Critical Care Nursing Assignment

Case: Acute Myocardial Infarction

Presented by:Zoriea S. Gaddong

Pearlyn Joy C. MirasolRaiza Q. Hasiman

Introduction

An intensive care unit (ICU), also sometimes known as a critical care unit or an

intensive therapy department is a special ward found inside most hospitals. It provides

intensive care (treatment and monitoring) for people who are in a critically ill or unstable

condition. Patients in ICUs need constant medical support to keep their body functions

going. They may not be able to breathe on their own, and may have multiple organ

failure, so medical equipment takes the place of these functions while they

recover.There are several circumstances in which a person may be admitted to

intensive care, for example, following surgery, or after an accident or severe illness. ICU

beds are a very expensive and limited resource because they provide specialized

monitoring equipment, a high degree of medical expertise and constant access to highly

trained nurses (usually one nurse for each bed). Being in an ICU can be a daunting

experience both for the patient and his or her friends and family. The healthcare

professionals in ICUs understand this and are there to help and support both patients

and their families during their time in intensive care.

Myocardial infarction (MI) is the irreversible necrosis of heart muscle secondary

to prolonged ischemia. This usually results from an imbalance of oxygen supply and

demand. The appearance of cardiac enzymes in the circulation generally indicates

myocardial necrosis. MI is considered, more appropriately, part of a spectrum referred

to an acute coronary syndromes (ACSs), which also includes unstable angina and non–

ST-elevation MI (NSTEMI). Patients with ischemic discomfort may or may not have ST-

segment elevation. Most of those with ST-segment elevation will develop Q waves.

Those without ST elevations will ultimately be diagnosed with unstable angina or

NSTEMI based on the presence of cardiac enzymes. MI may lead to impairment of

systolic function or diastolic function and to increased predisposition to arrhythmias and

other long-term complications.

Myocardial Infarction (MI) is one of the effects of the disease atherosclerosis. It is

characterized by the destruction of a portion of myocardium caused by an interruption in

blood flow resulting to the formation of localized necrotic areas. It is commonly known

as coronary thrombosis, cardiac arrest or heart attack. Acute MI can cause permanent

damaged of heart muscles as in thrombotic occlusion of a branch of an atherosclerotic

coronary artery. It is often accompanied by severe pain, shock, cardiac dysfunction and

even death.

This usually results from plaque rupture with thrombus formation in a coronary

vessel,, resulting in acute reduction of blood supply to a portion of the myocardium.

Atherosclerotic plaque formation involves many risk factors such as age, gender,

smoking, inherited lipoprotein disorders, diabetes mellitus (DM), poorly controlled

hypertension, type A personality, family history and having a sedentary lifestyle.

Increasing age predisposes more risk factors in an individual which make that individual

prone to cardiovascular diseases (CVDs). It is more common to males than females.

Smoking tends to increase the incidence of MI due to the vasoconstrictor effect of

nicotine or to some undesirable effects on the coagulability of the blood or the survival

of the platelets. Hypertension may also cause MI since it is the persistent elevation of a

systolic blood pressure above 140 mmHg and diastolic pressure above 90 mmHg.

Other causes of MI are coronary artery vasospasm, ventricular hypertrophy,

hypoxia due to CO poisoning or acute pulmonary disorders, coronary artery emboli,

cocaine, ampethamines and ephedrine, and other coronary anomalies.

A myocardial infarction can occur at any time of the day. This can be identified

with observations of the following signs and symptoms:

Chest pain described as a pressure sensation, fullness, or squeezing in the

midportion of the thorax.

Radiation of chest pain into the jaw or teeth, shoulder, arm and/or back

Associated with shortness of breath

Associated with epigastric discomfort which may or may not cause nausea or

vomiting.

Associated with sweating

Myocardial infarction can also be a cause of hyperlipoprotenemia type IV, which

is an elevation of lipoprotein factors in the blood. It is characterized by an

overproduction and impaired clearance of very low density lipoprotein (VLDL). This

order may be hereditary or associated with diabetes mellitus or another metabolic

disorder. Obesity and atherosclerosis are also frequent causes.

Overview of the Condition

The patient was never ask a consultation at the Physician as long as he can

stand alone and can walk. Until he woke up with vulnerable condition, the reason to

seek a health management. He doesn’t care, too much, what should be the food to be

intake, and what not should be, too. He always telling his wife “ano na lang ang kakainin

ko?!”. And now he is feeding thru NGT with low salt, low cholesterol and 1,800kCal.

He used to commode at least once a day before he admit MICU, according to his

wife. The physician ordered a Lactulose 30 cc to help him in bowel movement. The

patient working as a carpenter, before his condition getting bad. At the MICU, helping

the patient turning side-to-side every two hours, as ordered by the physician, and do the

passive R.O.M.

According to his wife, he sleep for almost 5-6 hour with irregular habit time of

sleep. The patient had never awake, since he transferred at MICU. He perform self-care

within the level of ability to do the ADL and other activity. Since he got an Intracerebral

hemorrhage, he had disturbed perceptual abilities due to his illness. He took a healthy

body for granted, a kind of denial of the eventuality of aging and illness. Due to the

threats to self-concepts about the self these condition may pose.

He was hard worker and good father to his family. Because of his condition, he is

now lying at room # 5, MICU. His family involved in decision making processes directed

at appropriate solution for the situation crisis. He had children by their own. Since, he

got CAD, less frequency and satisfaction of their sexual activity. When the patient felt

stress, he used to smoke. Although he know there is other way to move the stress

away.

They do visit their church together with their family aside from his son, working

on weekends. All we know, Adventist should not eat pork, but he still doing it.

Demographic Data

Name: A.P.G Age: 71 years old Sex: Male

Address: 181 D. Silang St. Batangas City

Birthday: October 2, 1937 Birthplace: Batangas

Religion: 7TH Day Adventist Status: Married

Race: Filipino

Admitted to E.R.: March 4, 2011

Chief Complaint: Right side body weakness

Diagnosis: Nosocomial Pneumonia; CAD, ACS, NSTMI, Killip II, HCVD, FC II,

Intracerebral he, (L) Basal Ganglia with intraventricular extension

Transferred to M.I.C.U.: March 7, 2011

Room #: 5 Rank: C/V/T

Health History

1. History of Present Illness

The patient was not able to get up at early morning, as they notice. Then after

two hours he had vomited episodely and cramping, so, their relatives rush up at

Fort Santiago General Hospital. Then, they transferred at AFPMC V.Luna, around

10:00 AM.

2. Past Medical History

He have a high blood pressure, not complaining for almost 10 years, he only

taking the drugs that given to him since the last consultation.

3. Family Medical History

He had history of hypertension and diabetes mellitus on paternal side.

4. Social History

According to his wife, he used to smoke 8-10 sticks per day but he occasionally

drinks any liquor. He sleeps 5-6 hours a day, irregular habit time of sleep.

Genogram

Grandmother(Old age)

Grandfather(hypertension)

Grandfather(stroke)

Grandmother(pneumonia)

Father(stroke)

Mother

APG

Physical Assessment: Head to Toe

General Survey:

Vital Signs BP – 110/80 RR - 40

Temp. 37.4˚C PR – 101 bpm

Unconscious patient lying on bed, with the position of semi-fowlers

Integument

Cold skin, from the body to lower extremity.

The head, right and left arm are enough heat skin.

Nails, delayed refill capillary

Moist skin on his face and neck

Head and neck

Skull and face, shape symmetry

Neck, no presence of contusions.

Eyes, yellow conjunctiva, unequal pupil 2-3 mm pupil on left and 3-4 pupil on

right

Ears, lesion on auricle of the Left ear

Nose, nasal flaring, placing an NGT (French 18) on his Left.

Mouth, placing an Endotracheal tube with 7.0, plastering on his right lips; dry lips,

yellowish teeth

Chest

RR- 40 auscultated chest with crackles sounds

Extra sounds on Heart sounds

Abdomen, no contour, no lesions

Apical pulse rate: 101 bpm

Extremity

Left arm infused IV Fluid

Right arm, no muscle tone, no strength muscle, +1 edema scale

Left and Right leg, are pale, cold & dry skin, delayed capillary refill

Genito Elimination

Urine, yellow-orange, 200 cc at 4 hours.

Bowel, no bowel movements

Neurological

Glasgow Coma Scale: total score of 6

Eye: 2, he slightly his upper eyelid on pain

Motor: 3, flexes abnormally

Verbal: 1, no response

Level of conciousness: comatose

Diagnosis

Persistent chest pain, ST- segment changes on the electrocardiogram (ECG),

and elevated levels of total creatinine kinase (CK) and the CK-MB isoenzyme over a 72

hour usually confirm an MI. Cardiac troponins are useful in differentiating an MI from

skeletal muscle injury, or when CK-MB measurements are low and a small MI has

actually occurred. Auscultation may reveal diminished heart sounds, gallops, and, in

papillary dysfunction, the apical systolic murmur of mitral valve area. When signs and

symptoms are equivocal, assume that the patient has had an MI until tests rule it out.

Diagnostic test results include the following:

Serial 12-lead ECG: ECG abnormalities may be absent or inconclusive during

first few hours following an MI. When present, characteristics abnormalities

include serial ST-segment depression in subendocardial MI and ST-segment

elevation in a transmural MI.

Coronary Angiography: visualization reveals which vessels have been affected

and the extent of damage.

Serial serum enzyme levels: CK levels are elevated ; specifically, CK-MB or

troponin levels.

Myoglobin: because myoglobin always rises within 3-6 hours after an MI, lack of

an increase within 6 hours indicates that an MI hasn’t occurred.

Echocardiography: may show ventricular-wall motion abnormalities in patients

with a transmural MI.

Nuclear ventriculography (multigated acquisition scan or radionuclide

ventriculography) scanning: Nuclear scanning can identify acutely damaged

muscle by picking up radioactive nucleotide, which appears as a “hot spot” on the

film. It’s useful in localizing a recent MI.

Chest X-ray: venous congestion, cardiomegaly, and kerley’s B lines

Cardiac catheterization: show decrease cardiac output, increase in Pulmonary

arterial pressure, pulmonary artery wedge pressure and central venous pressure.

Auscultation: reveals holosystolic murmur and thrill. And also reveals a friction

rub.

ABG Analysis: reduced partial pressure of arterial oxygen.

Hematology

Hematology:Hgb: still at normal ranges.

Hct: acute massive blood loss

RBC: decreasing due to side effects of the drugs.

WBC: Increasing due to immunocompromised, immune responses.

Platelet: increasing the fibrin that attract the platelet to increased

Blood indices:

MCHC: decreased in severe hypochromic anemia.

Coagulation:Bleeding time: defective in platelet function

INR: prolonged in deficiency of fibrinogen; used to standardized the

prothrombin time and anti-coagulation therapy.

Serum enzyme levels:Na+ : decreased; myxedema

K+ : decreased; GI losses, Vitamin D Deficiency

Cl+ : decreased; pneumonia, febrile condition.

Creatinine: decreased; check the status of the kidney

Troponin: negative; if increased the patient may experience

myocardial infarction.

Pathophysiology

In an MI, an area of the myocardium is permanently destroyed; a condition in

which the blood supply to the heart muscle is partially or completely blocked. The heart

muscle needs a constant supply of oxygen-rich blood. The coronary arteries, which

branch off the aorta just after it leaves the heart, deliver this blood. MI is usually caused

by the reduced blood flow in a coronary artery of an atherosclerotic plaque and

subsequent occlusion of the artery by a thrombus. Coronary artery disease can block

blood flow, causing chest pain. In unstable angina and acute MI are considered to be

the same process but different appoints along a continuum. specifically coronary

atherosclerosis (literally “hardening of the arteries,” which involves fatty deposits in the

artery walls and may progress to narrowing and even blockage of blood flow in the

artery., As an atheroma grows, it may bulge into the artery, narrowing the interior

(lumen) of the artery and partially blocking blood flow. With time, calcium accumulates

in the atheroma. As an atheroma blocks more and more of a coronary artery, An

atheroma, even one that is not blocking very much blood flow, may rupture suddenly.

The rupture of an atheroma often triggers the formation of a blood clot (thrombus), the

supply of oxygen-rich blood to the heart muscle (myocardium) can become inadequate.

The blood supply is more likely to be inadequate during exertion, when the heart muscle

requires more blood. An inadequate blood supply to the heart muscle (from any cause)

is called myocardial ischemia. If the heart does not receive enough blood, it can no

longer contract and pump blood normally. Other causes of MI include vasospasm,

(sudden constriction or narrowing) of a coronary artery, decreased oxygen supply (e.g.

from acute blood loss, anemia, or low blood pressure), and increased demand for

oxygen (e.g. rapid heart rate, thyrotoxicosis, or ingestion of cocaine). In each case, a

profound imbalance exists between myocardial oxygen supply and demand. The area of

infarction develops over minutes to hours. As the cells are deprived of oxygen, ischemia

develop, cellular injury occurs,, and the lack of oxygen results in infarction, or the death

of cells. The area of the heart muscle supplied by the blocked artery dies.

General Analysis

Activity intolerance —imbalance between myocardial oxygen supply/demand.

Grieving, anticipatory—perceived loss of general well-being, required changes in

lifestyle, confronting mortality.

Decisional Conflict (treatment)—multiple/divergent sources of information,

perceived threat to value system, support system deficit.

Family Processes, interrupted—situational transition and crisis.

Home Management, impaired—altered ability to perform tasks, inadequate

support systems, reluctance to request assistance.

Medications � Promotes adherence measures by thoroughly explaining the prescribed

medication regimen and other treatment measures.

� Warn the patients together with relatives about adverse reaction to drugs, and

advise them to watch the sign and symptoms of toxic (nausea, anorexia,

vomiting, and yellow vision)

Exercises� Organize patient care and activities to maximize periods of uninterrupted rest.

� Assist with range-of-motion exercise. And turn him, every two hours, as ordered

by physician.

� Don’t stress yourself, too much exercise. Enough, walk for 15 minutes.

Treatment� Antiembolism stockings help prevent venostasis and thromboplebitis.

� Encourage participation in a cardiac rehabilitation program.

Aesthetic way/ Art of Care

The health care provider follows nursing guidelines for the MI patients. Document

level of activity attempted and tolerance. Nurisng is responsible for documenting

whether expected outcomes are met or not met. The patient has performed activities of

daily living with no angina symptoms for the last 24 hours when he was admitted. While

the vital signs have been within patient’s norm for the last 24 hours.

Ethical-moralNurse judgment on what must to be done during health care to reach the goal of

care without unethical behavior. The presence of moral and ethical dilemma with the

patient themselves and their family can contribute to the enhancement and recovery of

the patient.

EthicalBehavior of the nurses and their sensitivity of the patients’ right and availability. It

is the responsibility of the nurse to claim the patient’s optimum care.

Legal Interaction/Implications in the careLength of stay in the hospital and reason for failure to discharge at an early time

is caused by thorough assessment of the patient’s performance and cope up with the

nursing care management. Informed consent during management of the disease and

illness, and other activities related to health care.

Synthesis and Conclusion

Case studies are based upon the real cases that are quite commonly

encountered in the everyday practice of nursing and allied profession. Case studies are

done to have the knowledge regarding different illness. In this case study, it describe

the critical care as a collaborative, holistic approach that includes the patient, family and

significant others. It established priority critical measures instituted for any patient with a

critical condition.

Almost all MIs are caused by rupture of coronary atherosclerotic plaques with

superimposed coronary thrombosis. Patients with MI usually present with signs and

symptoms of crushing chest pressure, diaphoresis, malignant ventricular arrhythmias,

heart failure (HF), or shock. MI may also manifest itself as sudden cardiac death, which

may not be apparent on autopsy (because necrosis takes time to develop).

Presentations may be atypical and clinically subtle, especially in women. Findings may

include new-onset or accelerated angina; atypical chest discomfort or abdominal

discomfort mimicking indigestion; decreased cerebral perfusion with syncope; dizziness;

cerebrovascular accident; altered mental status; or nausea and fatigue without chest

pain.

Evidence suggests a benefit from the use of beta blockers, angiotensin-

converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARB), and

possibly from insulin infusion (with potassium and glucose) to inhibit apoptosis (cell

death). New therapies will provide some incremental gains. Greater gains may be

improved with improved systems of care.