NURBN 2012: Clinical Scenario Assignment - Nursing Practice 3

This report analyzes a clinical scenario involving a patient, Betsy, presenting with symptoms suggestive of acute coronary syndrome (ACS). The report begins with the rationale for requesting an ECG and then delves into the pathophysiology of angina, including its causes and symptoms, and identifies Betsy's risk factors for ACS, such as hypertension and diabetes. The ECG report is analyzed, highlighting abnormalities in rhythm, rate, and ST segments, leading to a discussion of the central findings that support the diagnosis of ACS. The report includes a drug discussion covering glyceryl trinitrate, diltiazem, and pravastatin, detailing their mechanisms of action, side effects, and nursing considerations. The use and mechanism of action of aspirin, ticagrelor, and morphine in cardiac patients are examined, along with current research linking depression risks with chronic illness. References from the past five years are included, providing a comprehensive overview of the case and relevant medical information.

Running head: Clinical Scenario Assignment
CLINICAL SCENARIO ASSIGNMENT

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Clinical Scenario Assignment
Table of Contents
1. The rationale for ECG 3
2a. Pathophysiology of angina 3
2b. Risk factors for Betsy that can increase her risk of Acute Coronary Syndrome 4
3. ECG report analysis of Betsy 5
4. Central findings leading to Acute Coronary Syndrome diagnosis 6
5. Drug discussion 7
6. Use and mechanism of action of aspirin and ticagrelor in cardiac patients 10
7. Use of morphine in ACS 11
8. Current research evidence to link depression risks with chronic illness 11
References 13

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Clinical Scenario Assignment
1. Rationale for ECG
The rationale for ECG request, in this case, is owing to Betsy's initial observations of
nausea and breathing difficulties. As commented by Chen et al. (2018), ECG
(electrocardiogram) is defined as the clinical test to determine the reason for cardiac pain,
shortness of breath, fatigue and dizziness. Based on the past medical history of Betsy, it can be
devised that she has been suffering from a coronary heart ailment and chronic obstructive
pulmonary disease (COPD). She has also undergone bypass grafting thrice with a consistent
presence of hypertension and type II diabetes mellitus. Another important justification for
referring to ECG for Betsy is that it can help to deduce the drug mechanism rates for her
medications (Azariadi et al. 2016). Hence, it can be justified that buddy nurse has insisted on
doing an ECG to understand the efficiency of enoxaparin and diltiazem.
2a. Pathophysiology of angina
Angina refers to transient cardiac pain with chronic discomfort. This can result when the
cardiac requirement for oxygenated blood is more than its supply arising from coronary arteries.
As commented by Zardavas et al. (2017), reduced oxygenated blood supply results from
coronary artery spasm. Signs and symptoms of angina resemble distinct infarction. A significant
angina attack can enable the experiences of acute pain in the chest with discomfort in the
substernal location. Angina attack may occur during emotional or physical stress and can be
resolved through due rest. According to the findings of Zhou et al. (2017), angina pectoris
syndrome occurs from anger, exertion, fright, shock or violence. The pathophysiology of angina
is owing to the imbalance in supply and demand ratio of myocardial oxygen. As stated by Wahab
et al. (2017), the narrowing of coronary arteries from atherosclerosis can be caused by spasm or

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Clinical Scenario Assignment
valvular complications. In the case of Betsy, her systemic and pulmonary hypertension could be
a cause for angina.
In another scenario, syphilis, aortic regurgitation, anaemia, infective endocarditis, or
cardiomyopathy can be causative factors of angina. Clinical symptoms of angina that can be
noted in a patient are acute pain in the chest that lasts for a range of approximately 5 minutes. As
stated by Müllerova et al. (2015), patients do not suffer from substernal pain, though it can be
elaborated as a squeezing sensation. Betsy can be exposed to angina during exertion or exposure
to thermal fluctuations due to vasospasm or enhanced oxygen demands. The pain can radiate to
additional body parts like jaw, arms or back. As stated by Chen et al. (2018), diaphoresis or
sweating can be due to enhanced work done by the body in order to meet primary physiologic
needs. Tachycardia is another symptom that includes the heart pumping at a faster rate for
meeting oxygen demands. This leads to shortness of breathing or dyspnoea as observed in Betsy
and enhanced oxygenation and respiratory rate. Anxiety is also prevalent when the body is not
provided with ample oxygen to meet the demands of the cardiac muscles.
2b. Risk factors for Betsy that can increase her risk of Acute Coronary Syndrome
Prominent risk factors of ACS (Acute Coronary Syndrome) in case of Betsy are
hypertension and type II Diabetes Mellitus. The first risk factor includes hypertension or high
blood pressure that cans multiple the risk of acute coronary syndrome by at least three times
(Müllerova et al. 2015). This is because; hypertension can cause further degradation to the
arteries by depositing plaque or calcium in it. As opined by Al-Lamee et al. (2018), diabetes
mellitus refers to the inability of the body to develop an appropriate amount of insulin in the
pancreatic cells. Insulin is secreted by Islets of Langerhans in the pancreas to regulate glucose
levels in the blood. Beta cells may cease to function during diabetes that can result in an

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Clinical Scenario Assignment
enhanced risk for coronary artery complications for Betsy. Diabetes can also lead to cardiac
arrests by enhancing the rate of atherosclerosis by catalysing the growth of cholesterol in the
body.
3. ECG report analysis of Betsy
As provided in the above ECG report, the electrical impulses show certain aberrations in
case of Betsy. According to Appleton et al. (2017), irregularities observed in the cardiac
environment of a patient with a past medical history of COPD and hypertension can impose a
significant amount of risks.
● Rhythm: Rhythm between each trough and crest of the ECG graph shows distinct
irregularities between the P and V waves. This may give rise to a considerable case of
atrial flutter (Azariadi et al. 2016).
● Rate: As it can be noted from the ECG chart, three large squares in the graph sheet
indicate cardiac rate in an approximation of a 100 beats each minute.
● P wave presence and regularity: The ECG graph shows that the P waves start out to be
a fractionally enhanced from normal levels. Each increment in the voltage indicates
enlarged or hypertrophied atria due to irregular data observed (Azariadi et al. 2016).
● ST segment: A distinct depression is noted in the ST segment as clarified from the given
ECG report.
The overall conclusion drawn from this report is that Betsy may be experiencing atrial
flutter. Depression in the ST segment can amount to ischemia. However, medications like
digitalis can cause depression in the ST segments.

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Clinical Scenario Assignment
4. Central findings leading to Acute Coronary Syndrome diagnosis
Primary symptoms noted in case of the acute coronary syndrome can pertain to nausea,
sweating, rise in body temperature, dizziness or difficulty in breathing. In order to diagnose
ACS, three diagnostic variables can be checked that are angina, abnormal cardiac impulses and
troponin levels. Angina is one of the important symptoms observed in case of acute coronary
syndromes (Al-Lamee et al. 2018). Angina can start from acute and recurring pain in the chest
that gradually spreads to other parts of the body like back, neck, stomach or jaw. In addition to
this electrocardiogram tests measure electrical activity in the cardiac cavity through electrodes
that are attached to the skin.
Irregular or abnormal impulses can indicate a malfunctioning heart owing to insufficient
oxygen levels. Certain patterns for the electrical signal can indicate the confirmation of the
diagnosis. Troponin acts as a biomarker that provides an efficient diagnosis in this case. High-
sensitivity assays for cardiac troponin (hscTn) can diagnose the syndrome with enhanced
sensitivity (Zardavas et al. 2017). Troponin assay is proposed if the patient complains about
angina, diaphoresis, dyspnoea and electrocardiographic complications. This assay can be market
positive in case the threshold level corresponds to the concentration in the 99th percentile.
5. Drug discussion
Generic
name
GTN Diltiazem Pravastatin

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Clinical Scenario Assignment
Drug group Glyceryl trinitrate
belongs to the drug
group of Nitrates.
Diltiazem belongs to the drug
group of antianginal agent
compounds. It is a
Non-dihydropyridine based
calcium channel blockers
(Zhou et al. 2016).
Pravastatin belongs to
the drug group of
Reductase Inhibitors
(HMG-CoA) or Statins.
Mechanism
of action
The mechanism of
action for glyceryl
trinitrate can follow a
circulation-based
pathway. This drug
relaxes and widens
the prominent cardiac
blood vessels
(coronary arteries).
The drug can make
the blood vessels
relax in the body of
the patients
(Appleton et al.
2017). This can result
in decrease in
considerable stress in
Mechanism of action for
Diltiazem involves inhibition
of contractions dependent on
calcium. These contractions
take place in cardiac and
peripheral smooth muscles.
According to the findings of
Teply et al. (2016), these
contractions can result in
vasodilatation. Vasodilation
can reduce the arrhythmic
condition of cardiac
conductions and reduce stress
on the cardiac muscles.
Mechanism of action
for Pravastatin is
through its reducing
activity focused on
lipoproteins. Effect of
hydroxymethyl glutaryl
reductase (CoA) is
blocked by the drug
Pravastatin. In addition
to this, the drug may
prevent low-density
lipoprotein production
in the body. This can
enhance the number of
cellular LDL receptors
in the body that reduces
LDL and cholesterol

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Clinical Scenario Assignment
cardiac capacities. As
a result of this, blood
flow can be
normalised in the
body.
levels.
Side effects
or
complicatio
ns
Side effects involve
nausea, allergic
patches on the skin.
Furthermore, Chen et
al. (2018) comment
the patient can also
experience certain
episodes of dizziness,
atrial flutter,
arrhythmia and
migraine as
complications.
Complications of this drug
can result in the form of
constipation, bloating,
nausea, fatigue, shortness of
breath and malaise. Side
effects in severe events can
give rise to the patient losing
their consciousness and
developing yellowed skin or
eyes. Betsy can also feel
abdominal pain after
ingestion of this drug (Wada
et al. 2016).
In mild cases, the
patient may experience
side effects of this drug
in the form of nausea or
persistent malaise,
dizziness, or rashes
(Chauvet-Gelinier &
Bonin, 2017).
Complications of
Pravastatin intake
involve problems in
muscle and diabetic
health. Primary side
effects of the drug are
the creation of mild
cause confusion or mild
memory problems. In
the case of Betsy, it

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Clinical Scenario Assignment
may show
complications like
hepatic, gastric or renal
pain.
2 major
nursing
considerati
ons
1. GTNs sprays often
comprise of
flammable materials
as their secondary or
tertiary ingredients
(Wahab et al. 2017).
Hence, as a
professional nursing
practitioner, these
sprays must be stored
in cool and dark
places that do not
subject them to a
naked flame.
2. GTN medications
cannot be provided to
the patients who are
pregnant or are
suffering from
1. The traces of diltiazem are
not easy to be flushed out by
simple haemodialysis
method. Hence, Zhou et al.
(2017) opine patients
suffering from renal or
hepatic impairment requires a
trace amount of diltiazem
dose.
2. Professional nurses must
responsibly store diltiazem in
places dry and dark places in
room temperature.
The patients who are
suffering from
elevations in the levels
of hepatic transaminase
or are diagnosed with
one or the other form of
hepatic complications
must not be given
Pravastatin.
As per the
recommendations of
(Carney & Freedland,
2017), Pravastatin dose
must be regulated in the
case of paediatric and
geriatric patients owing
to their fragile
metabolism immunity.

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Clinical Scenario Assignment
complications from
renal failure,
hypothyroidism, low
blood pressure and
glaucoma.
6. Use and mechanism of action of aspirin and ticagrelor in cardiac patients
Ticagrelor can be mixed with aspirin in reduced dose to treat patients who are suffering
from COPD. According to the findings of Valkenburg et al. (2016), this drug brings specific
benefits for patients who suffer from atrial flutter by reducing the risk of a stroke. In the case of
Betsy, major cardiac events can reduce the risk of further attacks. It is also seen that Betsy has
undergone three bypass graft surgery with a medical history of COPD, hypertension, diabetes
and coronary cardiac ailment. Hence, a blend of ticagrelor and aspirin can aid in platelet-driven
clot prevention in the arteries. This is due to the fact that ticagrelor is an antiplatelet drug that
renders smoother blood flow in the body.
7. Use of morphine in ACS
Morphine can create an adverse impact on patients who are suffering from Acute
Coronary Syndrome or myocardial infarction. As opined by Valkenburg et al. (2016), morphine
can be beneficial due to its analgesic actions that relieve moderate to severe pain in the patients.
In case the morphine dosage is elongated in terms of time or concentration, the patient may

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Clinical Scenario Assignment
develop an unhealthy addiction. This is further supported by Chen et al. (2018), who state
repetitive application in care plan may bring deterioration in the health of the patient.
8. Current research evidence to link depression risks with chronic illness
As commented by Chauvet-Gelinier & Bonin (2017), patients suffering from chronic
cardiac events can develop a pathological depression as co-morbidity. This is further supported
by the evidence of Teplyet al. (2016), who show that almost 46.7% of patients suffering from
coronary ailments in the age group of 50 to 80 years are diagnosed with clinical depression. In
addition to this, almost 75.8% of these patients in the given age group suffer from non-clinical
depression. As per the research evidence gathered from Carney & Freedland (2017), depression
is developed as co-morbidity to life-threatening and chronic illnesses. In this case, Betsy has
shown a long medical history of suffering from chronic diseases. This has exposed her to
depressive disorders owing to a prolonged hospital stay and general malaise owing to the
complications. 85% of the depressive episodes occur following a massive cardiac event, such as
a stroke. Simultaneous occurrences of coronary diseases and depression are also common in
almost two-thirds of the cases occurring worldwide.

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Clinical Scenario Assignment
References
Al-Lamee, R., Thompson, D., Dehbi, H. M., Sen, S., Tang, K., Davies, J., ... & Nijjer, S. S.
(2018). Percutaneous coronary intervention in stable angina (ORBITA): a double-blind,
randomised controlled trial. The Lancet, 391(10115), 31-40.
Appleton, J. P., Sprigg, N., & Bath, P. M. (2017). Therapeutic potential of transdermal glyceryl
trinitrate in the management of acute stroke. CNS drugs, 31(1), 1-9.
Azariadi, D., Tsoutsouras, V., Xydis, S., & Soudris, D. (2016, May). ECG signal analysis and
arrhythmia detection on IoT wearable medical devices. In 2016 5th International
conference on modern circuits and systems technologies (MOCAST), 1-4.
Carney, R. M., & Freedland, K. E. (2017). Depression and coronary heart disease. Nature
Reviews Cardiology, 14(3), 145.
Chauvet-Gelinier, J. C., & Bonin, B. (2017). Stress, anxiety and depression in heart disease
patients: A major challenge for cardiac rehabilitation. Annals of physical and
rehabilitation medicine, 60(1), 6-12.
Chen, Z., Liu, R., Niu, Q., Wang, H., Yang, Z., & Bao, Y. (2018). Morphine Postconditioning
alleviates autophage in ischemia-reperfusion induced cardiac injury through up-
regulating lncRNA UCA1. Biomedicine & Pharmacotherapy, 108, 1357-1364.
Müllerova, H., Maselli, D. J., Locantore, N., Vestbo, J., Hurst, J. R., Wedzicha, J. A., ... &
Anzueto, A. (2015). Hospitalized exacerbations of COPD: risk factors and outcomes in
the ECLIPSE cohort. Chest, 147(4), 999-1007.
Teply, R. M., Packard, K. A., White, N. D., Hilleman, D. E., & DiNicolantonio, J. J. (2016).
Treatment of depression in patients with concomitant cardiac disease. Progress in
cardiovascular diseases, 58(5), 514-528.

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Clinical Scenario Assignment
Valkenburg, A. J., Calvier, E. A., van Dijk, M., Krekels, E. H., O’hare, B. P., Casey, W. F., ... &
Breatnach, C. V. (2016). Pharmacodynamics and pharmacokinetics of morphine after
cardiac surgery in children with and without Down syndrome. Pediatric Critical Care
Medicine, 17(10), 930-938.
Wada, A., Matsumoto, T., Taniguchi, A., Fujii, M., Hara, M., Kinoshita, M., & Horie, M. (2016).
High-Throughput Transcriptome Analysis Reveals Therapeutic Effects of Statin on
Alternations of Cardiac Gene Expression in Heart Failure. Journal of Cardiac Failure,
22(9), S167.
Wahab, M. A. K. A., Saad, M. M., & Baraka, K. A. G. (2017). Microalbuminuria is a late event
in patients with hypertension: Do we need a lower threshold?. Journal of the Heart
Association, 29(1), 30-36.
Zardavas, D., Suter, T. M., Van Veldhuisen, D. J., Steinseifer, J., Noe, J., Lauer, S., ... & de
Azambuja, E. (2017). Role of troponins I and T and N-terminal prohormone of brain
natriuretic peptide in monitoring cardiac safety of patients with early-stage human
epidermal growth factor receptor 2–positive breast cancer receiving trastuzumab: a
herceptin adjuvant study cardiac marker substudy. J Clin Oncol, 35(8), 878-84.
Zhou, Y., Zhang, M. L., Yuan, B. J., Yuan, J. Q., Zhao, X. F., Zhao, L., & Ren, H. Q. (2017).
Herbal carrier-based floating microparticles of diltiazem hydrochloride for improved
cardiac activity. Tropical Journal of Pharmaceutical Research, 16(6), 1239-1244.