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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.
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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
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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.
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, hypertension, or hypotension
• Type 3 - Sudden unexpected cardiac death, including cardiac arrest, often
with symptoms suggestive 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 cardiac biomarkers in the blood
• Type 4 - Associated with coronary angioplasty or stents:
o Type 4a - Myocardial infarction associated with PCI
o Type 4b - Myocardial infarction associated with stent thrombosis as
documented by angiography or at autopsy
• Type 5 - Myocardial infarction associated with CABG

C. General Signs and Symptoms


The 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
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left side of the neck, but may also radiate to the lower jaw, neck, right arm,
back, and epigastrium, where it may mimic heartburn.

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.
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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, 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.
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• 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 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.
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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
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III. PATIENT PROFILE

A.Demographic Data

Date of Admission: June 29, 2010


Name: Mr. R.T
Age: 47
Gender: Male
Address: 4-C Saint Philip St. L.F.S Tugatog Valenzuela City
Status: Married
Date of birth: October 6, 1962
Place of Birth: Northern Samar
Religion: Roman Catholic
Nationality: Filipino
Occupation: Fish Dealer

B. Chief Complaint/s
Chest pain

C. Physical Examination

Initial Physical Assessment (June 29, 2010)

EENT-Pink palpebral conjunctiva, anicteric sclera


CHEST-SCE, (-) retraction
HEART-AP,NRRR, (-) murmur
ABDOMEN- Flat, soft
GENITALIA- Remarkable
RECTUM AND ANUS- Remarkable
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EXTREMETIES- (-) edema


SKIN- (-) pallor
GCS- 15

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

FAMILY HISTORY
Diabetes Mellitus, Hypertension

PRESENT ILLNESS
2 days PTA, patient sought consult at ER and was diagnosed w/ inferior wall
MI but HAMA. Chest pain persisted only periodic relief hence consult.

PERSONAL AND SOCIAL HISTORY


(-) food & drug
(-) cigarette smoking
(-) alcoholic

SYSTEM REVIEW
(-) anorexia (+) epigastric pain
(+) dizziness (-) joint pain
(+) chest pain (+) vomiting
(+) dyspnea

ALLERGY: NO KNOWN ALLERGY

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

VITAL SIGNS
Blood pressure: 100/60 bpm
Pulse rate: 65 bpm; regular; radial pulse
Respiration Rate: 19 bpm
Temperature: 37.7°C (axillary)

ANTHROPOMETRIC MEASUREMENTS
BMI: 28.1 (overweight)
Weight: 72 kg
Height: 160 cm

GLASGOW COMA SCALE


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Eye Opening (E) Verbal Response (V) Motor Response (M)


4=spontaneous 5= normal conversation 6= Normal
3=to voice 4=disoriented 5= localizes pain
2= to pain conversation 4= withdraws to pain
1=none 3=words but not coherent 3=decorticate posture
2=no words only sounds 2= Decerebrate
1= None 1= none
4 5 6
Total GCS: (E+V+M)= 15

PUPIL SCALE MENTAL STATUS


Size: 3mm State of consciousness: Conscious,
Left and right pupils are reactive to alert
light and has the same pupil size Speech: Spontaneous, coherent
Orientation: Good
MOVEMENTS Signs of distress: None
R/L Arms: Normal power Headache: Mild
R/L Legs: Normal power Mood: Euthymic

CRANIAL NERVES
CN I: proper sense of smell
CN II (optic): Both eyes, equally CN IX, X (glossopharyngeal and
reactive to light vagus): (+) gag reflex
CN III, IV, VI (oculomotor, trochlear, CN XI (spinal accessory): Able to shrug
abducens): Full extra ocular muscles both shoulders
CN V (trigeminal): (+) corneal reflex CN XII (hypoglossal):
CN VII (facial): (+) facial symmetry Normal tongue midline
CN VIII (acoustic): Follows commands

NEUROMUSCULAR
Pupils: Pupils equally reactive to light
Reflexes: Normal reflexes
Activity Level: Requires little assistance from other person or device. Due to his
condition, he is not allowed to perform ADL yet.
Hemiplegia: None
Extremities: No deformities, symmetric
Motor Strength: 5/5 on all areas except his left arm which has
an IV line.
HEENT

HEAD: Normocephalic, Facial symmetry


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EYES
Vision: 150/100, wears glasses
Sclera: Clear, anicteric
Conjunctiva: No discharge, pale

EARS
Hearing: Has no difficulty of hearing
Discharge: None

NOSE
Discharge: None
Congestion: None
Orientation: Symmetrical
Nasal flaring: None

THROAT: No swelling

MOUTH
Moisture/color: moist/pink
Tongue: pink
Lips: intact
Teeth: with caries
Sore mouth: None

INTEGUMENTARY
Skin Integrity or Condition: Intact
Color: Pale
Turgor: Poor
Temperature: Cold
Moisture: Dry
IV access: Intact, Central (left metacarpal)
Nails: Thick and rough
Capillary Blood Refill: 3 seconds
Wound: None
Presence of pressure ulcers: None

RESPIRATORY
Lung Movement: Symmetrical chest expansion
Difficulty of breathing: Absent
Retractions: None
Cough: Absent
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Breath Sounds: Clear


Oxygen therapy: Nasal Canula

CARDIOVASCULAR
Heart Sounds: without murmurs
Apical Pulse: R/L regular
Radial Pulse: R/L regular
Brachial Pulse: R/L regular
Pedal Pulse: R/L faint
Neck veins:
Edema: Absent

GASTROINTESTINAL
Abdomen: Round, soft
Tenderness: None
Bowel Sounds: Normoactive
Feeds Independently: Can eat independently using right hand but chose to be fed
by his wife
Nasogastric tube feeding: None

GENITOURINARY
Urination: Normal
Genital Area: No pain, no discharge
Genital Pain: Absent
Flank Pain: Present

NUTRITIONAL STATUS
Appetite: Normal
Nausea/ Vomiting: None
Diet: Low salt, Low fat, soft diet
Feeding Precaution: None
Food allergy: No known allergies
Difficulty of swallowing: Absent

PAIN ASSESSMENT
Based on pain scale of 0-10:
Flank pain: 3/10
Cardiac pain: 2/10

GORDON’S FUNCTIONAL HEALTH PATTERN

Health Perception and Management


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On 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 Pattern


Mr. 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 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 Pattern


Before 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 Pattern


The 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.
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Self-perception and Self-concept


He 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


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 Pattern


The 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 Illness


Diabetes Mellitus Type II

E. Present History of Illness


Inferior wall MI but HAMA

F. Allergies
No known allergy

VITAL SIGNS (7/1/2010)


TIME BP T P R
12(A 120/8 37.0 75 28
M) 0
1 120/8 36.8 73 26
0
2 120/8 36.1 84 28
0
3 110/8 36.6 80 28
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0
4 120/9 37.1 80 29
0
5 120/8 36.0 75 28
0
6 120/8 36.9 76 33
0
7 120/8 37.2 77 30
0
8 120/9 38.6 76 32
0
9 120/8 38.3 84 30
0
10 120/8 37.6 84 33
0
11 120/9 37.3 78 26
0
12(P 110/8 37.6 80 23
M) 0
1 120/8 37.1 73 23
0
2 120/8 36.8 74 28
0
3 120/9 36.6 83 26
0
4 120/8 37.0 77 26
0
5 110/8 36.3 86 24
0
6 120/8 36.6 84 23
0
7 120/8 36.0 75 26
0
8 110/9 36.8 76 28
0
9 R E F U S D
E
10 R E F U S D
E
11 R E F U S D
E

VITAL SIGNS (7/2/2010)


TIME BP T P R
12(A R E F U S D
M) E
1 R E F U S D
E
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2 120/8 36.8 84 28
0
3 120/8 36.3 80 26
0
4 120/8 36.0 76 24
0
5 120/8 36.1 77 24
0
6 120/9 36.6 82 28
0
7 120/8 36.3 76 26
0
8 120/8 36.3 76 28
0
9 120/8 36.2 78 29
0
10 120/9 36.6 75 31
0
11 R E F U S D
E
12(P 120/9 37.7 77 28
M) 0
1 100/7 38.1 76 28
0

G. Course in the ward


6/29/10
>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
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> ST elevation improved


> Monitor patient’s vital sign every hour
>PO: soft diet, low salt, low fat
>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 PHYSIOLOGY


The 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 coronary 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
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instead 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 myocardium). The vessels that deliver oxygen-rich blood to the
myocardium are known as coronary arteries. 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.
PATHOPHYSIOLOGY

ACUTE MYOCARDIAL INFARCTION


DEFINITION:
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: MODIFIABLE:
►Gender (male) ► Hypertension
►Age (47 yrs. old) ► DM
► Diet (high fat) S/sx:
► ↑ HR & BP
►Dysrhythmia
Ruptured Atherosclerotic Plaque

Arterial Spasm & Thrombus Activation of SNS


S/sx: (Release of Catecholamine)
Formation
►Pai
(Occlusion of Coronary Artery)

↓Blood supply & ↓O2 Anaerobic Metabolism

↓ Contractility & pumping Metabolic Acidosis

S/sx:
► Light-headedness ↓ Blood flow to Body Circulation
►Dyspnea (Lungs, Kidney, Brain, & Digestive
►↓ Urinary output
In Myocardial Infarction, inadequate coronary blood flow rapidly results in myocardial ischemia in the affected
area. Ischemia depresses cardiac function and triggers autonomic nervous system responses that exacerbate the
imbalance between myocardial oxygen supply and demand. 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.
V. LABORATORY EXAMINATION/DIAGNOSTIC PROCEDURES

Date/Lab test Normal Value Client Result Reason for Nursing


test Intervention
June 6, 2010: 70-105mg/dL Glucose (FBS): The basic 1. The BMP
Blood 216.9 metabolic may be
Chemistry panel (BMP) is performed
a group of without any
Clinical tests that preparation in
significance: measures an emergency,
The patient different or it may be
has diabetes chemicals in done after
mellitus; thus, the blood. fasting.
there is These tests
elevation of usually are 2. FBS: The
glucose level. done on the client may be
fluid (plasma) asked to fast
part of blood. for 8 to 12
The tests can hours prior to
give doctors testing.
information
about your 3. Collect the
muscles sample and
(including the monitor
heart), bones, glucose levels.
and organs,
such as the
kidneys and
liver and may
also indicate
underlying
diseases.

*The plasma
24-38s contains water,
July 1, 2010: Control: 29.8s 51.7s glucose, etc.
Partial 1. Explain the
Thromboplas Clinical procedure to
A partial
tin Time significance: the client; how
thromboplastin
(PTT) The patient does it feel,
time (PTT) test
has elevated etc.
measures how
glucose level long it takes
making the 2. Tell the
for a clot to
blood thicker client to stop
form in a blood
than normal taking certain
sample. A clot
and more drugs before
is a thick lump
susceptible to the test (with
of blood that
clot formation. doctor’s
the body
Heparin, which produces to advice). Drugs
aids in thinning seal leaks, that can affect
of the blood, wounds, cuts, the results of a
may cause and scratches PTT test
longer PTT and prevent include
than normal. excessive antihistamines,
bleeding. vitamin C
(ascorbic acid),
Since the aspirin, and
client has chlorpromazin
elevated e (Thorazine).
glucose level,
his blood is
thicker than
normal; thus,
more
susceptible to
clot formation.

Date/Diagnostic Client Result Reason for test Nursing


Procedure intervention:
Preparation Pre
and Post
Procedure
June 28, 2010: Rate: 52 Electrocardiograph Pre:
Electrocardiogra Rate Atrial: S2 y provides a 1. Explain the
m (ECG) QRS: .08 graphic recording procedure to the
Axis: 60’ of the heart’s client; how does it
PR: .20 electrical activity. feel, etc.
QT: 400/s Electrodes placed
on the skin 2. Ask the client if
Diagnosis: transmit the he/she is taking
Sinus Bradycardia electrical impulses any medications.
Acute Inferior Wall to a graphic
Myocardial recorder. 3. Tell the client to
Infarction Contraction of refrain from
cardiac smooth drinking cold water
muscle produces immediately before
electrical activity, an ECG as it may
resulting in a series produce changes in
of waves on the one of the
ECG. With the waveforms
wave forms recorded (the T
recorded, the ECG wave).
can then be
examined to detect 4. All
dysrhythmias and metals/jewelries
alterations in should be taken off
conduction prior to the
indicative of procedure.
myocardial
damage, 5. If the client has
enlargement of the a lot of hair on the
heart, or drug. An chest, a small area
ECG monitors the may need to be
regularity and path shaved to put the
of the electrical electrodes on.
impulse through
the conduction 6. Instruct the
system. The client to remain
normal sequence silent and relax
on the ECG is during the
called normal sinus procedure.
rhythm (NSR). NSR
implies that the 7. Tell the client to
impulse originates wear a lab gown.
at the SA node and
follows the normal
sequence through
the conduction
system.
VI. DRUG STUDY
DRUG,
DOSAGE, CLASSIFICATION SIDE/ADVERSE IMPLICATIONS NURSING
ROUTE, and ACTION EFFECTS RESPONSIBILITIES/
FREQUENCY INTERVENTIONS

Generic Name: Class: Antilipidemic, Side Effects: • Check for allergy to • Check the drug label:
simvastatin HMG-CoA reductase • Headache simvastatin. the drug name, dosage,
inhibitor • Nausea route and if you are
Brand Name: • Flatulence • Contraindicated administering the drug to the
Zocor Action: Inhibits HMG- • Diarrhea with fungal right patient.
CoA reductase, the • Abdominal byproducts. • Explain to the patient
Dosage: 80mg enzyme necessary for pain what the drug is for, and its
hepatic production of side effects.
Route: Oral cholesterol Adverse Effects: • Administer drug in the
• Liver evening because highest
Frequency: once failure rates of cholesterol
a day • Acute synthesis occurs between
renal failure midnight and 5am.
• Instruct patient to avoid
drinking grape juice while
taking the drug.
• Instruct patient to report
severe GI upset, changes in
vision, unusual bleeding,
dark urine, light-colored
stools, muscle pain

Generic Name: Class: Antianginal, Side Effects: • Check for allergy to • Check the drug label:
isosorbide Nitrate, Vasodilator • Headache nitrates. the drug name, dosage,
dinitrate • Restlessness • Contraindicated route and if you are
Action: Relaxes • Weakness with severe administering the drug to the
Brand Name: vascular smooth • Nausea anemia, head right patient.
Isoket retard muscle which results trauma, cerebral • Explain to the patient
• dizziness
to decreased venous hemorrhage, what the drug is for, and its
Dosage: return and arterial BP, glaucoma. side effects.
20mg/tab which reduces left Adverse Effects: • Use cautiously in • Monitor vital signs, note
Route: Oral ventricular workload • Tachycardi patients’ with acute changes in blood pressure.
Frequency: once and myocardial a MI or heart failure. • Check for adventitious
a day oxygen consumption • Hypotensio sounds.
n • Check results of CBC
• syncope and hemoglobin
• Administer drug
sublingually and discourage
patient in swallowing.
• Administer drug 2 hours
before meals as ordered by
the physician.
• Provide patient a cool
environment and position
patient in supine when
headache occurs.
• Instruct patient to report
blurred vision, more severe
angina attacks, persistent
headache or fainting.

Generic Name: Class: Antianginal, Side Effects: • Check for allergy to • Check the drug label:
trimetazidine Nitrate, Vasodilator • Rash trimetazidine. the drug name, dosage,
route and if you are
Brand Name: Action: Relaxes Adverse Effects: administering the drug to the
Vastarel vascular smooth • Fever right patient.
muscle which results • respiratory • Explain to the patient
Dosage: to decreased illness what the drug is for, and its
35mg/tab • anemia side effects.
Route: oral • Monitor vital signs of
Frequency: once patient, note for changes in
a day temperature or for any
deviations from the normal.
Generic Name: Class: Anticoagulant Side Effects: • Check for allergy to • Assess for PTT and other
heparin • Headache heparin. blood coagulation tests and
Action: Inhibits • Abdominal pain • Contraindicated platelet count.
Brand Name: thrombus and clot • Back pain with severe • Check the drug label:
Hep-Lock formation by blocking thrombocytopenia. the drug name, dosage,
the conversion of Adverse Effects: • Use cautiously with route and if you are
prothrombin to • Bruising recent surgery. administering the drug to the
thrombin, fibrinogen • Fever right patient.
to fibrin. • hyperkale • Explain to the patient
mia what the drug is for, and its
Dosage: 25,000 side effects.
Units • Mix well when adding
heparin to IV infusion.
Route: TIV • Check for signs of
bleeding
• Provide safety measures
to prevent bleeding.
• Instruct patient to report
for abdominal or lower back
pain, severe headache.

Generic Name: Class: Antidiabetic, Side Effects: • Check for allergy to • Assess and check the
glipizide 2nd generation • Nausea sulfonylureas. urinalysis results, note for
Sulfonylurea • Epigastric • Contraindicated BUN, creatinine levels, check
Brand Name: discomfort with severe also blood glucose levels,
Glucotrol Action: Stimulates infections, severe CBC.
insulin release from Adverse Effects: trauma, ketosis, • Check the drug label:
Dosage: functioning beta cells • Diarrhea hepatic and renal the drug name, dosage,
2mg/tab in pancreas, increases • Hypoglycemia impairment. route and if you are
insulin receptors. • Use cautiously with administering the drug to the
• Allergic skin
Route: oral uremia, right patient.
reactions.
hyperglycemia, • Explain to the patient
Frequency: once thyroid or what the drug is for, and its
a day endocrine side effects.
impairment. • 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
alcohol when taking the
drug.
• Instruct patient to report
for sore throat, rash, dark
urine or light-colored stools.
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 provide 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 prevention 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
NURSING CARE PLAN
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.)
>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 assessment, 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, practiced 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 improve the quality of the nursing care that is provided.