43599015 Acute Myocardial Infarction

43
1 | Page I. OBJECTIVES General Objective This case study is for the group to understand Acute Myocardial Infarction and be able to know the appropriate and proper care needed by the patients with such disease. Specific Objectives Knowledge: Gain profound knowledge about acute myocardial infarction, its etiology, disease process, signs and symptoms and its treatment. Widen the understanding regarding the nature and management of disease. Impart the information to the concerned individuals especially to those persons with this kind of disease. Skills: Apply properly the learned skills in actual procedures as part of intervention in the said disease. Enhance critical thinking in making nursing care plans. Improve nursing skills in implementing nursing interventions. Attitude: Develop sense of responsibility and proper attitude in dealing with clients. Enhance self-confidence in handling and providing care for the patients. Observe positive behavior in promoting and maintaining wellness among clients.

Transcript of 43599015 Acute Myocardial Infarction

Page 1: 43599015 Acute Myocardial Infarction

1 | P a g e

I. OBJECTIVES

General Objective

This case study is for the group to understand Acute Myocardial Infarction and be able to know the appropriate and proper care needed by the patients with such disease.

Specific Objectives

Knowledge:

Gain profound knowledge about acute myocardial infarction, its etiology, disease process, signs and symptoms and its treatment.

Widen the understanding regarding the nature and management of disease. Impart the information to the concerned individuals especially to those persons with this kind of

disease.

Skills:

Apply properly the learned skills in actual procedures as part of intervention in the said disease. Enhance critical thinking in making nursing care plans. Improve nursing skills in implementing nursing interventions.

Attitude:

Develop sense of responsibility and proper attitude in dealing with clients. Enhance self-confidence in handling and providing care for the patients. Observe positive behavior in promoting and maintaining wellness among clients.

Page 2: 43599015 Acute Myocardial Infarction

2 | P a g e

II. INTRODUCTION

A. Background of the Study

This is a case of a 47 year old male who was diagnosed with Acute Myocardial Infarction. He was admitted to Meycauyan Doctor’s Hospital (MDH), June 29, 2010 with chief complaint of chest pain with dizziness, dyspnea, epigastric pain and vomiting.

Our group handled the patient for 3 days (July 1-July 3, 2010). Vital signs, physical assessment, appropriate nursing interventions, care and emotional support were given to the patient.

We chose to conduct this study to wholly understand the causes of this disease, how it affects the person and how this disease is treated. Moreover, this will serve as an overview for the coming cardiovascular concept that we will be discussing in our Medical-Surgical Nursing.

B. Definition of the Case

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 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 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).

There are two basic types of acute myocardial infarction:

Transmural: associated with atherosclerosis involving major coronary artery. It can be subclassified into anterior, posterior, or inferior. Transmural infarcts extend through the whole thickness of the heart muscle and are usually a result of complete occlusion of the area's blood supply.

Subendocardial/Nontransmural: involving a small area in the subendocardial wall of the left ventricle, ventricular septum, or papillary muscles. Subendocardial infarcts are thought to be a result of locally decreased blood supply, possibly from a narrowing of the coronary arteries. The subendocardial area is farthest from the heart's blood supply and is more susceptible to this type of pathology.

Page 3: 43599015 Acute Myocardial Infarction

3 | P a g e

Most myocardial infarctions are anterior or inferior but may affect the posterior wall of the left ventricle to cause a posterior myocardial infarction.

Clinically, an acute myocardial infarction refers to two subtypes of acute coronary syndrome, namely ST elevation MI (STEMI) versus a non-ST elevation MI (non-STEMI) based on ECG changes which are most frequently (but not always) a manifestation of coronary artery disease.

Classification of Myocardial Infarction: Type 1 - Spontaneous myocardial infarction related to ischaemia due to a primary coronary

event such as plaque erosion and/or rupture, fissuring, or dissection Type 2 - Myocardial infarction secondary to ischaemia due to either increased oxygen demand

or decreased supply, e.g. coronary artery spasm, coronary embolism, anemia, arrhythmias, hy-pertension, or hypotension

Type 3 - Sudden unexpected cardiac death, including cardiac arrest, often with symptoms sug-gestive of myocardial ischaemia, accompanied by presumably new ST elevation, or new LBBB, or evidence of fresh thrombus in a coronary artery by angiography and/or at autopsy, but death occurring before blood samples could be obtained, or at a time before the appearance of car-diac biomarkers in the blood

Type 4 - Associated with coronary angioplasty or stents: o Type 4a - Myocardial infarction associated with PCIo Type 4b - Myocardial infarction associated with stent thrombosis as documented by an-

giography or at autopsy Type 5 - Myocardial infarction associated with CABG

C. General Signs and SymptomsThe onset of symptoms in myocardial infarction (MI) is usually gradual, over several minutes, and rarely instantaneous.

Classical symptoms of acute myocardial infarction include:

Sudden chest pain - a sensation of tightness, pressure, or squeezing. Chest pain due to ischemia (a lack of blood and hence oxygen supply) of the heart muscle is termed angina pectoris. Pain radiates most often to the left arm or left side of the neck, but may also radiate to the lower jaw, neck, right arm, back, and epigastrium, where it may mimic heartburn.

Page 4: 43599015 Acute Myocardial Infarction

4 | P a g e

Pain zones in myocardial infarction (dark red = most typical area, light red = other possible areas, view of the chest).

Levine's sign - patient localizes the chest pain by clenching their fist over the sternum, has classically been thought to be predictive of cardiac chest pain.

Shortness of breath (dyspnea) - occurs when the damage to the heart limits the output of the left ventricle, causing left ventricular failure and consequent pulmonary edema.

Diaphoresis Weakness Light-headedness Nausea Vomiting Palpitations Sweating Anxiety Loss of consciousness (due to inadequate cerebral perfusion and cardiogenic shock) Sudden death (frequently due to the development of ventricular fibrillation) can occur in

myocardial infarctions.

An MI may occur at any time of the day, but most appear to be clustered around the early hours of the morning, are associated with demanding physical activity, or both. Women may experience fewer typical symptoms than men, most commonly shortness of breath, weakness, a feeling of indigestion, and fatigue.

Approximately one quarter of all myocardial infarctions are silent, without chest pain or other symptoms. These cases can be discovered later on electrocardiograms, using blood enzyme tests or at autopsy without a prior history of related complaints.

A silent course is more common in the elderly, in patients with diabetes mellitus and after heart transplantation, probably because the donor heart is not connected to nerves of the host. In diabetics,

Page 5: 43599015 Acute Myocardial Infarction

5 | P a g e

differences in pain threshold, autonomic neuropathy, and psychological factors have been cited as possible explanations for the lack of symptoms.

Approximately half of all MI patients have experienced warning symptoms such as chest pain prior to the infarction.

D. Etiology

The most frequent cause of myocardial infarction (MI) is rupture of an atherosclerotic plaque within a coronary artery with subsequent arterial spasm and thrombus formation. Intense exertion, be it psychological stress or physical, especially if the exertion is more intense than the individual usually performs also triggers MI.

Other causes include the following: Coronary artery vasospasm Ventricular hypertrophy (eg, left ventricular hypertrophy [LVH], idiopathic hypertrophic

subaortic stenosis [IHSS], underlying valve disease) Hypoxia due to carbon monoxide poisoning or acute pulmonary disorders (Infarcts due to

pulmonary disease usually occur when demand on the myocardium dramatically increases relative to the available blood supply.)

Coronary artery emboli, secondary to cholesterol, air, or the products of sepsis Cocaine, amphetamines, and ephedrine Arteritis Coronary anomalies, including aneurysms of the coronary arteries Increased afterload or inotropic effects, which increase the demand on the myocardium Aortic dissection, with retrograde involvement of the coronary arteries Although rare, pediatric coronary artery disease may be seen with Marfan syndrome, Kawasaki

disease, Takayasu arteritis, progeria, and cystic medial necrosis. Risk factors for atherosclerosis are generally risk factors for myocardial infarction: Diabetes (with or without insulin resistance) - the single most important risk factor for ischemic

heart disease (IHD) Tobacco smoking Hypercholesterolemia (more accurately hyperlipoproteinemia, especially high low density

lipoprotein and low high density lipoprotein) High blood pressure Family history of Cardiovascular disease such as ischemic heart disease (IHD) Obesity (defined by a body mass index of more than 30 kg/m², or alternatively by waist

circumference or waist-hip ratio). Age: Men acquire an independent risk factor at age 45, Women acquire an independent risk

factor at age 55; in addition individuals acquire another independent risk factor if they have a

Page 6: 43599015 Acute Myocardial Infarction

6 | P a g e

first-degree male relative (brother, father) who suffered a coronary vascular event at or before age 55. Another independent risk factor is acquired if one has a first-degree female relative (mother, sister) who suffered a coronary vascular event at age 65 or younger.

Hyperhomocysteinemia (high homocysteine, a toxic blood amino acid that is elevated when intakes of vitamins B2, B6, B12 and folic acid are insufficient)

Stress (occupations with high stress index are known to have susceptibility for atherosclerosis) Alcohol Studies show that prolonged exposure to high quantities of alcohol can increase the risk

of heart attack Males are more at risk than females. Other risks are: chronic kidney disease, heart failure, elevated CRP blood levels and the abuse of

certain drugs (such as cocaine and methamphetamine). Many of these risk factors are modifiable, so many heart attacks can be prevented by

maintaining a healthier lifestyle. Physical activity, for example, is associated with a lower risk profile. Non-modifiable risk factors include age, sex, and family history of an early heart attack (before the age of 60), which is thought of as reflecting a genetic predisposition.

E. Incidence

Cardiovascular diseases account for 12 million deaths annually worldwide. MI continues to be a significant problem in industrialized countries and is becoming an increasingly significant problem in developing countries.Myocardial infarction is the leading cause of death in the United States and in most industrialized nations throughout the world. Approximately 800,000 people in the United States are affected annually.

WHO estimated in 2002, that 12.6 percent of worldwide deaths were from ischemic heart disease with it the leading cause of death in developed countries, and third to AIDS and lower respiratory infections in developing countries. Worldwide more than 3 million people have STEMIs and 4 million have NSTEMIs a year.

MI can occur at any age, but its incidence rises with age. Approximately 50% of all MIs in the United States occur in people younger than 65 years.

Coronary heart disease (CHD) is the most common cause of death in the UK. CHD is responsible for the deaths of approximately one in five men, and one in six women.

The average incidence of myocardial infarction for those aged between 30 and 69 years is about 600 per 100,000 for men, and 200 per 100,000 for women.

Mortality rates from CHD are higher for men than women, people living in deprived areas and in people of South Asian origin. There is evidence of earlier deaths for men than women after an acute myocardial infarction

Page 7: 43599015 Acute Myocardial Infarction

7 | P a g e

III. PATIENT PROFILE

A. Demographic Data

Page 8: 43599015 Acute Myocardial Infarction

8 | P a g e

Date of Admission: June 29, 2010Name: Mr. R.TAge: 47Gender: MaleAddress: 4-C Saint Philip St. L.F.S Tugatog Valenzuela CityStatus: MarriedDate of birth: October 6, 1962 Place of Birth: Northern SamarReligion: Roman CatholicNationality: FilipinoOccupation: Fish Dealer

B. Chief Complaint/sChest pain

C. Physical Examination

Initial Physical Assessment (June 29, 2010)

EENT-Pink palpebral conjunctiva, anicteric scleraCHEST-SCE, (-) retraction HEART-AP,NRRR, (-) murmurABDOMEN- Flat, softGENITALIA- Remarkable RECTUM AND ANUS- RemarkableEXTREMETIES- (-) edemaSKIN- (-) pallorGCS- 15

PAST HISTORY(-) hypertension(-)Bronchial asthma(+) Diabetes Mellitus

FAMILY HISTORYDiabetes Mellitus, Hypertension

PRESENT ILLNESS2 days PTA, patient sought consult at ER and was diagnosed w/ inferior wall MI but HAMA. Chest

pain persisted only periodic relief hence consult.

Page 9: 43599015 Acute Myocardial Infarction

9 | P a g e

PERSONAL AND SOCIAL HISTORY(-) food & drug(-) cigarette smoking(-) alcoholic

SYSTEM REVIEW(-) anorexia(+) dizziness(+) chest pain(+) dyspnea

(+) epigastric pain(-) joint pain(+) vomiting

ALLERGY: NO KNOWN ALLERGY

Physical Assessment (July 1, 2010, 1:00pm)

VITAL SIGNSBlood pressure: 100/60 bpmPulse rate: 65 bpm; regular; radial pulseRespiration Rate: 19 bpmTemperature: 37.7°C (axillary)

ANTHROPOMETRIC MEASUREMENTSBMI: 28.1 (overweight)Weight: 72 kgHeight: 160 cm

GLASGOW COMA SCALE

Eye Opening (E) Verbal Response (V) Motor Response (M)4=spontaneous

3=to voice2= to pain

1=none

5= normal conversation4=disoriented conversation3=words but not coherent2=no words only sounds

1= None

6= Normal5= localizes pain

4= withdraws to pain3=decorticate posture

2= Decerebrate1= none

4 5 6Total GCS: (E+V+M)= 15

PUPIL SCALESize: 3mm

Left and right pupils are reactive to light and has the same pupil size

Page 10: 43599015 Acute Myocardial Infarction

10 | P a g e

MOVEMENTSR/L Arms: Normal powerR/L Legs: Normal power

MENTAL STATUS

State of consciousness: Conscious, alertSpeech: Spontaneous, coherentOrientation: GoodSigns of distress: NoneHeadache: MildMood: Euthymic

CRANIAL NERVESCN I: proper sense of smellCN II (optic): Both eyes, equally reactive to lightCN III, IV, VI (oculomotor, trochlear, abducens): Full extra ocular musclesCN V (trigeminal): (+) corneal reflexCN VII (facial): (+) facial symmetryCN VIII (acoustic): Follows commands

CN IX, X (glossopharyngeal and vagus): (+) gag reflexCN XI (spinal accessory): Able to shrug both shouldersCN XII (hypoglossal): Normal tongue midline

NEUROMUSCULARPupils: Pupils equally reactive to lightReflexes: Normal reflexesActivity Level: Requires little assistance from other person or device. Due to his condition, he is not allowed to perform ADL yet.Hemiplegia: NoneExtremities: No deformities, symmetric

Motor Strength: 5/5 on all areas except his left arm which has an IV line.HEENT

HEAD: Normocephalic, Facial symmetry

EYESVision: 150/100, wears glassesSclera: Clear, anictericConjunctiva: No discharge, pale

EARSHearing: Has no difficulty of hearingDischarge: None

NOSEDischarge: NoneCongestion: None

Page 11: 43599015 Acute Myocardial Infarction

11 | P a g e

Orientation: SymmetricalNasal flaring: None

THROAT: No swelling

MOUTHMoisture/color: moist/pinkTongue: pinkLips: intactTeeth: with cariesSore mouth: None

INTEGUMENTARYSkin Integrity or Condition: IntactColor: PaleTurgor: PoorTemperature: ColdMoisture: DryIV access: Intact, Central (left metacarpal)Nails: Thick and roughCapillary Blood Refill: 3 secondsWound: NonePresence of pressure ulcers: None

RESPIRATORYLung Movement: Symmetrical chest expansionDifficulty of breathing: AbsentRetractions: NoneCough: AbsentBreath Sounds: ClearOxygen therapy: Nasal Canula

CARDIOVASCULARHeart Sounds: without murmursApical Pulse: R/L regularRadial Pulse: R/L regularBrachial Pulse: R/L regularPedal Pulse: R/L faintNeck veins: Edema: Absent

Page 12: 43599015 Acute Myocardial Infarction

12 | P a g e

GASTROINTESTINALAbdomen: Round, softTenderness: NoneBowel Sounds: NormoactiveFeeds Independently: Can eat independently using right hand but chose to be fed by his wifeNasogastric tube feeding: None

GENITOURINARYUrination: NormalGenital Area: No pain, no dischargeGenital Pain: AbsentFlank Pain: Present

NUTRITIONAL STATUSAppetite: NormalNausea/ Vomiting: NoneDiet: Low salt, Low fat, soft dietFeeding Precaution: NoneFood allergy: No known allergiesDifficulty of swallowing: Absent

PAIN ASSESSMENTBased on pain scale of 0-10:

Flank pain: 3/10Cardiac pain: 2/10

GORDON’S FUNCTIONAL HEALTH PATTERN

Health Perception and ManagementOn July 1, 2010, the group had a face-to-face interaction with Mr. RT and his family. He claimed

that before he was confined, he feels good about his health. He doesn’t smoke and drinks alcohol occasionally. He has a history of DM type 2 and takes Metformin as maintenance drug. When asked what caused his illness he admitted that it was due to eating high cholesterol and fatty foods particulary lechon and crab fat prior to his admission. Moreover he hopes that he would be well monitored and given attention throughout his hospitalization to improve his condition.

Activity and Exercise PatternMr. RT is a fish vendor at night. He regularly goes to the market to get deliveries of fish and sell

them. Walking from their house to the market is his form of exercise every day. At home, he even

Page 13: 43599015 Acute Myocardial Infarction

13 | P a g e

performs household chores during his free time. His common leisure activities are eating, sleeping and watching the television. In addition, he admitted that he doesn’t have regular check-ups. He only see the doctor when it is needed.

Nutritional and Metabolic PatternBefore his confinement, the patient has a good appetite, frequently served with nutritious foods

such as vegetables and loves to eat fatty foods. He drinks a lot of water averaging of 8 glasses per day. In his span of confinement, he usually drinks 3 glasses of water per day and has good appetite. He is fed by her wife.

Elimination Pattern Before he was confined he normally defecates once a day with brown colored stools and urinate an average of four times a day characterized by light yellow color without any difficulty. In his span of confinement, he only defecated twice with yellow, slightly watery stools without difficulty. His urination in the hospital is just the same frequency and volume before his admission. Sleep and Rest Pattern

He gets to have an average of 6 hours of sleep before his confinement while in the hospital he experiences 4 hours or less than that due to interventions and medications given to him. The patient reported that he has no difficulty sleeping and gets to have continuous sleep unless he feels the urge to urinate. He also gets to take naps in the morning and afternoon as claimed by the patient.

Cognitive and Perception PatternThe patient asserted that he has no hearing difficulty, wears glasses with the vision of 150/100,

can recall in a few minutes and proclaims to his family whenever he is in pain.

Self-perception and Self-conceptHe generally feels good about himself although he experiences chest pain and flank pain. He

verbalized that these pains where only felt upon movement and characterized as non-throbbing pain. The student nurses assessed that his flank pain may be due to his sleeping position (semi-fowler’s position).

Role and Relationship Pattern

The family is made up of 24 members living in a compound together with their relatives. He has a caring and loving wife and has 4 children, 2 girls and 2 boys. The client expressed that his income is enough to support the needs of the family. He even verbalized, “Ah oo sapat, nakakakaen nga kami ng 3 beses sa isang araw e.” In general, Mr. RT is satisfied with his family relationship, work and life.

Coping and Stress Pattern

Page 14: 43599015 Acute Myocardial Infarction

14 | P a g e

The patient does not exhibit any tense appearance because of his eagerness to be well, he interacted happily and precisely to our questions as if he doesn’t have an illness. In times of stress, he’s way of coping is through rest and eating his favorite foods.

Value and Belief PatternThe patient finds religion an important part of his life. But he admitted that he seldom attends

Sunday Mass. The patient’s hospitalization does not interfere with his faith and is very thankful that he is still alive.

D. Past History of IllnessDiabetes Mellitus Type II

E. Present History of IllnessInferior wall MI but HAMA

F. AllergiesNo known allergy

VITAL SIGNS (7/1/2010)TIME BP T P R

12(AM) 120/80 37.0 75 281 120/80 36.8 73 262 120/80 36.1 84 283 110/80 36.6 80 284 120/90 37.1 80 295 120/80 36.0 75 286 120/80 36.9 76 337 120/80 37.2 77 308 120/90 38.6 76 329 120/80 38.3 84 30

10 120/80 37.6 84 3311 120/90 37.3 78 26

12(PM) 110/80 37.6 80 231 120/80 37.1 73 232 120/80 36.8 74 283 120/90 36.6 83 264 120/80 37.0 77 265 110/80 36.3 86 246 120/80 36.6 84 237 120/80 36.0 75 268 110/90 36.8 76 289 R E F U S E D

10 R E F U S E D

Page 15: 43599015 Acute Myocardial Infarction

15 | P a g e

11 R E F U S E D

VITAL SIGNS (7/2/2010)TIME BP T P R

12(AM) R E F U S E D1 R E F U S E D2 120/80 36.8 84 283 120/80 36.3 80 264 120/80 36.0 76 245 120/80 36.1 77 246 120/90 36.6 82 287 120/80 36.3 76 268 120/80 36.3 76 289 120/80 36.2 78 29

10 120/90 36.6 75 3111 R E F U S E D

12(PM) 120/90 37.7 77 281 100/70 38.1 76 28

G. Course in the ward6/29/10 >IMA,INFERIOR KILLIPS I >Admit to ICU under the supervision of Dr.Cureba >Secure consent for administration and management >NPO except meds >IVF-PNSS 1L x KVO >Diagnostic test: -ECG -BUN,CREA,NA,K,Hgt -243 mg/dl - REFER -CBC,FBS,LIPID PROFILE,PT,PTT - REFER >Therapeutics: -Isoket drip: 1 amp isoket + 90 cc D5Lr to run at 10 gtts/min -Simvastatin: 80 mg, 1 tab -Trimetazidine 35 mg tab TID -Heparin bolus 5000 IV -Heparin Drip 25000 u D%W250x 10 mgtts/min -O2 at 2L nasal canula

6/30/10 > Transfer to a private room (406) > Complete bed rest w/out bath room privileges > ST elevation improved > Monitor patient’s vital sign every hour >PO: soft diet, low salt, low fat

Page 16: 43599015 Acute Myocardial Infarction

16 | P a g e

>refer BP less than 90/60 > HEPARIN - check for bleeding

7/1/10 >Monitor vital sign Q1 >Patient was given paracetamol due to an elevated temperature. (T-38.1) >Perform TSB >Latest result of PTT was done

> Perform CBG to the patient

7/2/10 >Patient can seat with dangled legs but still w/out bathroom privileges >Patient’s Vital sign is stable (Q1)

IV. ANATOMY AND PHYSIOLOGYThe heart is responsible for pumping the blood to every cell in the body. It is also responsible for pumping blood to the lungs, where the blood gives up carbon dioxide and takes on oxygen. In the systemic circuit, blood leaves the heart through the aorta, goes to all the organs of the body through the systemic arteries, and then returns to the heart through the systemic veins.

The heart is no different from any other organ. It must have its own source of oxygenated blood. The

heart is supplied by its own set of blood vessels. These are the coronary arteries. There are two main ones with two major branches each. They arise from the aorta right after it leaves the heart. The coro-nary arteries eventually branch into capillary beds that course throughout the heart walls and supply the heart muscle with oxygenated blood. The coronary veins return blood from the heart muscle, but in-stead of emptying into another larger vein, they empty directly into the right atrium.

Coronary circulation is the circulation of blood in the blood vessels of the heart muscle (the my-ocardium). The vessels that deliver oxygen-rich blood to the myocardium are known as coronary arter-

Page 17: 43599015 Acute Myocardial Infarction

17 | P a g e

ies. The vessels that remove the deoxygenated blood from the heart muscle are known as coronary veins.

The coronary arteries are classified as "end circulation", since they represent the only source of blood supply to the myocardium: there is very little redundant blood supply, which is why blockage of these vessels can be so critical.

Page 18: 43599015 Acute Myocardial Infarction

↓ Blood flow to Body Circulation(Lungs, Kidney, Brain, & Digestive System)

PATHOPHYSIOLOGY

ACUTE MYOCARDIAL INFARCTIONDEFINITION:

Acute myocardial infarction (MI) is defined as death or necrosis of myocardial cells. It is a diagnosis at the end of the spectrum of myocardial ischemia or acute coronary syndromes.

NON-MODIFIABLE:►Gender (male)►Age (47 yrs. old)

MODIFIABLE:► Hypertension ► DM► Diet (high fat)

Ruptured Atherosclerotic Plaque

Arterial Spasm & Thrombus Formation(Occlusion of Coronary Artery)

S/sx:►Pain

S/sx:► Light-headedness ►Dyspnea►↓ Urinary output ►SOB ►Nausea& vomiting ► Pale

Activation of SNS(Release of Catecholamine)

Metabolic Acidosis

↓Blood supply & ↓O2 (myocardium)

S/sx:► ↑ HR & BP►Dysrhythmia

↓ Contractility & pumping ability

Anaerobic Metabolism

Page 19: 43599015 Acute Myocardial Infarction

In Myocardial Infarction, inadequate coronary blood flow rapidly results in myocardial ischemia in the affected area. Ischemia depresses car-diac function and triggers autonomic nervous system responses that exacerbate the imbalance between myocardial oxygen supply and de-mand. Persistent ischemia results in tissue necrosis and scar tissue formation, with permanent loss of myocardial contractility in the affected area. Cardiogenic shock may develop because of inadequate CO from decreased myocardial contractility and pumping capacity.

Page 20: 43599015 Acute Myocardial Infarction

V. LABORATORY EXAMINATION/DIAGNOSTIC PROCEDURES

Date/Lab test Normal Value Client Result Reason for test Nursing Intervention

June 6, 2010: Blood Chemistry

July 1, 2010: Partial Thromboplastin Time (PTT)

70-105mg/dL

24-38sControl: 29.8s

Glucose (FBS): 216.9

Clinical significance:

The patient has diabetes mellitus;

thus, there is elevation of

glucose level.

51.7s

Clinical significance:

The patient has elevated glucose level making the

blood thicker than normal and more susceptible to clot

formation.

The basic meta-bolic panel (BMP) is a group of tests that measures dif-ferent chemicals in the blood. These tests usually are done on the fluid (plasma) part of blood. The tests can give doctors information about your muscles (in-cluding the heart), bones, and organs, such as the kid-neys and liver and may also indicate underlying dis-eases.

*The plasma contains water, glucose, etc.

A partial thromboplastin time (PTT) test measures how long it takes for a clot to form in a blood sample. A clot is a thick lump of blood that the body produces to seal leaks, wounds, cuts, and scratches and prevent excessive bleeding.

1. The BMP may be performed without any preparation in an emergency, or it may be done after fasting.

2. FBS: The client may be asked to fast for 8 to 12 hours prior to testing.

3. Collect the sam-ple and monitor glucose levels.

1. Explain the procedure to the client; how does it feel, etc.

2. Tell the client to stop taking certain drugs before the test (with doctor’s advice). Drugs that can affect the results of a PTT test include antihistamines,

Page 21: 43599015 Acute Myocardial Infarction

Heparin, which aids in thinning of

the blood, may cause longer PTT

than normal.

Since the client has elevated glucose level, his blood is thicker than normal; thus, more susceptible to clot formation.

vitamin C (ascorbic acid), aspirin, and chlorpromazine (Thorazine).

Date/Diagnostic Procedure

Client Result Reason for test Nursing intervention: Preparation Pre and

Post ProcedureJune 28, 2010: Electrocardiogram (ECG)

Rate: 52Rate Atrial: S2QRS: .08Axis: 60’PR: .20QT: 400/s

Diagnosis:Sinus BradycardiaAcute Inferior Wall Myocardial Infarction

Electrocardiography provides a graphic recording of the heart’s electrical activity.Electrodes placed on the skin transmit the electrical impulses to a graphic recorder. Contraction of cardiac smooth muscle produces electrical activity, resulting in a series of waves on the ECG. With the wave forms recorded, the ECG can then be examined to detect dysrhythmias and alterations in conduction indicative of myocardial damage, enlargement of the heart, or drug. An ECG monitors the regularity and path of the electrical impulse through the conduction system. The normal sequence on the ECG is called normal sinus

Pre: 1. Explain the procedure to the client; how does it feel, etc. 2. Ask the client if he/she is taking any medications.

3. Tell the client to refrain from drinking cold water immediately before an ECG as it may produce changes in one of the waveforms recorded (the T wave).

4. All metals/jewelries should be taken off prior to the procedure.

5. If the client has a lot of hair on the chest, a small area may need to be shaved to put the electrodes on.

6. Instruct the client to remain silent and relax during the procedure.

Page 22: 43599015 Acute Myocardial Infarction

rhythm (NSR). NSR implies that the impulse originates at the SA node and follows the normal sequence through the conduction system.

7. Tell the client to wear a lab gown.

Page 23: 43599015 Acute Myocardial Infarction

VI. DRUG STUDYDRUG, DOSAGE,

ROUTE, FREQUENCY CLASSIFICATION and ACTION

SIDE/ADVERSE EFFECTS

IMPLICATIONS NURSING RESPONSIBILITIES/ INTERVENTIONS

Generic Name: simvastatin

Brand Name: Zocor

Dosage: 80mg

Route: Oral

Frequency: once a day

Class: Antilipidemic, HMG-CoA reductase inhibitor

Action: Inhibits HMG-CoA reductase, the enzyme necessary for hepatic production of cholesterol

Side Effects:• Headache• Nausea • Flatulence• Diarrhea• Abdominal

pain

Adverse Effects:• Liver failure• Acute renal

failure

Check for allergy to sim-vastatin.

Contraindicated with fungal byproducts.

• Check the drug label: the drug name, dosage, route and if you are administering the drug to the right patient.

• Explain to the patient what the drug is for, and its side effects.

• Administer drug in the evening because highest rates of cholesterol synthesis occurs be-tween midnight and 5am.

• Instruct patient to avoid drink-ing grape juice while taking the drug.

• Instruct patient to report se-vere GI upset, changes in vision, un-usual bleeding, dark urine, light-col-ored stools, muscle pain

Generic Name: isosorbide dinitrate

Brand Name: Isoket retard

Dosage: 20mg/tabRoute: OralFrequency: once a day

Class: Antianginal, Nitrate, Vasodilator

Action: Relaxes vascular smooth muscle which results to decreased venous return and arterial BP, which reduces left ventricular workload and myocardial oxygen

Side Effects: Headache Restlessness Weakness Nausea dizziness

Adverse Effects:• Tachycardia• Hypotension

Check for allergy to ni-trates.

Contraindicated with se-vere anemia, head trauma, cerebral hemor-rhage, glaucoma.

Use cautiously in pa-tients’ with acute MI or heart failure.

• Check the drug label: the drug name, dosage, route and if you are administering the drug to the right patient.

• Explain to the patient what the drug is for, and its side effects.

• Monitor vital signs, note changes in blood pressure.

• Check for adventitious sounds.• Check results of CBC and he-

Page 24: 43599015 Acute Myocardial Infarction

consumption • syncope moglobin• Administer drug sublingually

and discourage patient in swallow-ing.

• Administer drug 2 hours be-fore meals as ordered by the physi-cian.

• Provide patient a cool envi-ronment and position patient in supine when headache occurs.

• Instruct patient to report blurred vision, more severe angina attacks, persistent headache or fainting.

Generic Name: trimetazidine

Brand Name: Vastarel

Dosage: 35mg/tabRoute: oralFrequency: once a day

Class: Antianginal, Nitrate, Vasodilator

Action: Relaxes vascular smooth muscle which results to decreased

Side Effects: Rash

Adverse Effects: Fever respiratory illness anemia

Check for allergy to trimetazidine.

• Check the drug label: the drug name, dosage, route and if you are administering the drug to the right patient.

• Explain to the patient what the drug is for, and its side effects.

• Monitor vital signs of patient, note for changes in temperature or for any deviations from the normal.

Generic Name: heparin

Brand Name: Hep-Lock

Class: Anticoagulant

Action: Inhibits thrombus and clot formation by blocking the conversion of prothrombin to thrombin,

Side Effects: Headache Abdominal pain Back pain

Adverse Effects:

Check for allergy to hep-arin.

Contraindicated with se-vere thrombocytopenia.

Use cautiously with re-cent surgery.

• Assess for PTT and other blood coagulation tests and platelet count.

• Check the drug label: the drug name, dosage, route and if you are administering the drug to the right

Page 25: 43599015 Acute Myocardial Infarction

Dosage: 25,000 Units

Route: TIV

fibrinogen to fibrin. • Bruising• Fever• hyperkalemia

patient.• Explain to the patient what

the drug is for, and its side effects.• Mix well when adding heparin

to IV infusion.• Check for signs of bleeding• Provide safety measures to

prevent bleeding.• Instruct patient to report for

abdominal or lower back pain, se-vere headache.

Generic Name: glipizide

Brand Name: Glucotrol

Dosage: 2mg/tab

Route: oral

Frequency: once a day

Class: Antidiabetic, 2nd generation Sulfonylurea

Action: Stimulates insulin release from functioning beta cells in pancreas, increases insulin receptors.

Side Effects: Nausea Epigastric discom-

fort

Adverse Effects: Diarrhea Hypoglycemia Allergic skin reac-

tions.

Check for allergy to sul-fonylureas.

Contraindicated with se-vere infections, severe trauma, ketosis, hepatic and renal impairment.

Use cautiously with ure-mia, hyperglycemia, thy-roid or endocrine im-pairment.

• Assess and check the urinaly-sis results, note for BUN, creatinine levels, check also blood glucose lev-els, CBC.

• Check the drug label: the drug name, dosage, route and if you are administering the drug to the right patient.

• Explain to the patient what the drug is for, and its side effects.

• Administer drug 30 minutes before breakfast and drug must be given before meals.

• Monitor urine and blood for glucose levels and ketones, and to determine effectiveness of drug dosage.

• Instruct patient to avoid alco-hol when taking the drug.

• Instruct patient to report for sore throat, rash, dark urine or

Page 26: 43599015 Acute Myocardial Infarction

light-colored stools.

Page 27: 43599015 Acute Myocardial Infarction

VII. THEORETICAL FRAMEWORK

FAYE GLENN ABDELLAH

Abdellah’s typology was divided into three areas: (1) the physical, sociological, and emotional

needs of the patient; (2) the types of interpersonal relationships between the nurse and the patient; and

(3) the common elements of patient care. Adbellah and her colleagues thought the typology would pro-

vide a method to evaluate a student’s experiences and also a method to evaluate a nurse’s competency

based on outcome measures.

Typology of 21 Nursing Problems are as follows:

1. To promote good hygiene and physical comfort

2. To promote optimal activity, exercise, rest, and sleep

3. To promote safety through prevention of accidents, injury, or other trauma and through the preven-

tion of the spread of infection

4. To maintain good body mechanics and prevent and correct deformities

5. To facilitate the maintenance of a supply of oxygen to all body cells

6. To facilitate the maintenance of nutrition of all body cells

7. To facilitate the maintenance of elimination

8. To facilitate the maintenance of fluid and electrolyte balance

9. To recognize the physiologic responses of the body to disease conditions

10. To facilitate the maintenance of regulatory mechanisms and functions

11. To facilitate the maintenance of sensory function

12. To identify and accept positive and negative expressions, feelings, and reactions

13. To identify and accept the interrelatedness of emotions and organic illness

14. To facilitate the maintenance of effective verbal and nonverbal communication

15. To promote the development of productive interpersonal relationships

16. To facilitate progress toward achievement of personal spiritual goals

17. To create and maintain a therapeutic environment

18. To facilitate awareness of self as an individual with varying physical, emotional, and developmental

needs

19. To accept the optimum possible goals in light of physical and emotional limitations

20. To use community resources as an aid in resolving problems arising from illness

21. To understand the role of social problems as influencing factors in the cause of illness

Page 28: 43599015 Acute Myocardial Infarction

NURSING CARE PLAN

Page 29: 43599015 Acute Myocardial Infarction
Page 30: 43599015 Acute Myocardial Infarction
Page 31: 43599015 Acute Myocardial Infarction
Page 32: 43599015 Acute Myocardial Infarction

VIII. DISCHARGE PLANNING

MEDICATION>Instruct patient and relatives the importance of drug compliance and possible complications that may arise if drug regimens are not followed.>Advice patient to have a pill organizer marked by the time and day he should take his medication to avoid missed doses or over doses.>Inform relatives to help patient in taking his medicine regularly.>Teach relatives and patient the importance of the given medications.>Instruct the patient to take drug before meals ( trimetazidine, simvastatine and other cardiovascular drugs)

ENVIRONMENT>Instruct relatives at home to provide a quiet, calm and restful environment.>Instruct relatives to remove stressful stimulus such as loud noise, intense light and frequent visitors to the patient.>Advise patient to visit a place with fresh air and free from pollution environment.>Instruct patient and relatives to maintain cleanliness of the surroundings by regular changing of bed linens, curtains and dusting to remove allergens.

TREATMENT>Advise patient to incorporate therapeutic regimens into activities of daily living such as including specific exercises or light house work before going to work.>Instruct relatives to record any progress to the patient’s status.>Instruct relatives to report immediately to the physician if any abnormal events happened to the patient.

HEALTH TEACHINGS >Teach patient to have adequate rest to prevent fatigue.

>Stress proper hand washing techniques by all relatives/caregivers.>Emphasize the importance of the participation of family members in the therapeutic regimen for easy acceptance of the patient of his condition.>Encourage hypoallergenic bath soap, keep skin moist and maintain oral hygiene to prevent infection.

OUT PATIENT>Inform the patient about the follow-up checkups with the physician and emphasize the importance of this to his health.>Encourage patient to seek immediate health care facilities, even when not scheduled like chest pain, dyspnea & infections.>Encourage patient to have a regular contact with his physicians.

DIET AND NUTRITION>Encourage a diet low in sodium (avoid canned and preserved food, fish sauce and etc because it contains high sodium).>Advise patient a diet low in fat and cholesterol (avoid pork, chorizo and etc.)

Page 33: 43599015 Acute Myocardial Infarction

>Encourage patient to eat plenty of magnesium rich foods such as tofu, wheat germ, broccoli, potatoes, spinach and chard to help regulate heart activity.>Promote food like cayenne pepper because it can lowers cholesterol, dilates arteries, increases blood flow to the coronary circulation, and inhibits blood platelets from collecting.

SPIRITUAL>Seek assistance and Blessings from God.>Provide opportunity for patient to express spiritual beliefs.>Encourage relatives to accompany the patient in church mass and or seminars.

IX. NURSING IMPLICATION

A. Nursing research Health because of research outcomes is the key to knowing not only what quality of care can

be achieved but also how it can be achieved. When the care that patients receive is linked with the outcomes they experience.

This case study can be a reference for new researches and may be useful for other cases in the future.

B. Nursing Education As we all know, Cardiovascular diseases account for 12 million deaths annually worldwide.

Myocardial Infarction continues to be a significant problem in industrialized countries and is becoming an increasingly significant problem in developing countries. So the study will assist and help readers in gaining a basic knowledge of what Acute Myocardial Infarction is all about, its evident symptoms, risks, and proper management of the disease.

The outcome of this case study is enhanced knowledge, which will then lead to improved as-sessment, reduced delay in treatment time, and more effective teaching strategies.

C. Nursing Practice

Through this case study, student nurses were able to understand the disease process, prac-ticed thorough assessment and provided necessary interventions for a patient diagnosed with acute myocardial infarction.

The outcomes of this study can become a key in developing better ways to monitor and im-prove the quality of the nursing care that is provided.