PHILIPPINE CHRISTIAN UNIVERSITY Mary Johnston College of Nursing 415 Morga St., Tondo Manila
In Partial Fulfillment of the requirements In the Medicine Ward Duty
Case study On
Unstable Angina
Submitted by: Ms. Cayas, Jennylyn Ms. Moleta, Hazel Joyce
BSN-III, RLE Group 2
Submitted to: Ms. Ma. Nicoleta M. Dizon
I. ABSTRACT, IDENTIFICATION and INTRODUCTION Unstable angina generally represents a condition more serious than chronic stable angina pectoris. The terms “unstable” indicates that the patient is in a changing situation, which may be a prelude to an acute myocardial or a return to more stable pattern. ( by E.P Dutton, HEARTBOOK, The American Association, USA, New York) Chest pain is the most common symptom of cardiovascular disease. Angina pains, while possibly severe, are usually temporary, occurring after physical exertion, during emotion stress, or after heavy meals. The last few decades have witnessed remarkable advances in the understanding of coronary heart disease, and yet the disease still presents a very great challenge to the medical profession. The purpose of this study is to gain knowledge and to increase our competency in assessment especially in cardiovascular part and also in rendering nursing care that are appropriate based on the client’s case. In our case, a 69 year old, a lawyer is brought to the Mary Johnston Hospital due to loss of consciousness. He has been diagnosed to have hypertensive cardiovascular disease. His initial BP: 160/100mmHg. The patient has a type two diabetes. He is fond of eating high fat and high salt foods, smoker and alcoholic drinker. He had also hypertensive history within the family. Problem that was identified were the ff: chest pain, having productive cough, activity intolerance, electrolyte imbalances and diet modification.
II. CASE REPORT
Demographic Data
Name: Santos, E. A. Age: 69 years old Birthday: September 23, 1942 Gender: Male Status: Widow Religion: Roman Catholic Nationality: Filipino Nursing History
History of Present Illness
The client was seeing in the comfort room by his relatives with loss of consciousness but can still respond by nodding. He experienced pain in the chest. He was immediately brought to hospital. His BP was 160/100 mmHg and known to have HCVD. He was known to have CAP. He was then admitted to Medical ICU for 11 days and then transferred to Medicine Ward.
Past Medical History
The client is Diabetic but he doesn’t know since when. He was admitted to MICU last April or May because of the same condition. The client has Insomnia.
Family History The client’s Siblings are Hypertensive.
Personal-Social History
- Retired Lawyer but still accepting easy to handle cases. - Smoker 30packs/year - Alcoholic Drinker 2L/day
Gordon’s Functional Health Pattern
Health Perception -
“Ok naman ako, gusto ko na nga umuwi” – as stated by patient
Nutrition-Metabolic -
“Di siya mahilig sa gulay, kadalasan mga baboy” –as stated by son “Di siya kumakain ng Isda, pero nkain siya ng satdinas” –as stated by son “Tuwing kumakain lang siya nainom ng tubig, di siya mahilig” –as stated by son “ Nainom siya ng kape sa umaga” –as stated by son
Elimination -
“Araw-araw naman siya dumudumi” –as stated by son “Wala naman siyang sinasabi na masakit ang pag-ihi niya” –as stated by son With Foley Catheter connected to CDU
Activity-Rest -
“Madalas lang siya sa bahay, mahilig manuod ng T.V.” –as stated by son “Mahilig yan magbasabasa ng Dyaryo” -as stated by son
Sleep-Rest -
“May Insomnia siya eh, di siya nakakatulog kapag di siya nakakainom ng alak” –
as stated by son “Pampatulog na niya ang alak” –as stated by son Cognitive Perceptual -
“Di malabo mata niya, sa dyaryo nga nababasa niya pa eh” –as stated by son “Ok din naman pandinig niya” –as stated by son
Self-Perception
-
“Ok lang ako, magaling na ko” –as stated by son
Roles and Relationship -
“Sa bahay tatlo lang kami magkakasama, siya, ako at yung kapatid ko na isa” –
as stated by son Sexuality-Reproductive -
“Tatlo kaming anak lahat yung isa iba yung nanay” –as stated by son “Si mama namatay dahil sa stroke” –as stated by son
Coping Stress Tolerance -
“Naiistress kapag di nakakainom” –as stated by patient “Dapat makainom ako ng alak” –as stated by patient
Values and Belief -
“Di na nagsisimba yan si papa, sa bahay lang palagi” –as stated by son “Di naman nakakalimot magdasal yan” –as stated by son
Physical Examination
Head
Normocephalic No lesion No mass
Hair
Grayish in color Dry hair
Eyes Ears
Symmetrical Dry eyes noted Pinkish conjunctivae
No lesion Symmetrical No discharge
Nose
Nasal septum Intact No mucus
Mouth
Incomplete set of teeth Dry lips Pinkish oral mucosa
Chest
Use of respiratory muscle No lesion No mass noted
Abdomen
Soft and flabby No lesion No mass
Skin
Dry and sagging skin Fair complexion
Extremities
Symmetrical Complete set of fingers and toes Can do ROM but with assistance
Laboratory/Diagnostics (from oldest to latest) February 25, 2012 Na
137 mmol/L
135-145
normal
K
2.3 mmol/L
3.6-5.0
low
March 02, 2012 Na
133.9 mmol/L
135-145
low
K
3.55 mmol/L
3.6-5.0
low
Interpretation
The client has a low sodium and potassium. The client is taking a medication of
diuretics and the Na and K was been excreted. This indicates that there is an inadequate Na and K in the body. As a nurse, encourage the client to eat foods rich in sodium and potassium like seafood, banana and potatoes. ECG February 23, 2012 Interpretation- Atrial Tachycardia, Normal Axis, Left Atrial Abnormality February 25, 2012 Interpretation- Atrial Tachycardia, Normal Axis, Poor R wave progression. Drug Study 1.
Furosemide Loop diuretics Inhibits sodium and chloride reabsorption at the proximal tubules, distal tubules
and ascending loop of henle leading to excretion of water together with Na, Cl and K. Diuretic, Anti-hypertensive. This is given because the client has a Foley catheter and his output was being measured. The fluids in the body must be secreted to prevent fluid excess in the body that can cause hypertension and the worst is heart congestion. 2.
Clopidogrel Anti-coagulant, Anti-platelets Blocks ADP receptors, which prevents fibrinogen binding at the site and thereby
reduce the possibility of platelet and aggregation.
The client is hypertensive and known to have Diabetes Mellitus. This drug is
given to prevent thrombus or clot formation in the vessels because patients with hypertension and DM have the higher risk to have it. 3.
Enoxaparine Anti-coagulant Stimulates both Alpha and Beta receptors within sympathetic nervous system
that relaxes bronchial smooth muscle. The client is hypertensive and known to have Diabetes Mellitus. This drug is given to prevent thrombus or clot formation in the vessels because patients with hypertension and DM have the higher risk to have it. 4.
Amiodarone Anti-arrhythmics Blocks sodium channels at rapid pacing frequencies, prolonging myocardial cell
action potential and refractory period. This drug is given to normalize the heart rhythm because the client experienced increased in heart contraction. 5.
Pantoprazole Proton pump inhibitor Inhibits both basal and stimulated gastric acid secretion by suppressing the final
step in acid production, through the inhibition of proton pump by binding to and inhibiting hydrogen-potassium adenosine-triphospate the enzyme system located at the secretory surface of the gastric parietal cell. This drug contributes in the action of clopidogrel. It is also given because the client eats in little amount, this is given to prevent the increase in acid production that can cause ulceration. 6.
Kalium durule Supplements for hypokalemia The client has a decrease in Potassium. This is given to supply the inadequacy
of potassium in the body. III. DISCUSSION Literature Scott Wright, R. et al. (2011). Guidelines for the management of patients with unstable angina/ non ST
Findings Clo pidogrel in combinati on with
Claim 1. T here are drugs that
Evidence o Data from a number of observation al studies
elevation myocardial infarction. http://circ.ahajournals. org/content/ 123/18/2022.full#sec7
ASA has been shown to reduce recurrent coronary events in post hospitaliz ed ACS. Pro ton pump inhibitor medicatio ns have been found to interfere with the metabolis m of clopidogre l. Dia betes as well as the often concurren t comorbidi ty of CKD, is not only a highrisk factor but also benefits from an invasive approach.
can preven t having throm bus or plaque format ion.
have demonstrate d an association between an increased risk of adverse cardiovascul ar events and the presence of ≥1 of the nonfunctioni ng alleles and are well delineated in the ACCF/AHA Clopidogrel Clinical Alert (Scott Wright, R. et al. 2011). o Two novel findings have emerged from this analysis. First, in contrast to the studies, clopidogrel had the same relative benefit across all of the risk strata. The relative benefit was ≈20% in the low-risk, intermediate -risk, and high-risk
Rabin, E. & Bullard, M. (1999). Chest pain observation units for patients with unstable angina. http://www.cjemonline.ca/v1/n1/ p39
An Emergenc y Departme nt Chest Pain Unit is safe, effective
2. T here are diseas es that can be a risk factor
patients. It is worth noting that because the baseline risk is higher, the absolute benefit is greatest in the highestrisk patients. The second novel finding of this analysis is that there was a statistically significant benefit of clopidogrel plus aspirin over aspirin alone in the low-risk patients. (Cannon, C. P. 2005) o Antith rombotic therapy is designed to stop platelet aggregation and interfere with the coagulation process. (Matura, L. A. et al. 2003) o Diabe tes is another characteristi c associated with high risk for adverse
and economic al means of providing appropriat e care to patients with unstable angina at intermedi ate risk for cardiovas cular events.
of unstab le angina .
outcomes after UA/NSTEMI. (Scott Wright, R. et al. 2011) o The observation al data with regard to patients with mild to severe CKD also support the recognition that CKD is an underapprec iated highrisk characteristi c in the UA/NSTEMI population (Scott Wright, R. et al. 2011) o Out of all patients 35.8% were female, 30% were diabetics (Duration 13.4 ± 8.7 years), 42% were smoker and 91% were hypertensiv e (Abbasi, M. et el. 2006) o Threevessel disease was diagnosed in 42% of diabetic and
31% of nondiabetic patients. In a multivariate analysis including the extent of CAD, diabetes remained a strong independent predictor of the combined end point. (Norhammar , A. et al. 2004) o Data were collected on 1046 ACS patients of whom 170 (16%) had a prior diagnosis of DM. Based on the rate of recruitment and the population covered in the study, about 21,000 patients with DM will be admitted with non-ST elevation ACS each year in the UK. (Bakhai, A. et al. 2005) o Calcifi
Collet, J. P. et al. (2002). Enoxaparin in unstable angina patients who would have been excluded from randomized pivotal trials. http://www.sciencedir ect.com/ science/article/pii/ S0735109702026645
Eno xaparin with dose adjustme nt to creatinine clearance provides adequate anti-Xa and no excess of bleeding.
3. T here are ways to reduce mortal ity in patien t with ACS.
ed plaques in the DM group were significantly greater than those in the non-DM group (42.9% vs. 23.1%; p = 0.03). (Feng, T. et al. 2010) o The ISIS-2 trial, the second study of infarct survival, indicated an ASA dose of 160mg chewedon arrival to the ED as soon as a diagnosis of ACS is suspectedor made decreases mortality rate. (Matura, L. A. et al. 2003) o He Clopidogrel has shown a 34% reduction in cardiovascul ar death or recurrent MI when the patient is given a loading dose of 300mg and then
75mg orally daily. (Matura, L. A. et al. 2003) o Altho ugh patients with a higher risk score had an increased rate of death or MI within 42 days and 365 days (p < 0.001) in both managemen t strategies, early invasive managemen t for patients in the high and very high risk categories was associated with a lower rate of death or MI within 42 days compared with conservative managemen t. (Solomon, D. H. et al. 2001) o In only one study found a statistically significant beneficial association
Abbasi, M. et el. (2006). Prevalence of diabetes and other cardiovascular risk factors in an Iranian population with acute coronary syndrome. http://www.biomedcen tral.com/ 14752840/5/15
Dia betes and Hypertens ion are leading risk factors, which may directly or indirectly interfere and predict more serious complicati ons of coronary heart disease.
4. T here are metho ds that can be done to patien ts with ACS.
between PA and hospital mortality. After combining the data found a significant reduction in the probability of hospital death in patients with PAD ( odds ratio = 0.61, confidence interval 95%, from 0.48 to 0.78, P <0.0001). (IglesiasGarriz, I. et al. 2008) o Ninet y-seven (46%) of 212 patients assigned to the CPU had an uncomplicat ed stay and negative provocative tests, allowing them to be discharged home. This led to an absolute 45.8% lower admission rate compared with those in the routine
admission group. (Rabin, E. & Bullard, M. 1999) o Altho ugh patients with a higher risk score had an increased rate of death or MI within 42 days and 365 days (p < 0.001) in both managemen t strategies, early invasive managemen t for patients in the high and very high risk categories was associated with a lower rate of death or MI within 42 days compared with conservative managemen t. (Solomon, D. H. et al. 2001) o The approach to risk stratification has evolved during the past 2 decades
from a practice that once involved an evaluation for residual ischemia and for left ventricular dysfunction after myocardial infarction (MI). However, risk stratification has now evolved more to include assessment of the risk of future cardiac events, which can be predicted on the basis of clinical features at the time of the initial assessment in the emergency department. (Cannon, C. P. 2005) Solomon, D. H. et al. (2001). Use of risk stratification to identify patients with unstable angina likeliest to benefit from an invasive versus conservative management strategy. http://www.sciencedir
Ris k stratificati on may be an effective method for identifyin g those patients
ect.com/science /article/pii/S07351097 01015030
Feng, T. et al. (2010). Assessment of coronary plaque characteristic by coherence tomography in patients with diabetes mellitus complicated with unstable angina pectoris. http://www.sciencedir ect.com/science /article/pii/S00219150 1000794X
with unstable angina most likely to benefit from early invasive managem ent. Sel ective use of early managem ent can have a substantia l impact in reducing morbidity and mortality in higher risk patients, but may not be warranted in lower risk patients. Hig her calcificati on and dissection in were detected in diabetic patients with unstable angina pectoris, and the difference in coronary plaque
Norhammar, A. et al. (2004). Diabetes mellitus: the major risk factor in unstable coronary artery disease even after consideration of the extent of coronary artery disease and benefits of revascularization. http://www.sciencedir ect.com/science / article/pii/S07351097 03015407 Bakhai, A. et al. (2005). Diabetic patients with acute coronary syndromes in the UK: high risk and under treated. http://www.sciencedir ect.com/science /article/pii/S01675273 04004041 Iglesias-Garriz, I. et al. (2008). Hospital mortality and early preinfarction angina: meta-analysis of published studies. http://www.sciencedir ect.com/science /article/pii/S03008932 05739348
characteri stics can explain the difference in clinical prognoses between DM and non-DM patients. Dia betes mellitus remained an independ ent and important risk factor for death and myocardi al infarction in the invasive group. DM is common amongst patients admitted with ACS.
The presence of angina during the 24 hours before the onset of myocardi al infarction was associate
Cannon, C. P. (2005). Evidence-based risk stratification to target therapies in acute coronary syndromes. http://circ.ahajournals. org/content/ 106/13/1588.full
Matura, L. A. et al. (2003). Guidelines for diagnosis and management of unstable angina and non-ST-segment elevation myocardial infarction. http://www.ispub.com/ journal/the-internetjournal-of-advancednursingpractice/volume-6number-1/guidelines-
d with a significant reduction in hospital mortality. Clo pidogrel in unstable angina have now applied the risk score to evaluate the newest of the beneficial treatment . Ris k Stratificati on has been found to be very useful in identifyin g the relative benefit of new interventi ons. Ant i-platelets prevent the formation of thrombox ane A2 that diminishe s platelet aggregati on.
for-diagnosis-andmanagement-ofunstable-angina-andnon-st-segmentelevation-myocardialinfarction.html
Clo pidogrel works by inhibiting platelet aggregati on.
IV. CONCLUSION AND RECOMMENDATION Angina pectoris is a syndrome characterized by episodes or paroxysms of pain or pressure in the anterior chest. One type of this is the unstable angina. The pain is triggered by an unpredictable degree of exertion or emotion. It attacks characteristically increase in number, duration, and severity over time. And most causes appear to be related on having diabetes mellitus, we conclude that the probable cause that triggered the unstable angina attack of Mr. Santos was his type 2 diabetes mellitus. It contributes because DM patient has a thick blood that may creates a clot or thrombus formation. This can decrease the flow that can result in ischemia and cause to induce pain. Having unstable angina may be a life changing disease. We recommend the patient must learn the health and condition in order to manage the disease properly and appropriately
in case the disease will attack again and to promote healthy lifestyle. Instructed to do deep breathing exercises. Instructed to choose low sodium snacks such as fresh fruit and vegetables. Reduce the amount of alcohol you drink or to drink not at all. Too much alcohol damages heart muscle. Instructed to avoid fatty foods intake. Instructed the client to avoid eating junkfoods and avoid drinking softdrinks. Instructed to pick and wash the foods carefully.
V. NURSING CHALLENGES ENCOUNTERED 1) Chest pain The pain or discomfort of angina pectoris is felt under the breastbone and is usually transient. It signals a temporary imbalance between the demands of the heart and the supply of oxygen-carrying blood that it is receiving. In most cases, angina is not disabling, and many patients can lead active and productive lives by following appropriate medical recommendations. ( by E.P Dutton, HEARTBOOK, The American Association, USA, New York) The patient had experienced chest pain for 1 year as for estimation. The quality of chest pain experience is tight heaviness. It lasts for more than 15 minutes. The chest pain occurs even at rest. 2) Non compliance to subcutaneous medications Patient S.E.A verbalizes difficulty with regulation of prescribed regimen for treatment of illness and its effect or prevention of complications acceleration of illness symptoms. The patient complains of pain when administering subcutaneous meds. That’s why he doesn’t want to comply anymore to SQ meds. According to Ackley Ladwig, Ineffective management of therapeutic regimen is a pattern of regulating and integrating into daily living a treatment program for an illness and it’s aftereffects that are unsatisfactory for meeting specific health goals. 3) Productive cough Our patient had right pneumonia based on chest x-ray result. He also had difficulty of breathing. According to E.P Dutton, acute inflammation of an area of the lung resulting from bacterial invasion may have serious side effects on the heart, particularly if there is an underlying heart disease. The body attempts to combat the infection by
increasing the demand for blood, in turn places an added burden on the heart, forcing it to pump more blood with each beat. The degree of distress varies with the client position, activity and level of stress. 4) Risk for imbalanced nutrition The patient had difficulty swallowing. “nahirapan ako lumunok kasi tuloytuloy yung pagkain ko” stated by the patient. Patient had risk for altered nutrition because of the inability to ingest food due to biological status. Altered nutrition is the state in which an individual experiences an intake of nutrients insufficient to meet metabolic needs. 5) Lifestyle of family (diet) The client stated that they often eat fatty foods and oily foods in their homes. They don’t have proper nutritional diet plan and don’t mind the foods that will cause hypertension. These diets have been linked to the development of atherosclerosis and hypertensive disease. 6) Activity Intolerance The patient experienced body weakness and dizziness upon moving. He had limited movement, weak in appearance, unable to sit or stand. He can do ADLs with assistance. In addition, patients with angina pectoris learn to slow the pace of their physical activity
VI. Nursing Solutions/Approaches Used 1) Chest pain
Provide massage (generalized cutaneous stimulation of the body)
R: used to stimulate non-pain receptors, which are thought to block or decrease the transmission of pain impulses. It also produces muscle relaxation, which promotes comfort. -
Porth CM. Essentials of Pathophysiological: Concept of Altered Health States,
The Path to Managing Neuropathic Pain. Philadephia, Pa., Lippincott Williams and Wilkins, 2006
Provide skeletal muscle relaxation such as slow, rhythmic abdominal breathing
R: it can relieve pain by relaxing tense muscles, which may contribute to pain. This is also used as a distraction technique -
Porth CM. Essentials of Pathophysiological: Concept of Altered Health States,
The Path to Managing Neuropathic Pain. Philadephia, Pa., Lippincott Williams and Wilkins, 2006 2) Non compliance to subcutaneous medications Interventions made to this nursing challenge are more on psychological approach. Based on patient’s case we must teach safety in taking medications.. Another is to teach about all aspects of therapeutic regimens; provide as much knowledge as person will accept. R: Knowledge of scientific rationales improves understanding of the therapeutic regimen and increases responsibility for the therapeutic regimen. Although decisions about actions to meet therapeutic goals are made by the client, the presence of the nurses, and the collaborative nature of a nurse0client relationship can help the client with decision-making 3) Productive cough
Assist in mobilizing secretion like increasing room humidification
Rationale: to facilitate airway clearance and to liquefy secretion
Encourage patient to cough out secretions if there is
Rationale: to have clear airway
Assist in bronchial tapping and back rub as a performed chest physical therapy if
needed and instruct relative to do it also Rationale: to create vibration thus mobilizing secretion; chest physical therapy technique using force of gravity and motion to facilitate secretion removal
Teach and supervise effective coughing technique
Rationale: proper coughing technique conserves energy, reduce lung collapse
Assess breath sounds before and after coughing episodes
Rationale: helps in evaluation of coughing effectiveness
Encourage slower/deeper respirations. Used of pursed-lip breathing
Rationale: to enhance lung expansion
Encourage to have adequate rest
Rationale: reduce fatigue, metabolic/ oxygen demand
Position appropriately like elevation the head and side-lying
Rationale: to prevent vomiting with aspiration into lungs
Encourage ambulation & exercise
Rationale: to promote good blood circulation thus improving good oxygenation
Maintain semi-fowlers position
Rationale: it decreases pressure on diaphragm by the use of gravity
Evaluate clients cough and swallowing ability
Rationale: to determine ability to protect own or airway 4) Risk for imbalanced nutrition As for intervention these are the ff:
Provide companionship at mealtime to encourage nutritional intake.
R: mealtime usually is a time for social interaction
Eating small frequent meals
R: it reduces the sensation of fullness and decreases the stimulus to vomit. 5) Lifestyle of family (diet) Dietary Approaches to Stop Hypertension (DASH) study have established that a diet high in fruits, vegetables, and low in cholesterol and total and saturated fat reduces BP significantly. 6) Activity Intolerance Instructed to do active range of motion
VII. REFERENCES (APA FORMAT) E.P Dutton, HEARTBOOK, The American Association, USA, New York Black, JM, Hawks, JH, Keene, AM, (2002), Medical-Surgical Nursing, Elsevier Science Singapore, 6TH Edition, volume 2, pp1579-1582 Smeltzer, Suzanne C., Medical-Surgical Nursing, Lippincott Williams & Wilkins 004, Tenth Ed., volume 1
Doenges, Marilyn., Moorhouse, Mary Frances., Murr, alice C., Nurses Pocket Guide, F.A Davis Company 2004, Ninth Edition Scott Wright, R. et al. (2011). Guidelines for the management of patients with unstable angina/ non ST elevation myocardial infarction. http://circ.ahajournals.org/content/ 123/18/2022.full#sec-7 Rabin, E. & Bullard, M. (1999). Chest pain observation units for patients with unstable angina. http://www.cjem-online.ca/v1/n1/ p39 Collet, J. P. et al. (2002). Enoxaparin in unstable angina patients who would have been excluded from randomized pivotal trials. http://www.sciencedirect.com/ science/article/pii/ S0735109702026645 Abbasi, M. et el. (2006). Prevalence of diabetes and other cardiovascular risk factors in an Iranian population with acute coronary syndrome. http://www.biomedcentral.com/ 1475-2840/5/15 Solomon, D. H. et al. (2001). Use of risk stratification to identify patients with unstable angina likeliest to benefit from an invasive versus conservative management strategy. http://www.sciencedirect.com/science /article/pii/S0735109701015030 Feng, T. et al. (2010). Assessment of coronary plaque characteristic by coherence tomography in patients with diabetes mellitus complicated with unstable angina pectoris. http://www.sciencedirect.com/science /article/pii/S002191501000794X Norhammar, A. et al. (2004). Diabetes mellitus: the major risk factor in unstable coronary artery disease even after consideration of the extent of coronary artery disease and benefits of revascularization. http://www.sciencedirect.com/science /article/pii/S0735109703015407 Bakhai, A. et al. (2005). Diabetic patients with acute coronary syndromes in the UK: high risk and under treated. http://www.sciencedirect.com/science /article/pii/S0167527304004041
Iglesias-Garriz, I. et al. (2008). Hospital mortality and early preinfarction angina: metaanalysis of published studies. http://www.sciencedirect.com/science /article/pii/S0300893205739348 Cannon, C. P. (2005). Evidence-based risk stratification to target therapies in acute coronary syndromes. http://circ.ahajournals.org/content/ 106/13/1588.full Matura, L. A. et al. (2003). Guidelines for diagnosis and management of unstable angina and non-ST-segment elevation myocardial infarction. http://www.ispub.com/journal/theinternet-journal-of-advanced-nursing-practice/volume-6-number-1/guidelines-fordiagnosis-and-management-of-unstable-angina-and-non-st-segment-elevationmyocardial-infarction.html