication
which is used to treat moderate to severe pain. It works by reducing the pain perception center
in the brain as mentioned by James A. Mays (2013).

Indications

Morphine is very widely used analgesic for the relief of acute and chronic moderate to severe
pain. This is indicated for patients with acute and old myocardial infarction and acute coronary
syndrome when pain has not been relieved by nitrate drugs (i.e. nitroglycerin) (ACLS
Certification Institute, 2016)

Contraindication/Precautions

Nurseslabs (2012) explained that Morphine are contraindicated for hypersensitivity to opiates;
increased intracranial pressure; convulsive disorders; acute alcoholism; acute bronchial
asthma, chronic pulmonary diseases, severe respiratory depression; chemical-irritant induced
pulmonary edema; prostatic hypertrophy; diarrhea caused by poisoning until the toxic material
has been eliminated; undiagnosed acute abdominal conditions; following biliary tract surgery
and surgical anastomosis; pancreatitis; acute ulcerative colitis; severe liver or renal
insufficiency; Addisons disease; hypothyroidism; during labor for delivery of a premature
infant, in premature infants; pregnancy; lactation.

Adverse Reactions/Side Effects

In pursuance of Nurseslabs (2012), serious adverse reactions related to Morphine Sulfate

involves respiratory depression, apnea, and to a lesser degree, circulatory depression,
respiratory arrest, shock and cardiac arrest. Seldom, anaphylactoid reactions have been
reported when morphine or other phenanthrene alkaloids of opium are administered
intravenously.

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Other potential adverse reactions (Nurseslabs, 2013) comprises:

Central Nervous System Euphoria, dysphoria, weakness, headache, agitation, tremor,

uncoordinated muscle movements, visual disturbances, transient hallucinations and
disorientation.
Gastrointestinal Constipation, biliary tract spasm.
Cardiovascular Tachycardia, bradycardia, palpitation, faintness, syncope and orthostatic
hypotension.
Genitourinary Oliguria and urinary retention; an antidiuretic effect has been reported.
Allergic Pruritus, urticaria and skin rashes. Anaphylactoid reactions have been reported
following intravenous administration.
Other Opiate-induced histamine release may be answerable for the flushing of the face,
diaphoresis and pruritus frequently seen with these drugs. Wheals and urticaria at the site
of injection are likely related to histamine release and will depress the cough reflex.

Nursing Responsibilities

Nursing responsibilities before, during and after giving Injection Morphine should be applied
as advised by Nurseslabs (2012):

Assessment & Drug Effect.

1. Obtain baseline respiratory rate, depth, and rhythm and size of pupils before administering
the drug. Withhold drug and inform doctor if any abnormalities observed such as
respirations of 12/min or below and myosis are signs of toxicity.
2. Observe patient closely to be certain pain relief is achieved. Record relief of pain and
duration of analgesia.
3. Observe any abnormalities such as increase pulse or respiratory rate, restlessness,
anorexia, or facial grimacing that may signify need for analgesia.
4. Differentiate among restlessness as a sign of pain and the need for medication,
restlessness associated with hypoxia, and restlessness caused by morphine-induced
Central Nerve System stimulation (a paradoxic reaction that is particularly common in
women and older adult patients).
5. Assess vital signs at regular intervals. Morphine-induced respiratory depression may occur
even with small doses, and it increases progressively with higher doses (generally max:
90 min after SC, 30 min after IM, and 7 min after IV).
6. Encourage changes in position, deep breathing, and coughing (unless contraindicated) at
regularly scheduled intervals. Narcotic analgesics also depress cough and sigh reflexes
and thus may induce atelectasis, especially in postoperative patients.

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7. Be alert for nausea and orthostatic hypotension (with light-headedness and dizziness) in
ambulatory patients or when a supine patient assumes the head-up position or in patients
not experiencing severe pain.
8. Strictly monitor intake and output pattern. Report oliguria or urinary retention if present.
Morphine may dull perception of bladder stimuli; therefore, encourage the patient to void
at least q4h. Palpate lower abdomen to detect bladder distention.

Patient Family & Education.

1. Instruct to avoid alcohol and other Central Nerve System depressants while receiving
morphine.
2. Inform do not use any drug available without a prescription from the doctor.
3. Instruct the family do not ambulate the patient without assistance after receiving drug.
Bed rails up and lock the bed are advised.
4. Explained to avoid tasks requiring alertness (e.g., driving a car) until response to drug is
known since morphine may cause drowsiness, dizziness, or blurred vision.

Table 5. Drug study for coronary stenting

Drugs Names Dosage Frequency Indication Side effects

Plavix 75 mg/tab Once a day Blood clot Blood tinged urine

Concor 10 mg/tab Once a day Chest pain Mild headache, and

skin rashes

Ramipril 5 mg/tab Once a day Hypertension Dizziness & nausea

Lipitor 40 mg/tab Once a day Cholesterol Dark colored urine

Lipantyl 145 mg/tab Once a day Triglyceride Runny nose

Pantozol 40 mg/tab Once a day Duodenal ulcer Headache

Juspirin 81 mg/tab Once a day Clotting Discoloration of urine

Morphine 3 mg As necessary Chest pain Drowsiness

intravenous

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NURSING CARE PLAN

Specifically, for this patient, the priority nursing diagnosis would be acute pain related to
decrease in myocardial blood flow. Lopez et al., 2006, Yusuf et al., 2001a, Reddy, 2004 and
Yusuf et al., 2001b stated that pain due to myocardial infarction is one of the causes of death
worldwide leading to ischemic heart disease and is expected to grow more than 120% in
developing countries by the year 2020.

Which is why the primary nursing intervention is to assess for vital signs and symptoms of
pain such as facial grimacing, rubbing of neck or jaw, reluctance to move, increased blood
pressure and tachycardia. Note onset, duration, location and pattern of pain. This will
differentiate angina pain from other referred pains. Pain was monitored hourly (appendix 2).
Secondly, oxygenation were provided to relax the myocardial muscles. It is also important to
stay with the patient to decrease anxiety that may increase myocardial workload. Complete
bed rest and maintained on moderate high back rest at 450 angle head of bed to decrease
myocardial oxygen demands through vasodilation, preload and after load reduction.
Medications are the lesser priority intervention since these are dependent nursing actions that
requires licensed physicians orders. The other nursing interventions support the surgical
plans for percutaneous coronary stenting (table 6).

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 Table 6. Nursing Care Plan

Assessment Planning Intervention Rationale Evaluation

Nursing Diagnosis: Acute pain related to decreased myocardial blood flow
Subjective: After 8 hours of Assess for vital signs and symptoms To differentiate angina pain After 8 hours of
The patient nursing of pain such as facial grimacing, from pain related to another nursing
reports: interventions the rubbing of neck or jaw, reluctance to causes. interventions and
Retrosternal patient will be move, increased blood pressure and health teaching,
compressing able to: tachycardia. Note onset, duration, patient verbalized
type of chest Reduce pain location and pattern of pain. was free from pain
pain from 7 to 3 in Provide oxygenation using nasal To promote heart muscle with rated pain as 3
Rated pain as the scale of cannula at 2LPM. relaxation in the scale of 10,
5 in the scale 10 being the maintained stable
Stayed with the patient during chest To decrease anxiety and
of 10 most painful vital signs and
pain episodes. promote comfort.
Objective: Maintain prepared for
Restlessness stable vital Instructed complete bed rest and To decrease myocardial coronary stenting.
Weak pulse signs maintained on moderate high back oxygen demands through
Facial Prepared for rest at 450 angle head of bed. vasodilation, preload and
grimacing emergency after load reduction and
Palpitation coronary decreased cardiac work
stenting load.
 Jugular vein Administer analgesic such as Potent option analgesic may
distention Morphine by appropriate route be used in acute angina
Cool and example an IV and other because of its beneficial side
clammy skin appropriate medications as ordered effects. Such effects include
Fatigue (table 5) peripheral vasodilation and
Peripheral reduced myocardial
cyanosis workload; sedation which
Shortness of produces relaxation; and
breath interrupted flow of

vital signs: vasoconstricting

BP: catecholamines, thereby

122/80mm effectively relieving severe

Hg chest pain.

Pulse Rate:
Instructed the patient to notify nurse To minimize ischemia
92/min
immediately when experiencing produced by increased
SPO2: 97%
pain. myocardial workload.
on room air
Obtained a 12-lead ECG To monitor ischemic
RBS:
immediately during acute cheat changes.
139mmoL.
pain.
VAS 7/10
Maintained a quiet, comfortable Mental or emotional stress
environment; restrict visitors as increases myocardial
necessary. workload.

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 Prepared for potential surgery
Observed associated symptoms,
such as dyspnea, nausea, vomiting,
dizziness, palpitation and desire to
urinate.
For coronary stent
application as ordered
Decreased cardiac output,
which may occur during
ischemic myocardial
episode, stimulate
sympathetic or
parasympathetic nervous
system, causing a variety of
vague sensation that patient
may not identified as related
to angina like episodes
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Trans-out

Mr. Fouad stayed overnight in Coronary Care Unit. Mr. Fouad was referred to dietitian,
nutrition status assessed by Ms. Nouf Bassemet on 10 August 2016 prior to coronary
angiography. Mr. Fouad was diagnosed at high nutritional risk due to compromised lipid profile
as evidence in recent laboratory results show Mono: 7.90 (high), MPV:11.1(high), Chol: 5.98
(high), CL: 97 (low), HbA1c: 96 (high), HDL: 0.83 (low), TG: 6.6 (high), Trop-I: 0.423 (positive).
Based on the laboratory report, Ms. Nouf suggested Cardiac Diabetic Mellitus Diet to be taken
by Mr. Fouad. Since generally condition and vitally are stable, Mr. Fouad transferred out to
Telemetry Unit on 11 August 2016 at 1500H. In Telemetry unit, Mr. Fouad was seen by DR.
Alaa and made an order discharge home tomorrow morning if stable.

DISCUSSION

Zubaid et al., 2009 explained that myocardial infarction is associated due to the high usualness
of cardiovascular risk factors, such as diabetes mellitus (DM), hypertension (HTN), smoking,
and hyperlipidemia; which probable resulted from notable changes in the lifestyle behaviors
in the last few decennary; such as decrease exercise and poor dietary habits. According to
new research, the younger generation in Saudi Arabia known as the "generation of electronic
potatoes" and one in four are meant to possibly afflicted mortal heart attacks within 10 years.
In retrospect about the risk factors of heart disease in more than 4,900 Saudi, majorities of
age between 20 to 40 years old who do not have a background of heart disease and lived in
large urban areas like Riyadh and the data was obtained through research that collected 26 %
were probably to experience heart attack. Among the reasons explained by Dr. Adil Soofi the
cause of young people at risk of heart attack found is because the practice of unhealthy
lifestyle from an early age, lack of knowledge, urbanization and westernization could be to
condemn. He said "they like to eat fast food and fried greasy and also do not exercise."
Atherosclerosis, obesity and other risk factors have been identified as one of the factors
leading to early and ultimately the heart attacks and even death at a young age.

Meanwhile, men are more at risk of having coronary artery disease as shown in table 1.1
because in general woman live longer than men. Men also appear like engaging in riskier
behavior as shown in table 1.2. Although, the study by Hersi A1, Al-Habib K, Al-Faleh H, Al-
Nemer K et al., shows that from 5061 patients, 1142 (23%) were women. Women were more
frequently diagnosed with non ST-segment elevation myocardial infarction (NSTEMI [43%])
than unstable angina (UA [29%]) or ST-segment elevation myocardial infarction (STEMI
[29%]). More men had STEMI (42%) than NSTEMI (37%) or UA (22%).
While smoking is the most main risk factor for heart disease. Generally, about 36% and obesity
the cause of 20% of coronary artery disease. Lack of exercise has been linked to 712% of
cases. Less common causes include stress-related causes such as job stress, which accounts
for about 3% of cases, and chronic high stress levels. Smoking can cause high blood pressure,
lipids worsen, and make a very sticky platelets, raising the risk of clots. Therefore, it goes
without saying that smoking is often practiced by men than women. Meanwhile, heavy
cigarette smokers are at substantial risk, people who smoke as few as three cigarettes a day
are at risk for blood vessel influential defect that expose danger to the heart. When are often
exposed to passive smoke can also increases the risk of heart disease in non-smokers.

However, people's risk of heart disease may be different based on their work according to the
new report. It is known that workers in service and blue-collar occupations, as well as
unemployed people, have an increased risk for heart disease and stroke. It is likely to
contribute to heart disease risk because of stress in the workplace environment and a lot of
the workload. Stress influence everyone in separate ways. Theres a link between people who
experience high amounts of stress over long time and heart disease. The link isnt well
understood. Stress can cause insomnia, pain, and headaches, and fatigue. Chronic stress can
cause the heart to work more. This will aggravate any other risk factors for heart disease we
may have. Researchers found that people's risk of heart disease and stroke differ with their
industry. Table 1.4 show those working in wholesale came in at top of the list, as 2.9 percent
of the people in that industry had suffered heart disease or a stroke.

Ikeda et al., 2007; Johnson, Backlund, Sorlie, & Loveless, 2000; Manzoli, Villari, Pirone, &
Boccia, 2007 argue that all of the various unmarried such as being single never married, being
separated/divorced and being widowed have been relevant with higher fatal risks of coronary
heart disease. In my opinion, whether someone is already married or still single, and whatever
the person's status, should not adopt a healthy lifestyle would be risky suffered heart disease.

A minimal case of myocardial infarction are caused essentially by genes, endocrine disorders,
medications, or mental illness. The study done by The Saudi Project for Assessment of
Coronary Events from December 20052007 and found 72% were either overweight or obese.
Overweight and obese patients were significantly younger than the normal-weight group
(P=.006). In general, obesity prevail throughout the world which is found that 33.1% and 32.2%
of Americans were overweight and obese according to the available sources from The
National Health and Nutrition Examination Survey in 2003 to 2004.

16
Conclusion

Mr. Fouad sent to cardiac cath lab at 1030H. Received Mr. Fouad at 1230H from Cardiac Cath
Lab post Percutaneous Coronary stenting to mid Right Coronary Artery (1 Drug-Eluting Stent)
done on 10 August 2016 at 1130H with Terumo TR band hemostatic device through radial
approach. TR Band removed after an hour with no sign of hematoma or bleeding seen.

In conclusion, the factors that trigger myocardial infarction is the unhealthy lifestyles such as
consumption of fatty foods, oily, salty, fast food and so on, which led to Mr. Fouad suffer from
heart disease. In addition, other factors are identified that are less encouraged to do physical
activity such as sports and so forth. Stress at work also the possibility of one additional factor
that led Mr. Fouad having heart attack. Mr. Fouad possibility of denial or unconsciously and
idly took out will his health which showed that he was suffering from diabetes and obesity.
Although RBS (120-139mmol/L) found within normal limits but HbA1c laboratory tests (6.96%)
showed that the excess sugar content of obtained. Whereas, the amount of fat contained is
more than ideal body weight. Therefore, there are several things that have been
recommended for Mr. Fouad to take and practice to improve the health of his back optimally
and as prevention for the future as set out in column recommendation as below.

Recommendation

As recommended by AHA/ACC 2014 guidelines for the management of patients of NSTEMI

as follow:

1. Prescribe the following medications for all patients

2. Ensure that the patient is instructed about how to modify cardiac risk factors:

Smoking Cessation

Patient should be advised to quit smoking and avoid exposure to environmental tobacco
smoke at home, work or public. Patient are recommended for counseling and plan
development for quitting, including nicotine replacement and referral to special smoking
cessation programs. Patient should be referred to smoking cessation programs after 1
month of hospitalization.

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 Optimal Weight

Patient should be encouraged to maintain his body mass index as shows at Table 1.9. The
initial target to reduce body weight by approximately 5-10% from baseline. Diet and
exercise is a combination should be involves to this end.

Daily Exercise

A month after the post-NSTEMI events, patient should be favorable to perform 30-60
minutes of exercise for 7 days a week to improve heart function, body function, reduce
cardiac risk factors, reduce risk of a second heart attack and improve psychological well
being.

Diet

Low intake of salt and saturated fats, and regular intake of fruits, vegetables and fish would
be perfect recommended. Table 1.8 explained "Mediterranean diet" has been taken as
model for optimum mental and physical fitness. However, taking moderate wine and
alcohol as shows below should not encouraged.

3. Blood pressure control (< 140/90 mmHg)

Counseling of lifestyle adjustment is needed to create the conditions for optimal blood
pressure management. It involves a number of things that need to be practiced such as
weight control, increased physical activity, alcohol moderation, salt reduction and greater
consumption of fresh fruits, vegetables and low fat dairy products. If the blood pressure
exceed the limits, pharmacological therapy with beta blockers and/or ACE (angiotensin-
converting enzyme) inhibitors or ARB (angiotensin-receptor blockers) should be
commence, with introduction of other drugs such as calcium channel blockers or thiazides
diuretics as needed to attain the treatment objective.
4. Management of Diabetes
More than 30% of patients with NSTE-ACS have diabetes. Nowadays, a lessening in blood
glucose levels is associated with improved result in patients with diabetes or pre diabetes
who have suffered UA/NSTEMI or STEMI. This lessening may be attained as the outcome
of lifestyle modification (including weight management, physical activity, and medical
nutrition therapy) or medication therapy. The patient's primary care physician and/or
endocrinologist commonly control the management of diabetes.
The objective of diabetes management (apart from reversal of the condition though
intensive lifestyle change) is tight glycemic control, as both hyperglycemia and
hypoglycemia have a intense effect on in-hospital and 6-month mortality rates following a
cardiac phenomenon.

18
5. Consider referring an out patient cardiac rehabilitation program
Cardiac rehabilitation is intend to give a comprehensive long-term program that limits
physiological and physiological impact of cardiac illness by involving medical evaluation,
prescribed exercise, lifestyle and cardiac risk factor modification, education and
counseling. Exercise may include bicycle, treadmill, calisthenics, walking and jogging.
6. Post discharge Follow up
Effective communication and therapeutic relationship with patient and their family increase
long-term compliance with lifestyle adapt and prescribed drugs. At discharge, patient
should received details direction regarding medication, diet, exercise, smoking cessation
counseling, referral to cardiac rehabilitation/secondary prevention programs and follow up
appointments. Low risk and revascularized patient should given appointment to come back
within 2-6 weeks and higher risk within 14 days.
7. Others activities
Patients should be given specific instruction on activities (eg, lifting, climbing stairs, and
household activities) that are allowable and avoided. Particular state should be made of
resumption of driving, return to work, and sexual activity.

19
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 Appendix:
Activities done in the ward

1. Electrocardiography

2. First 8 hours monitoring of vital signs

Date/Time Temp Pulse RR* Blood SPO2* Capillary blood VAS* pain
Pressure glucose score
10/08/2016 36.6 92/min 21/min 122/80mmHg 97% 139mmol/L 2/10

0040H

0140H 36.5 94/min 20/min 120/75mmHg 98% 138mmol/L 2/10

0230H 36.3 100/min 30/min 140/88mmHg 93% 137mmol/L 4/10

0245H 36.4 98/min 28/min 135/78mmHg 94% 136mmol/L 3/10

0300H 36.5 94/min 26/min 130/80mmHg 95% 135mmol/L 2/10

0330H 36.5 96/min 24/min 132/82mmHg 96% 134mmol/L 2/10

0400H 36.6 90/min 20/min 128/76mmHg 95% 133mmol/L 1/10

0430H 36.8 93/min 19/min 136/70mmHg 96% 132mmol/L 1/10

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0500H 36.7 75/min 18/min 118/70mmHg 96% 130mmol/L 1/10

0530H 36.6 85/min 21/min 120/80mmHg 97% 125mmol/L 1/10

0600H 36.5 80/min 20/min 122/75mmHg 98% 120mmol/L 0/10

0700H 36.4 88/min 20/min 110/70mmHg 97% 140mmol/L 0/10

*RR=respiratory rate; SP02=saturated partial oxygenation; VAS=visual analogue scale

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