CHAPTER I

INTRODUCTION

A. Background of the Study

Myocardial infarction (MI), commonly known as heart attack occurs when blood
flow decreases or stops to a part of the heart, causing damage to the heart muscle. This
most commonly occurs when a coronary artery becomes occluded following the rupture
of an atherosclerotic plaque, which then leads to the formation of a blood clot (coronary
thrombosis). There are 32.4 million myocardial infarctions and strokes worldwide every
year. Patients with previous myocardial infarction (MI) and stroke are the highest risk
group for further coronary and cerebral events. Survivors of MI are at increased risk of
recurrent infarctions and have an annual death rate of 5% - six times that in people of
the same age who do not have coronary heart disease.

Based on the 2011 Philippine Health Statistics study by the Department of

Health, the most leading disease in the country involves the main organ of the human
body which is the heart. Out of 498,486 deaths registered in 2011, Diseases of the Heart
remained to stay on the top with 107,294 deaths. DOH has recorded that more than one
in every five deaths was caused by Diseases of the Heart, making it the number one
leading cause of death in the Philippines.

Diseases of the Heart have been the number one leading cause of death in the
country as it increases at least four percent every year. According to the data provided
by the Department of Health, more males than females die from this cause. Out of the
107,294 total deaths, 60,452 cases were males while 46,572 cases were females.
Military personnel were no exemption in having Myocardial Infarction. According to
Camp Navarro General Hospital (Ward 2) census, there were 8 reported cases of
Myocardial Infarction from November 2011 to present.

The authors chose this case in order to raise awareness, understanding and be able
to develop clinical decisions regarding patient’s health condition utilizing the nursing
process appropriately. The mortality rate on cardiovascular problem specifically, MI has
been gradually increasing due to different factors which contribute t28o the development
of the disease condition. The military personnel are also devastatingly manifesting some

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of the signs and symptoms of MI. This comprehensive case study will also deepen and
accentuate the knowledge of nurses on cardiovascular disease pathophysiology, its risk
factors, causes, managements and prognosis. Furthermore, this study importantly
promotes the role of the client as throughout the process that he may gain optimum
health through the assistance of the nurse as promptly as possible to prevent acquiring
further complications.

B. Objectives of the Study

General Objective
To present a comprehensive case study in order to enhance knowledge, develop
skills and right attitude in caring of patient agonized with Myocardial Infarction.

Specific Objectives
1. Collect and discuss relevant information with relation to complete health history
of the patient.
2. Discuss the anatomy, physiology and pathophysiology affecting the disease
process veraciously.
3. Identify and interpret laboratory and diagnostic results pertinent to patient’s case
appropriately.
4. Formulate an individualized nursing care plan on the identified nursing problems
accurately.
5. Develop a home care management through discharge planning precisely.

C. Significance of the Study

This case study was formulated in order to attain further understanding on
Myocardial Infarction (MI) in order to provide quality healthcare to patients afflicted with
this disease condition.

For the patient, the study will be a significant aid in providing nursing care to a
patient with Myocardial Infarction through assisting and promoting in the performance
and management of patient’s appropriate activities on a continuous basis in order to
hasten his progress in the hospital, recover from disease, cope with its effects, achieve
independence and optimum level of functioning as well as to sustain life and health.

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 For the family or significant others, the study will serve as a guide in helping the
members of the family with MI to have knowledge regarding the disease and will prevent
acquiring the illness and further complications will be avoided. There will be additional
knowledge that will teach them to value health.

For the nurses and allied health professionals, the study will also be beneficial
as it will improve decision-making skills. It will improve their approach in caring for
patients with MI, as well as those patients with other related conditions. It will also help
nurses in assisting patients with activities of daily living, especially those who are
incapable of doing so because of a debilitating condition.

For the nursing research, finally, the study will enhance, support and serve as a
guideline to nursing education, practice and nursing research by validating pertinent data
and results that can be utilized as a ground for more study in the provision of nursing
care to patients with Myocardial Infarction as well as with other different medical-surgical
health conditions. Thereupon, this will provide the nursing profession an evidence-based
practice.

D. Scope and Limitation of the Study

The scope of this study covers the duration of the patient’s hospitalization from
day of his admission to the time he was discharged. Upon admission, the patient was
diagnosed with Congestive Heart Failure and Acute Gastritis but this study focuses on
the discussion of Myocardial Infarction which is his final diagnosis. Significant data for
this case study were collected and gathered from the patient himself, significant others,
ward nurses, attending physician and clinical records obtained from the ward 2.

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 Chapter II
PROFILE, HISTORY AND PHYSICAL EXAMINATION

A. Patient’s Profile
Initials: M.I.B.
Rank: CAFGU
Age: 56
Gender: Male
Marital Status: Married
Unit: 19 SFC, SFBN, SFRA, SOCOM, PA
Address: Barangay Pintasan, Basilan Province
Chief Complaint: Crushing substernal pain (pain scale of 8/10) radiating to his neck
and left arm for 2-3 minutes but pain subsides (pain scale of 5/10)
upon rest for 6 days PTA
Date/Time Admitted: 17 0930H July 2017
Admitting Diagnosis: Congestive Heart Failure, Acute Gastritis
Date/Time Discharged: 28 1000H July 2017
Final Diagnosis: Myocardial Infarction Lateral Wall

B. Socio – demographic Characteristics

M.I.B. grew up in Barangay Pintasan, Basilan Province. His father was an
Imam (a Muslim worship leader), and his mother was a “traditional hilot” or “panday” in
Muslim term. He is the youngest of (6) six siblings and finished elementary education.
At present, he is the Imam in their community. He speaks Tausug, Tagalog and a little
Bisaya Dialect. The family owned a wide land approximately 5 hectares for farming
and also has fishing boats for their sources of income. When he reached 40 years old,
he joined CAFGU on December 22, 2000 and still on the service at present. He got
married and has 4 children who each have their own families.

C. Concept of Health, Illness and Hospitalization

M.I.B. defines health in good body condition, always happy with the family and
working together in the family business, because he believes that “health is wealth”.
Illness for him is caused by environmental factors and mostly it goes along with the
aging process. Hospitalization for him is only necessary when all natural means of

4
treating illness have been exhausted. He will see a doctor if he remains sick. It is only
when the doctor recommends admission to the hospital for treatment will he follow the
doctor’s advice.

D. Common Health Practices at Home

MIB wakes up at around 5 AM and drinks his coffee and smokes a cigarette.
He takes a bath every day before he takes his breakfast. He eats 3 meals a day and
snacks in between. Most of his food are being harvested from the farm (vegetables,
fruits, crops rice, etc.) and from the sea (fishes, sea shells, etc.) He drinks water and
coffee only because he doesn’t like juice and softdrinks. He consumes 1-2 liters of
water and an average of 3-4 cups of coffee daily. His daily routine includes walking for
30 minutes.

E. Immediate Factor That Brought About Illness

MIB smokes 20 sticks of cigarettes per day (1 pack/ day). That is 30 packs of
cigarettes in a month and 360 packs a year (7,200 sticks for a year). He started smoking
since 13 years old, in which 43 pack years smoking history.

F. Comprehensive History
1. History of Present Illness
M.I.B., 56 years of age stated that he has been feeling this for about 2 months
now, but he would just drink herbs such as “ugat-ugat” that he could find as medicine.
Somehow, there was an alleviation of the ailment. Until 6 days prior to his admission
he complained that he has been feeling a burning sensation lasting for almost 1 – 2
hours with a pain scale of 8/10 radiating from his chest going up his nape area; in
which not resolved with medication. The patient also experienced body weakness
whenever he would walk even for a bit, subsequently consulted and admitted at Camp
Navarro General Hospital, Zamboanga City on 17 July 2017.
2. Past Medical History
M.I.B. has never been admitted before. He has no knowledge of having asthma,
hypertension and heart disease; nor has any surgery. He doesn’t have any allergies
and any recollection of being immunized.

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3. Family History
The patient has no knowledge regarding the medical history and cause of death
of his family.

Legend:
Grandfather Grandmother

Male
Female
Deceased

(Unknown Death)
Father Mother

MIB
4. Nursing History
In obtaining the nursing history, the author used Gordon’s Functional Health
Pattern.

a) Health Perception – Health Management Pattern

M.I.B. has not been seriously ill and has not been hospitalized. The patient said
that when he or any of his family members got sick they would just find some herbs
such as lagundi for cough and “tawa-tawa” for fever, boil them and drink it as
medicine. He smokes a lot and used to drink alcohol. They would keep a healthy diet
by eating plenty of vegetables, and sometimes some fruits.

b) Nutritional and Metabolic Pattern

The patient has a good appetite, he eats anything that he wants and is not very
picky about what he eats. He specially loves foods that are salty and spicy. He loved
to eat salty foods such as dried fish, anchovies, instant noodles and canned goods.
The patient typically drink 1-2 liter of water a day. There were no changes in his
weight and he didn’t have any eating discomforts. The patient doesn’t take any
vitamins or food supplements.

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 c) Elimination Pattern
M.I.B. stated that he defecates once a day without any discomforts of pain
during defecation. When the patient isn’t able to defecate in a day he would just drink
plenty of water and eat bananas. He voids at least 3-4 times a day without any
discomforts or pain during urination.

d) Activity – Exercise Pattern

M.I.B. doesn’t have a regular exercise pattern but sometimes, he does walk and
has sufficient energy to complete simple task such as walking sitting, etc. and also to
complete different activities that he want or requires to do but not all the time.

e) Sleep and Rest Pattern

The patient sleeps at least 6-7 hours a day and often takes a nap during the
afternoon. He sleeps around 9pm at night and wakes up around 5am in the morning.
The patient doesn’t have any trouble sleeping. He doesn’t experience any
nightmares.

f) Cognitive – Perceptual Pattern

The patient doesn’t have any hearing difficulty or any vision impairment.
Patients’ memory seems to be fair, because he can still remember and recall
different events and things. He’s an elementary graduate but didn’t proceed to
further his education.

g) Self – Perception Self – Concept Pattern

M.I.B. describes himself as a proud person; he once stated that as long as he
can still bear the pain he is feeling he doesn’t want to go to the hospital. He’s also
very caring; he takes care of his grandchildren when his children are working. He
is quite happy and contended with himself and his life, having a happy and healthy
family with his children and his grandchildren.

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 h) Role-Relationship Pattern
M.I.B. belongs to an extended family. He is the patriarch and breadwinner of his
growing family. He also takes care of his grandchildren when their parents are
working. Their income is sufficient for their daily needs.

i) Sexuality – Reproductive Pattern

The patient has four (4) children, two boys and 2 girls; who also already have
their own families.

j) Coping – Stress Tolerance Pattern

The patient and his family cope in time of crisis by talking to one another about
the problem and together they discuss and decide as a family. Being the father of
the house, his authority and opinions are followed. When he is tensed or in stress,
he relaxes by watching television, cooking for his family and sometimes listening
to music.

k) Value – Belief Pattern

The patient is the current Imam of their compound or subdivision, with this said
he is the religious man. He considers Allah and his family the most important or
valuable thing in his life. Whenever he feels depressed or scared he would pray to
Allah and ask for guidance

G. Physical Assessment (25 0900H July 2017)

General Appearance:
Patient is a brown skinned male. Appearance consistent with stated age and well-
groomed.

Vital Signs:
Blood Pressure: 130/80 mmHg
Pulse Rate: 112 bpm
Respiratory Rate: 24 bpm
Temperature: 36.5 C
O2 Saturation: 97%

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 Pain scale: 8/10 Crushing substernal pain up to his neck and left arm
for 2-3 minutes.

BMI: 25 (High-Normal)
Height: 5’5’’ Weight: 68 kg

Skin:
 Skin is tanned in complexion, unblemished and no presence of any foul odor. He
has a good skin turgor and skin’s temperature is within normal limit.
Head/Hair:
 Head is rounded and symmetrical; No nodules or masses; Hair is short and thin,
equally distributed. Black in color mixed with a few white hairs; no presence of
infestation by pediculosis or dandruff.
Nails:
 Pinkish nail bed without cyanosis noted; smooth in texture. Has a good capillary
refill where in the color returned immediately for about 2-3 seconds when
pinched.
Eyes:
 Brows are equally distributed. Eye lashes are also equally distributed and
straight. Conjunctiva appeared transparent with few capillaries evident. Sclera
appears white and iris is black. Cornea is transparent and shiny with the details
of the iris visible. Pupils are equally round, reacts to light and accommodation.
No presence of any unusual discharges noted.
Ears:
 Auricles are symmetric, and have the same color with his facial skin; aligned with
the outer canthus of the eye. No lesions, discharges, bleeding were present.
Sense of hearing is functioning well.
Nose:
 Nose appeared symmetric, straight and uniform in color. No lesion; discharges,
obstructions or tenderness noted. No displacement of bones or cartilage.
Mouth/Throat/Oral Cavity:
 Lips are brownish in color with negative signs of cyanosis and pallor; oral
mucosa is pale and gums are brownish in color without any lesions. Tonsils
are not inflamed, teeth is tar-coated. Tongue is pinkish in color; there were no
presence of lesions.

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Neck:
 No stiffness noted, can turn head to the sides freely and easily with no pain or
discomfort. No masses, lesions or nodules noted upon palpation.
Chest:
 Chest is symmetric; spine is vertically aligned. A full chest expansion is noticed
during inhalation and returns to its size upon exhalation. There was difficulty of
breathing. The patient manifested crushing substernal pain (pain scale of
8/10) radiating to his neck and left arm for 2-3 minutes but pain subsides
(pain scale of 5/10) upon rest.
Abdomen:
 Soft, no tenderness noted. There was also no presence of nodules, mass,
lesions or any enlargement of the internal organs upon auscultation, percussion,
palpation and inspection. He manifested burning sensation (heartburn) on
epigastric area radiating to his anterior chest lasting for 1-2 hours.
Genitourinary:
 Voids at least 3-4 times a day without any discomforts or pain during urination;
Color is usually yellow; No discharges; No history of any sexually transmitted
diseases and hasn’t used a urinary catheter or any aid for urinating.
Extremities:
 Both arms are symmetrical, average in length. No lesions were present. There
was no swelling noted. Both legs are also symmetrical with no present lesions at
his feet; there were no complaints of any joint pain or difficulty in walking.

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 CHAPTER III
CLINICAL DISCUSSION
In this section, the anatomy and the normal processes of the heart will be discussed
which is mainly affected in Myocardial Infaction.

A. Anatomy
The cardiovascular system consists of the heart, which is an anatomical pump, with
its intricate conduits (arteries, veins, and capillaries) that traverse the whole human body
carrying blood. The blood contains oxygen, nutrients, wastes, and immune and other
functional cells that help provide for homeostasis and basic functions of human cells and
organs. 

The pumping action of the heart usually maintains a balance between cardiac output
and venous return. Cardiac output (CO) is the amount of blood pumped out by each
ventricle in one minute. The normal adult blood volume is 5 liters (a little over 1 gallon)
and it usually passes through the heart once a minute. Note that cardiac output varies
with the demands of the body. 

The cardiac cycle refers to events that occur during one heart beat and is split into
ventricular systole (contraction/ejection phase) and diastole (relaxation/filling phase). A
normal heart rate is approximately 72 beats/minute, and the cardiac cycle spreads over
0.8 seconds. The heart sounds transmitted are due to closing of heart valves, and
abnormal heart sounds, called murmurs, usually represent valve incompetency or
abnormalities. 

Blood is transported through the whole body by a continuum of blood vessels.

Arteries are blood vessels that transport blood away from the heart, and veins transport
the blood back to the heart. Capillaries carry blood to tissue cells and are the exchange
sites of nutrients, gases, wastes, etc. 

The vital importance of the heart is obvious. If one assumes an average rate of
contraction of 75 contractions per minute, a human heart would contract approximately
108,000 times in one day, more than 39 million times in one year, and nearly 3 billion
times during a 75-year lifespan. Each of the major pumping chambers of the heart
ejects approximately 70 mL blood per contraction in a resting adult. This would be

11
equal to 5.25 liters of fluid per minute and approximately 14,000 liters per day. Over
one year, that would equal 10,000,000 liters or 2.6 million gallons of blood sent through
roughly 60,000 miles of vessels. In order to understand how that happens, it is
necessary to understand the anatomy and physiology of the heart.

Figure 1. Anatomy
of the heart. Galang, P. Anatomy and Physiology of Heart. Retrieved from
https://www.scribd.com/doc/43606993/Anatomy-and-Physiology-of-Heart-and-Rhd

Above figure shows different part of the heart which includes the different parts such
as (1) Right Coronary (2) Left Anterior Descending (3) Left Circumflex (4) Superior Vena
Cava (5) Inferior Vena Cava (6) Aorta (7) Pulmonary Artery (8) Pulmonary Vein (9) Right
Atrium (10) Right Ventricle (11) Left Atrium (12) Left Ventricle (13) Papillary Muscle (14)
Chordae Tendineae (15) Tricuspid Valve (16) Mitral Valve.

Coronary Arteries. Because the heart is composed primarily of cardiac muscle

tissue that continuously contracts and relaxes, it must have a constant supply of oxygen
and nutrients. The coronary arteries are the network of blood vessels that carry oxygen-
and nutrient-rich blood to the cardiac muscle tissue. The blood leaving the left ventricle
exits through the aorta, the body’s main artery. Two coronary arteries, referred to as the
"left" and "right" coronary arteries, emerge from the beginning of the aorta, near the top
of the heart. The initial segment of the left coronary artery is called the left main

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coronary. This blood vessel is approximately the width of a soda straw and is less than
an inch long. It branches into two slightly smaller arteries: the left anterior descending
coronary artery and the left circumflex coronary artery. The left anterior descending
coronary artery is embedded in the surface of the front side of the heart. The left
circumflex coronary artery circles around the left side of the heart and is embedded in
the surface of the back of the heart. Just like branches on a tree, the coronary arteries
branch into progressively smaller vessels. The larger vessels travel along the surface of
the heart; however, the smaller branches penetrate the heart muscle.

The smallest branches, called capillaries, are so narrow that the red blood cells
must travel in single file. In the capillaries, the red blood cells provide oxygen and
nutrients to the cardiac muscle tissue and bond with carbon dioxide and other metabolic
waste products, taking them away from the heart for disposal through the lungs, kidneys
and liver. When cholesterol plaque accumulates to the point of blocking the flow of blood
through a coronary artery, the cardiac muscle tissue fed by the coronary artery beyond
the point of the blockage is deprived of oxygen and nutrients. This area of cardiac
muscle tissue ceases to function properly. The condition when a coronary artery
becomes blocked causing damage to the cardiac muscle tissue it serves is called a
myocardial infarction or heart attack.

Superior Vena Cava. The superior vena cava is one of the two main veins bringing
de-oxygenated blood from the body to the heart. Veins from the head and upper body
feed into the superior vena cava, which empties into the right atrium of the heart.

Inferior Vena Cava. The inferior vena cava is one of the two main veins bringing
de-oxygenated blood from the body to the heart. Veins from the legs and lower torso
feed into the inferior vena cava, which empties into the right atrium of the heart.

Aorta. The aorta is the largest single blood vessel in the body. It is approximately
the diameter of your thumb. This vessel carries oxygen-rich blood from the left ventricle
to the various parts of the body.

Pulmonary Artery. The pulmonary artery is the vessel transporting de-oxygenated

blood from the right ventricle to the lungs. A common misconception is that all arteries

13
carry oxygen-rich blood. It is more appropriate to classify arteries as vessels carrying
blood away from the heart.

Pulmonary Vein. The pulmonary vein is the vessel transporting oxygen-rich blood
from the lungs to the left atrium. A common misconception is that all veins carry de-
oxygenated blood. It is more appropriate to classify veins as vessels carrying blood to
the heart.

Right Atrium. The right atrium receives de-oxygenated blood from the body through
the superior vena cava (head and upper body) and inferior vena cava (legs and lower
torso). The sinoatrial node sends an impulse that causes the cardiac muscle tissue of
the atrium to contract in a coordinated, wave-like manner. The tricuspid valve, which
separates the right atrium from the right ventricle, opens to allow the de-oxygenated
blood collected in the right atrium to flow into the right ventricle.

Right Ventricle. The right ventricle receives de-oxygenated blood as the right
atrium contracts. The pulmonary valve leading into the pulmonary artery is closed,
allowing the ventricle to fill with blood. Once the ventricles are full, they contract. As the
right ventricle contracts, the tricuspid valve closes and the pulmonary valve opens. The
closure of the tricuspid valve prevents blood from backing into the right atrium and the
opening of the pulmonary valve allows the blood to flow into the pulmonary artery toward
the lungs.

Left Atrium. The left atrium receives oxygenated blood from the lungs through the
pulmonary vein. As the contraction triggered by the sinoatrial node progresses through
the atria, the blood passes through the mitral valve into the left ventricle.

Left Ventricle. The left ventricle receives oxygenated blood as the left atrium
contracts. The blood passes through the mitral valve into the left ventricle. The aortic
valve leading into the aorta is closed, allowing the ventricle to fill with blood. Once the
ventricles are full, they contract. As the left ventricle contracts, the mitral valve closes
and the aortic valve opens. The closure of the mitral valve prevents blood from backing
into the left atrium and the opening of the aortic valve allows the blood to flow into the
aorta and flow throughout the body.

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 Papillary Muscles. The papillary muscles attach to the lower portion of the interior
wall of the ventricles. They connect to the chordae tendineae, which attach to the
tricuspid valve in the right ventricle and the mitral valve in the left ventricle. The
contraction of the papillary muscles opens these valves. When the papillary muscles
relax, the valves close.

Chordae Tendineae. The chordae tendineae are tendons linking the papillary
muscles to the tricuspid valve in the right ventricle and the mitral valve in the left
ventricle. As the papillary muscles contract and relax, the chordae tendineae transmit
the resulting increase and decrease in tension to the respective valves, causing them to
open and close. The chordae tendineae are string-like in appearance and are
sometimes referred to as "heart strings."

Tricuspid Valve. The tricuspid valve separates the right atrium from the right
ventricle. It opens to allow the de-oxygenated blood collected in the right atrium to flow
into the right ventricle. It closes as the right ventricle contracts, preventing blood from
returning to the right atrium; thereby, forcing it to exit through the pulmonary valve into
the pulmonary artery.

Mitral Value. The mitral valve separates the left atrium from the left ventricle. It
opens to allow the oxygenated blood collected in the left atrium to flow into the left
ventricle. It closes as the left ventricle contracts, preventing blood from returning to the
left atrium; thereby, forcing it to exit through the aortic valve into the aorta.

Pulmonary Valve. The pulmonary valve separates the right ventricle from the
pulmonary artery. As the ventricles contract, it opens to allow the de-oxygenated blood
collected in the right ventricle to flow to the lungs. It closes as the ventricles relax,
preventing blood from returning to the heart.

Aortic Valve. The aortic valve separates the left ventricle from the aorta. As the
ventricles contract, it opens to allow the oxygenated blood collected in the left ventricle
to flow throughout the body. It closes as the ventricles relax, preventing blood from
returning to the heart.

15
B. Physiology
The heart is a muscular organ about the size of a closed fist that functions as the
body’s circulatory pump. It takes in deoxygenated blood through the veins and delivers it
to the lungs for oxygenation before pumping it into the various arteries (which provide
oxygen and nutrients to body tissues by transporting the blood throughout the body).
The heart is located in the thoracic cavity medial to the lungs and posterior to the
sternum.

On its superior end, the base of the heart is attached to the aorta, pulmonary arteries
and veins, and the vena cava. The inferior tip of the heart, known as the apex, rests just
superior to the diaphragm. The base of the heart is located along the body’s midline with
the apex pointing toward the left side. Because the heart points to the left, about 2/3 of
the heart’s mass is found on the left side of the body and the other 1/3 is on the right.

The heart sits within a fluid-filled cavity called the pericardial cavity. The walls and
lining of the pericardial cavity are a special membrane known as the pericardium.
Pericardium is a type of serous membrane that produces serous fluid to lubricate the
heart and prevent friction between the ever beating heart and its surrounding organs.
Besides lubrication, the pericardium serves to hold the heart in position and maintain a
hollow space for the heart to expand into when it is full. The pericardium has 2 layers—a
visceral layer that covers the outside of the heart and a parietal layer that forms a sac
around the outside of the pericardial cavity.

16
Figure 2. Shows the blood flow to the heart. Source: Blackpool Teaching Hospitals
NHS Foundation Trust. (2015) How your heart works. Retrieved from
http://www.lancashirecardiaccentre.nhs.uk/howyourheartworks.shtml.

The human heart is actually two pumps in one. The right side receives oxygen-poor
blood from the various regions of the body and delivers it to the lungs. In the lungs,
oxygen is absorbed in the blood. The left side of the heart receives the oxygen-rich
blood from the lungs and delivers it to the rest of the body.

Systole. The contraction of the cardiac muscle tissue in the ventricles is called
systole. When the ventricles contract, they force the blood from their chambers into the
arteries leaving the heart. The left ventricle empties into the aorta and the right ventricle
into the pulmonary artery. The increased pressure due to the contraction of the
ventricles is called systolic pressure. Diastole. The relaxation of the cardiac muscle
tissue in the ventricles is called diastole. When the ventricles relax, they make room to
accept the blood from the atria. The decreased pressure due to the relaxation of the
ventricles is called diastolic pressure.

Figure 3. Shows the cardiac conduction system of the heart. Source: Anatomy and
Physiology Website. (2013). Cadiac Muscle and The Conduction System. Retrieved
from https://anatomygroup.wordpress.com/cardiovascular-system/heart/cardiac-muscle-
and-the-conduction-system/

17
 The electrical conduction system of the heart transmits signals generated usually
by the sinoatrial node to cause contraction of the heart muscle. The conducting system
of the heart consists of cardiac muscle cells and conducting fibers (not nervous tissue)
that are specialized for initiating impulses and conducting them rapidly through the heart.
They initiate the normal cardiac cycle and coordinate the contractions of cardiac
chambers. Both atria contract together, as do the ventricles, but atrial contraction occurs
first.

The conducting system provides the heart its automatic rhythmic beat. For the heart
to pump efficiently and the systemic and pulmonary circulations to operate in synchrony,
the events in the cardiac cycle must be coordinated.

The Sinoatrial Node (often called the SA node or sinus node) serves as the natural
pacemaker for the heart. Nestled in the upper area of the right atrium, it sends the
electrical impulse that triggers each heartbeat. The impulse spreads through the atria,
prompting the cardiac muscle tissue to contract in a coordinated wave-like manner.

The impulse that originates from the sinoatrial node strikes the Atrioventricular
node (or AV node) which is situated in the lower portion of the right atrium. The
atrioventricular node in turn sends an impulse through the nerve network to the
ventricles, initiating the same wave-like contraction of the ventricles. The electrical
network serving the ventricles leaves the atrioventricular node through the Right and
Left Bundle Branches. These nerve fibers send impulses that cause the cardiac
muscle tissue to contract.

C. Pathophysiology
In a Myocardial infarction, 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.

18
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.

The risk factors for atherosclerosis are generally risk factors for myocardial
infarction. Many of these risk factors are modifiable such as hypertension, smoking,
obesity, high levels of triglyceride, high total cholesterol and high low density lipoprotein
(LDL), excessive intake of saturated fat, salt, as well as sedentary lifestyle, stress and
drug abuse; so many heart attacks can be prevented by maintaining a healthier lifestyle.
Physical activity is associated with a lower risk profile. Non-modifiable risk factors
include age (40 and above), gender (men and postmenopausal women 45 and above).
The prevalence of MI for women are those who used combined oral contraceptive pills
especially in the presence of other risk factor, such as smoking. The family history of MI

19
and socioeconomic factors such as a lower educational achievement, poverty may also
contribute to the risk of MI.

To understand epidemiological study results, it’s important to note that many

factors associated with MI mediate their risk via other factors. For example, the effect of
education is partially based on its effect on income and marital status. The prevalence of
MI for women are those who used combined oral contraceptive pills especially in the
presence of other risk factor, such as smoking.

Inflammation is known to be an important step in the process of atherosclerotic

plaque formation. C-reactive protein (CRP) is a sensitive but non-specific marker for
inflammation. Elevated CRP blood levels, especially measured with high sensitivity
assays, can predict the risk of MI, as well as stroke and development of diabetes.
Moreover, some drugs for MI might also reduced CRP levels. The use of high sensitivity
CRP assays as a means of screening the general population is advised against, but it
may be used optionally at the physician’s discretion, in patients who already present with
other risk factors or known coronary artery disease. Whether CRP plays a direct role in
atherosclerosis remains uncertain.

Heart attack rates are higher in association with intense exertion, be it

psychological stress or physical exertion, especially if the exertion is more intense than
the individual usually performs Quantitatively, the period of intense exercise and
subsequent recovery is associated with about a 6-fold higher MI rate (compared with
other more relaxed time frames) for people who are physically very fit for those in poor
physical condition, the rate differential is over 35-fold higher. One observed mechanism
for this phenomenon is the increased arterial pulse pressure stretching and relaxation of
arteries with each heart beat which, as has been observed with intravascular ultrasound,
increases mechanical “shear stress” on atheromas the likelihood of plaque rapture.

Acute MI is a type of acute coronary syndrome, which is most frequently (but not
always) a manifestation of coronary artery disease. The acute coronary syndromes
classification includes ST segment elevation MI (STEMI), non-ST segment elevation MI
(NSTEMI), and unstable angina (UA). Depending on the location of the obstruction in the
coronary circulation, different zones of the heart can become injured. Using the

20
anatomical terms of location, one can describe anterior, inferior, lateral, apical and septal
infarctions (and combinations, such as anteroinferior, anterolateral, and so on). For
example, an occlusion of the left anterior descending coronary artery will result in an
anterior wall MI.

Another distinction is whether an MI is subencardial, affecting only the inner third

to one half of the heart muscle, or transmural, damaging (almost) the entire wall of the
heart. The inner part of the heart muscle is more vulnerable to oxygen shortage,
because the coronary arteries run inward from the epicardium to the endocardium, and
because the blood flow through the heart muscle is hindered by the heart contraction.

The phrases transmural and subendocardial infarction used to be considered

synonymous with Q-wave and non-Q-wave MI respectively, based on the presence or
absence of Q waves on the ECG. It has since been shown that there is no clear
correlation between the presence of Q waves with a transmural infarction and the
absence of Q waves with a subendocardial infarction, but Q waves are associated with
larger infarctions, while the lack of Q waves is associated with smaller infarctions. The
presence or absence of Q-waves also has clinical importance, with improved outcomes
associated with a lack of Q waves.

The onset of signs and symptoms in MI is usually gradual, over several minutes,
and rarely instantaneous. Chest pain is the most common symptom of acute MI and is
often described as 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, but may also radiate to the
lower jaw, neck, right arm, back, and epigastrium, where it may mimic heartburn. Any
group of symptoms compatible with a sudden interruption of the blood flow to the heart is
called an acute coronary syndrome. Other conditions such as aortic dissection or
pulmonary embolism may present with chest pain and must be considered in the
differential diagnosis. Associated signs and symptoms include shortness of breath
(dyspnea) which occurs when the damage to the heart limits the output of the left
ventricle, causing left ventricular failure and consequent pulmonary edema. Other
symptoms include diaphoresis (an excessive form of sweating), weakness, light-

21
headedness, nausea, vomiting, and palpitations. Loss of consciousness and even
sudden death can occur in MI.

Approximately half of all MI patients have experienced warning symptoms such

as chest pain prior to the infarction. Approximately one third of all MIs are silent, without
chest pain or other symptoms. These cases can be discovered later on
electrocardiograms or at autopsy without 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 diabetes, differences in pain threshold, autonomic neuropathy, and psychological
factors have been cited as possible explanations for the lack of symptoms.

22
 SCHEMATIC DIAGRAM OF MYOCARDIAL INFARCTION

Modifiable Factors Non-modifiable Factors

 Hypertension
 Smoking  (+) Family history of Mycocardial Infarction
 Obesity  Aging 40 and above
 High levels of triglyceride, total cholesterol & LDL  Men and postmenopausal women 45 and
 Excessive intake of saturated fat , salt
above
 Sedentary lifestyle/physical inactivity
 Stress/type A personality  Socioeconomic factors such as low
 Drug abuse educational achievement and poverty

Causes:
 Vasospasm
 Decreased oxygen supply
 Increased demand for oxygen

Atheromatous plaque

Narrowed blood vessels

Atheromatous rupture or

Platelet aggregation
Narrowing the artery further

Clot formation

Reduced blood flow to an artery

Blood clot blocked the coronary artery

Reduced/occluded blood flow to the ventricles

Reduced Coronary Tissue Perfusion

Diminished Myocardial Oxygenation

Next Page (Myocardial Infaction)

Anaerobic Metabolism

Increased Lactic Acid Production (Lactic

Acidosis) 23
 Signs and Symptoms: Diagnostic
 Chest pain described as a pressure Procedures:
Myocardial Infarction sensation, fullness, or squeezing in the  Patient historyl
midportion of the thorax  Myoglobin
 Radiation of chest pain into the jaw or  Cardiac Enzymes
teeth, shoulder, arm, and/or back  K+ level
 Associated dyspnea or shortness of  ECG
breath  Chest X-ray
 Associated epigastric discomfort with or  WBC count
without nausea and vomiting  2D-ECHO
 Associated diaphoresis or sweating
 Syncope or near syncope without other
cause

Medical Management: Nursing Management: Surgical

Pharmacologic Therapy 1. Administer oxygen along with Management:
 Morphine administered in IV boluses medication therapy to assist with relief
is used for MI to reduce pain and of symptoms. 1. Percutaneous
anxiety. 2. Encourage bed rest with the back rest Coronary
 Angiotensin-Converting Enzyme elevated to help decrease chest Intervention
(ACE) Inhibitors discomfort and dyspnea.
2. Coronary artery
 Thrombolytics 3. Encourage changing of positions
 Anti-platelet agent frequently to help keep fluid from
 Anti-ischemic agent pooling in the bases of the lungs.
 Beta-blockers 4. Check skin temperature and peripheral
 Cholesterol-lowering agents pulses frequently to monitor tissue
perfusion.
5. Monitor the patient closely for
changes in cardiac rate and rhythm,
heart sounds, blood pressure, chest
pain, respiratory status, urinary
output, changes in skin color, and
laboratory values.
No Intervention

Multi-organ
Failure

GOOD PROGNOSIS
DEATH

24
D. Course in the Ward

Day 1 (July 17, 2017)

Patient was admitted at Ward 2 of Camp Navarro General Hospital with a chief
complaint of crushing substernal pain (pain scale of 8/10) radiating to his neck and left
arm for 2-3 minutes but pain subsides (pain scale of 5/10) upon rest. Consent for
admission was secured and oriented to hospital and ward policies. Patient was placed in
semi-fowlers position in bed. Assessed patient’s condition, vital signs were taken and
recorded including pain scale with character, location, duration, trigger and alleviation
data. Intravenous therapy started with PNSS 1 Liter at KVO rate via metacarpal vein on
left hand. Obtained 12-Lead ECG. Non-pharmacological intervention for pain was given;
encouraged diversional activities such as listening to soft music, reading books and
watching T.V series. Encouraged deep breathing exercise and elevated the head of the
bed at 30 degree angle. Instructed on low salt and low fat diet. Health teaching on
disease process was conducted. Encouraged patient to verbalize feelings and answered
questions related to present illness. Discouraged strenuous activities such lifting heavy
objects. Administered pain medication such as Celecoxib 200mg/cap 1 cap BID PRN as
physician’s ordered. Informed patient of the required tests and instructed on what to
expect. Coordinated with laboratory staff for standard tests and diagnostics procedures
as ordered. Referred to attending physician all tests result and carried out doctor’s order.
Recorded pertinent information. Evaluated effective nursing interventions by obtaining
the pain scale of 3/10.

Day 2 (July 18, 2017)

Assessed patient’s condition. Monitored vital signs at regular interval with pain
scale of 3/10. Advised to limit activity to bathroom privilege only; and to avoid stressful
situations like worrying about hospitalization and expenses. Coordinated with social
service for assistance in further diagnostic exams (2D echo) and followed up other tests
result. Encouraged to verbalize feelings. Carried out new doctor’s order for medication.
Clopidogrel75mg 1 tablet once a day started. Trimitazidine 30mg 1 tablet two times a
day started. ISMN 30mg 1 tablet once a day started. Monitored for any drug reactions.
Discontinued IVF aseptically as ordered. Provided clear, thorough, and understandable
explanations of the risks, causes, signs and symptoms of MI and demonstrations of the
proper treatment through health teaching. Kept sessions short. Monitored for any
untoward side effects of medication. Evaluated nursing intervention with patient

25
verbalizing understanding of disease condition, its risk, causes and symptoms as well as
complications. The patient identified and demonstrated proper treatment. Nursing
documentation done.

Day 3 (July 19, 2017)

Assessed patient’s condition. Monitored vital signs at regular interval with pain
scale of 5/10. Non-pharmacological intervention for pain was given; encouraged
diversional activities such as listening to soft music, reading books and watching T.V
series. Encouraged deep breathing exercise and elevated the head of the bed at 30
degree angle. Administered pain medication such as Celecoxib 200mg/cap 1 cap BID
PRN as physician’s ordered. Allowed and encouraged proper rest periods in between
individual exercise/activities to ensure optimal performance during sessions. Advised
significant others to assist patient with ADLs regularly. Health teachings done. Evaluated
effective nursing interventions with patient demonstrating progressive in tolerance for
activity with vital signs within normal limit. Vital signs taken: T-36.6 C, PR- 92 bpm, RR-
20 cmp, BP-13-/80 mmHg, O2 sat of 98% and pain scale of 3/10. The patient performed
ADL and can walk at least 200 feet four times a day without chest discomfort and
shortness of breath. He also demonstrated and verbalized at least 2 energy conserving
techniques such having proper rest periods in between individual activities and
eliminating unnecessary activities.

Day 4 (July 20, 2017)

Body temperature was recorded at 37.9ᶿ C and was referred to attending
physician. Administered Paracetamol 500mg 1 tablet for fever as ordered. Provided
tepid sponge bath. Encouraged to increase oral fluid intake. Advised to wear loose-
clothings. Discouraged strenuous activities. Provided adequate rest periods. Monitored
for any unusualities. Health teaching on elevated body temperature was discussed with
patient and significant others.

Day 5 (July 21, 2017)

Assessed the current health condition of the patient. Monitored vital signs.
Obtained pain scale of 4/10. Non-pharmacological intervention for pain was given;
encouraged diversional activities such as listening to soft music, reading books and
watching T.V series. Encouraged deep breathing exercise and elevated the head of the

26
bed at 30 degree angle. Administered pain medication such as Celecoxib 200mg/cap 1
cap BID PRN as physician’s ordered. Provided adequate rest periods. Monitored for any
discomforts. Patient was brought to Ciudad Medical Zamboanga (CMZ) for 2D-Echo with
Doppler accompanied by NOD. Procedure was explained.

Day 6 (July 22, 2017)

Patient was referred to attending physician for cough. Acetylcysteine 600mg 1
sachet with ½ glass of water once a day for 2 days and Carbocisteine 500mg three
times a day for 1 week was started as ordered. Watched-out for drug reactions.

Day 7 (July 23, 2017)

Result for 2D-echo exam was in and referred to attending physician.

Day 8-12 (July 24-27, 2017)

Continuous monitoring of the patient’s condition and necessary needs and
concerns have been addressed.

Day 9 (July 28,2017)

The patient was discharged from the ward. Discharged instructions was given
such as home medications, perform regular exercises, avoid smoking and other vices as
well as maintaining proper diet with low salt and fat content as well as consume a high
fiber diet.

D. Laboratory and Diagnostic Procedures

 12-Lead Electrocardiography (17 July 2017)

Result: Inferior wall ischemia
Analysis:
The result showed impression of an Inferior Wall Ischemia. This occurs
when blood flow to the heart is reduced, preventing it from receiving enough
oxygen. The reduced blood flow is usually the result of a partial or complete
blockage of the heart’s arteries (coronary arteries). A sudden, severe blockage of
a coronary artery can lead to heart attack.

27
 Blood Chemistry (18 July 2017)

TEST RESULTS REFERENCE VALUES

Fasting Blood Sugar 4.02 33.86 – 5.76 umol/L
(FBS)
Cholesterol 2.11 3.64 – 5.20 umol/L
Creatinine 64.1 Male: 61.8 – 123.7 umol/L
Blood Urea Nitrogen 4.45 1.78 – 8.34 mmil/L
(BUN)

Result: Normal blood chemistry

Analysis: M.I.B.’s blood chemistry showed that it is within the normal limits.

 Chest X-ray PA (18 July 2017)

Result: Cardiomegaly
Analysis:
M.I.B.’s finding on Chest X-ray showed that there were no focal lung
infiltrates or areas of consolidation. The heart is enlarged. Hemidiaphragms and
sulci are intact. Osseous structures are unremarkable. An impression that he has
Cardiomegaly which is most commonly refers to an enlarged heart may be due to
stress, weakening of the heart muscle, coronary artery disease, heart valve
problems or abnormal heart rhythms.

 Urinalysis (24 July 2017)

Color Yellow
Transparency Slightly Hazy
Reaction Ph 5.0
Specific Gravity 1.020
Sugar Negative
Protein Negative
Pus Cells 4-6/hpf
RBC 1-3/hpf
Epithelial Cells Rare
Mucus Threads Rare
Urinalysis Result of MIB

Result: UTI (Urinary Tract Infection)

Analysis: There were 4-6/hpf pus with 1-3 RBC noted in which may indicate
infection in the urinary tract.

28
 Echocardiography and Color Flow Doppler (22 JULY 2017)
Result: Left Ventricular Hypertrophy, Aortic Calcific Sclerosis, Mitral
Regurgitation, Pulmonic Regurgitation
Analysis:
The result showed that the patient has Left Ventricular Hypertrophy
which is an enlargement (hypertrophy) of the muscle tissue that makes up the
wall of your heart’s main pumping chamber (left ventricle) with segmental wall
motion abnormality indicative of Coronary Artery Disease, a disease in which a
waxy substance called plaque builds up inside the coronary arteries. These
arteries supply oxygen-rich blood to the heart muscle. If the flow is blocked or
reduced, angina or heart attack can occur. Additional findings include, dilated left
atrium without thrombus which is a form of cardiomegaly. There was also Aortic
Calcific Sclerosis, a condition whereby the aortic valve becomes thickened but
does not significantly obstruct flow. The procedure also traced Mitral
Regurgitation which is a leakage of blood backward through the mitral valve
each time the left ventricle contracts and Pulmonic Regurgitation which is a
leaky pulmonary valve, this valve helps control the flow of blood passing from the
heart to the lungs. A leaky pulmonary valve allows blood to flow back into the
heart chamber before it gets to the lungs for oxygen.

29
 Name of drug Indication and Contraindication Adverse effect Nursing
Responsibilities
Date Started: 17 July 2017 Indications • CNS: Headache, dizziness, 1. Administer drug with
 Acute and long-term treatment somnolence, insomnia, fatigue, food or after meals if
Generic Name of signs and symptoms tiredness, dizziness, tinnitus, GI upset occurs.
Celecoxib of rheumatoid ophthamologic effects 2. Establish safety
arthritis and osteoarthritis • Dermatologic: Rash, pruritus, measures if CNS,
Brand Name  Reduction of the number of sweating, dry mucous visual disturbances
Celebrex colorectal polyps in membranes, stomatitis occur.
familial adenomatous polyposis (FA • GI: Nausea, abdominal pain, 3. Provide further
Classification: P) dyspepsia, flatulence, GI bleed comfort measures to
 Anti-rheumatics  Management of acute pain • Hematologic: Neutropenia, reduce pain (eg,
 NSAID eosinophilia, leukopenia, positioning,
Contraindications and cautions pancytopenia, environmental
Pharmacokinetics:  Contraindicated with allergies thrombocytopenia, control), and to reduce
Dosage: 200mg to sulfonamides, celecoxib, NSAID agranulocytosis, inflammation (eg,
Route: P.O s, or aspirin; significant renal granulocytopenia, aplastic warmth, positioning,
Onset: Slow impairment; anemia, decreased hemoglobin rest).
Peak: 3 hr  Use cautiously with impaired or hematocrit, bone marrow
Frequency: BID, PRN hearing, hepatic, and CV depression,menorrhagia
conditions. • Other: Peripheral edema,
Therapeutic actions anaphylactoid reactions to
It protects the lining of the GI tract and anaphylactic shock
has blood clotting and renal functions.
It also decreases pain inflammation
caused by arthritis or spondylitis.
E. Drug Study

30
 Name of drug Indication and Adverse effect Nursing Responsibilities
Contraindication
Date Started: 18 July 2017 Indications  CNS: Headache, 1. Provide small, frequent
 Treatment of patients at dizziness, weakness, meals if GI upset occurs
Generic Name risk for ischemic events— syncope, flushing (not as common as
Clopidogrel history of MI, ischemic stroke,  CV: Hypertension, with aspirin).
peripheral artery disease edema 2. Provide comfort measures
Brand Name  Treatment of patients with  Dermatologic: Rash, pr and arrange for analgesics
Plavix acute coronary syndrome uritus if headache occurs.
 GI: Nausea, GI 3. Advise client that he may
Classification: Contraindications distress, constipation, di experience these side
Therapeutic: Anti-platelet agents  Contraindicated arrhea, GI bleed effects: Dizziness, light-
with allergy to clopidogrel,  Other: Increased bleedi headedness (this may pass
Pharmacokinetics: active ng risk as you adjust to the drug);
Dosage: 75 mg pathological bleeding such headache (lie down in a
Route: P.O. as peptic ulcer or intracranial cool environment and rest;
Onset: Varies hemorrhage. OTC preparations may
Peak: 75 min  Use cautiously help); nausea, gastric
Duration: 3–4 hr with bleeding disorders, distress (eat frequent small
Frequency: OD recent surgery, hepatic meals);
impairment. prolonged bleeding (alert
Therapeutic actions doctors, dentists of this drug
Inhibits platelet aggregation by use).
inhibiting the binding of ATP to platelet
receptors.

31
 Name of drug Indication and Adverse effects Nursing Responsibilities
Contraindication
Date Started: 18 July 2017 Indications  Headache, 1. Monitor blood pressure
 Prevention of angina dizziness, and intensity and duration
Generic Name: pectoris due to coronary lightheadedness, of response to drug.
Isosorbide Mononitrate nausea, and 2. Instruct patient to remain
artery disease.
flushing
seated or lying during and
Brand Names: Contraindications after administration to
Imdur, Monoket, ISMO  Severe anemia, Heart prevent dizziness.
Attack, Hypertrophic 3. Monitor client for chest
Classification: Cardiomyopathy, pain.
Therapeutic: Anti-anginals Hemorrhage in the Brain, 4. Store in cool place, in
Pharmacologic: Nitrates Abnormally Low Blood tightly closed container,
Pressure, Malabsorption, away from light.
Pharmacokinetics Head Injury
Dosage: 30 mg
Route: P.O
Onset: 1 hour
Peak: Regular release 30–60 min;
Duration: Regular release 5–12 h; sustained
release 12 h.
Frequency: OD

Therapeutic action:
Prevent chest pain (angina) in patients with a
certain heart condition (coronary artery
disease). This medication belongs to a class
of drugs known as nitrates. It works by
relaxing and widening blood vessels so blood
can flow more easily to the heart.

32
Name of drug Indication and Adverse effect Nursing Responsibilities
Contraindication

33
Date Started: 20 July 2017 Indications:  Minimal GI upset. 1. Monitor CBC, liver and
 Control of pain due to  Methemoglobinemia renal functions.
Generic Name: headache, arthralgia,  Hemolytic Anemia 2. Assess for fecal occult
Paracetamol myalgia,  Neutropenia blood and nephritis.
musculoskeletal pain,  Thrombocytopenia 3. Advise patient to take
Brand Name: arthritis, i.reduce fever with food or milk to
 Pancytopenia
Biogesic, Panadol, Tylenol in viral and bacterial minimize GI upset.
 Leukopenia
infectionsAs a 4. Advise client to avoid
 Urticaria
substitute for aspirin in alcohol.
 CNS stimulation
Classification: upper GI disease,
 Hypoglycemic coma
 Antipyretic bleeding disorders
 Jaundice
 Analgesic clients in
anticoagulant therapy  Glissitis
Pharmacokinetics: and gouty arthritis  Drowsiness
Dosage: 500 mg  Liver Damage
Route: PO Contraindications:
Onset: 0.5-1 hour  Renal Insufficiency
Peak: 1`-3 hours
Duration: 3-8 hours
Frequency: Q 4 hours,PRN

Therapeutic Actions:
Decreases fever through sweating and
vasodilation. Inhibits pyrogen effect on the
hypothalamic-heat-regulating centers
Inhibits CNS prostaglandin synthesis with
minimal effects on peripheral prostaglandin
synthesis
Does not cause ulceration of the GI tract and
causes no anticoagulant action.

34
 Name of drug Indication and Adverse effect Nursing Responsibilities
Contraindication

Date Started: 18 July 2017 Indications • Dizziness, headache, 1. Measure and record weight
 Angina pectoris. abdominal pain, to monitor fluid changes.
Generic Name dyspepsia, diarrhea, 2. Monitor serum electrolytes,
Trimetazidine Contraindications and cautions nausea, vomiting, hydration, liver and renal
 Parkinson's disease, pruritus, rash, function.
Brand Name parkinsonian symptoms, urticaria, asthenia. 3. Administer with food or
Angimet,trimet tremors, restless leg Rarely, tachycardia, milk to prevent GI upset.
syndrome and other palpitations,
Classification: movement related disorders. extrasystoles,
 Anti-ischemic metabolic agent Severe renal impairment orthostatic
(CrCl<30 mL/min). hypotension, arterial
Pharmacokinetics: hypotension, flushing.
Dosage: 35 mg
Route: P.O
Frequency: BID

Therapeutic actions
Inhibits β-oxidation of fatty acids
through inhibition of long-chain 3-
ketoacyl-CoA thiolase, which
enhances glucose oxidation. It
ensures proper functioning of ionic
pumps and regulate Na-K flow by
preventing decrease in intracellular
ATP levels.

35
 Name of drug Indication and Contraindication Adverse effect Nursing Responsibilities

Date Started: 21 July 2017 Indications Cardiovascular: 1. Advise patient or caregiver

 Chronic bronchopulmonary disease Tachycardia, hypotension that medication has a
Generic Name (chronic emphysema, emphysema disagreeable odor but that
Acetylcysteine with bronchitis, chronic asthmatic Dermatologic: this should become
bronchitis, tuberculosis, Rash, flushing, pruritus, unnoticeable after continued
Brand Name bronchiectasis and primary urticaria use.
Mucomyst, NAC, Acetadote, amyloidosis of the lung), acute 2. Advise patient or caregiver
Acys-5 bronchopulmonary disease EENT: that treatment is expected to
(pneumonia, bronchitis, Pharyngitis, rhinorrhea, increase volume of
Classification: tracheobronchitis), pulmonary throat tightness respiratory secretions and
 Antidote complications of cystic fibrosis, that effective coughing will
 Mucolytic tracheostomy care, pulmonary GI: be required to clear the
complications associated with Vomiting, nausea, stomatitis secretions.
Pharmacokinetics: surgery, during anesthesia, 3. Advise patient or caregiver
Dosage: 600 mg posttraumatic chest conditions, Respiratory: to immediately notify health
Route: P.O. atelectasis caused by mucous  Rhonchi, care provider if respiratory
Onset: 2 hours obstruction, and diagnostic bronchoconstriction, secretions cannot be
Frequency: OD bronchial studies (eg, bronchospasm; irritation adequately removed by
bronchograms, bronchospirometry, to the tracheal and coughing.
Therapeutic actions bronchial wedge catheterization) bronchial tracts; 4. Advise patient, family, or
Used to help thin and loosen (inhalation); prevention or hemoptysis; edema caregiver that medication will
mucus in the airways due to lessening of liver damage after be prepared and
certain lung diseases (such as potentially toxic quantity of administered by a health
emphysema, bronchitis, cystic acetaminophen (oral or IV). care provider in a hospital
fibrosis, pneumonia). This setting.
effect helps you to clear the Contraindications:
mucus from your lungs so that  Hypersensitivity
you can breathe easier.

36
 Name of drug Indication and Adverse effect Nursing Responsibilities
Contraindication

Date Started: 21 July 2017 Indications:  Nausea, gastric 1. Advise to increase oral fluid
 Chronic emphysema, discomfort, GI intake at least 2 to 3 liters daily
Generic Name bronchitis, CHF bleeding, skin rash, 2. Instruct patient to report cough
Carbocisteine Stevens-Johnson of more than 1 week
Contraindications syndrome, erythema 3. If the medication taste bad,
Brand Name  Active peptic ulceration multiforme. advise patient to take it with
Solmux juice.
4. Instruct patient that the sputum
Classsification: will be more liquid when
Mucolytic. coughing, the sputum is easier
to cough up
Pharmacokinetics:
Dosage: 500mg|cap
Route: P.O
Frequency: TID

Therapeutic actions
Management of condition
associated with thick viscid mucous
secretions. It helps clear the mucus
from the lungs so you can breathe
at ease.

37
 CHAPTER IV
NURSING MANAGEMENT
A. Problem List

Table No. 3 Problem List

Problem Prioritization Date Identified Date Resolved
1. Acute chest pain related to myocardial
tissue damage from inadequate blood 17 July 2017 21 July 2017
supply
2. Activity Intolerance to generalized
weakness 17 July 2017 19 July 2017

3. Readiness for enhanced knowledge

related to unfamiliarity with information 18 July 2017 18 July 2017
resources

4. Elevated Body Temperature 20 July 2017 20 July 2017

5. Ineffective airway clearance 22 July 2017 26 July 2017

B. Long Term Objective

Upon discharge, M.I.B. together with the help and support of immediate family
members will be able to attain quality of life, resume activities of daily living,
compliance with the follow-up referrals without complications.

38
E. Nursing Care Plan
ASSESSMENT
17 1000H July 2017
Nursing Diagnosis:
Acute Chest Pain related to
myocardial tissue damage
from inadequate blood
supply
Subjective Cue:
“Sumasakit po ma’am yung
dibdib ko”, as verbalized by
the patient.
Objective Cue:
 Facial grimace
 Restlessness
 Chest pain, heaviness,
or pressure that radiates
to the shoulder and
neck with pain scale
8/10
 Vital Signs taken:
BP – 130/80 mmHg
O2 Sat – 97%
NURSING OBJECTIVES
At the end of 2 hours of 1. Administered supplemental oxygen
nursing intervention, the
patient will be able to: 2. Assessed patient pain for intensity
1. Verbalize decrease of
pain.
2. Demonstrate activities
and behaviors that will
prevent the
recurrence of pain.
INTERVENTION
via nasal cannula as indicated.
using a pain scale, for location and
precipitating factors.
3. Obtained a 12-Lead
electrocardiogram if indicated.
4. Assessed the response to pain
medication.
5. Provided comfort measures.
6. Elevated head of bed.
7. Instructed to take several deep
breaths to increase oxygenation.
8. Encouraged patient to do diversional
activities such as listening to soft
music, reading books, and watching
T.V. series.
9. Administered pain medication such
as Celecoxib 200mg/cap 1 cap BID
PRN as ordered.
39
EVALUATION
At the end of 2 hours of nursing
intervention, the patient was
able to:
1. Verbalized decrease of pain
with pain scale of 3/10. Vital
signs taken:
BP- 130/80mmHg
O2 Sat – 98%
2. Demonstrated activities and
behaviors that will prevent
the recurrence of pain such
as position to semi fowlers to
enhance relaxation. Patient
seen resting on bed while
watching T.V.
 Assessment Nursing Objectives Nursing Intervention Evaluation

17 1000H July 2017

Nursing Diagnosis: After 2 days of nursing 1. Monitored cardio respiratory At the end of 2 days nursing
Activity Intolerance related intervention, the patient response to activity through intervention, the patient was
to generalized weakness will be able to: obtaining the vital signs to have a able to:
baseline information.
Subjective cues: 1. Demonstrate 2. Determined client’s physical 1. Demonstrated progressive in
“MadaliASSESSMENT
akong mapagod progressive
NURSING increase
OBJECTIVES limitation.
NURSING INTERVENTION tolerance for activity with
EVALUATION
pagkatapos kong gumawa in tolerance for 3. Observed and addressed restrictive vital signs within normal
ng konting trabaho”. As activity with vital clothing and items that may impact limit. Vital signs taken:
19 1000H July
verbalized 2017
by patient. signs within normal PR- 92 bpm
proper blood flow, oxygen levels and
limit. physical comfort. RR- 20 bpm
Objective cues: 4. Allowed and encouraged proper rest
Nursing
 PaleDiagnosis:
looking At the end of 30 minutes 1. Assessed patient or significant At
2. the end of 30
Performed minutesofnursing
activities daily
2. Perform activities of periods in between individual
Readiness for enhance nursing intervention, the intervention,
living suchthe aspatient
others level of knowledge and was
 Weakness daily living such as exercise/ activities to ensure optimal bathing, eating
knowledge related to patient will be able to: ability and desire to learn by able to:
 Palpitation bathing, eating and performance during sessions. and dressing and can walk
unfamiliarity with asking their educational
 Shortness of breathing dressing and can 5. Eliminated nonessential activities or at least 200 feet four times a
information resources 1. Show motivation to background and frequently asking 1. day Showed motivation in
 Skin cool to touch walk at least 200 feet procedures without chest discomfort
about thetodisease
conserve energy
learn. condition. learning by actively
and shortness of breath.
 Chest Cues:
pain with pain four times a day output, conserve strength for
Subjective 2. Observed and note existing participating in the
scale without chest important activities.
“Ma’am anoofpo8/10
ba yung 2. Verbalize discussion. and
misconceptions regarding material 3. Demonstrated
 Vital Signs taken:as discomfort or 6. Encouraged patient to develop good
tungkol sa sakit ko?”, understanding to be taught.
PR – 112 bpm shortness of breath. breathing habits in order to improve verbalized at least 2 energy
verbalized by the patient. regarding disease 3. Identified cultural influences on Verbalized techniques
2. conserving understanding
RR – 24 cpm cardiovascular functions and reduce such
3. condition,
Display andits risk,
use health teaching.
stress levels
regarding disease
as having proper rest condition,
Objective Cues: causes,
effectivesigns and 4. Provided clear, thorough, and its risk, in
periods causes,
betweensigns and
individual
energy 7. Advised significant others to assist
 Questioning members of symptoms and understandable explanations of symptoms and
management/conser patient with ADLs (activities of daily activities and eliminating
health care team complications. the risks, causes, signs and complications.
vation techniques. living) regularly. nonessential activities.
symptoms of Myocardial infarction
8. Arranged physical activities to 3. Identified and demonstrated
and demonstrations of the proper
3. Identify and reduce competition for oxygen proper treatment on the
treatment through health teaching.
demonstrate proper supply to vital body functions such as disease condition to prevent
5. Paced the instruction and keep
treatment and how to avoid activity immediately after acquiring complications.
sessions short.
incorporate new meals.
6. Provided immediate feedback on
health regimen into performance.
lifestyle on the 7. Allowed repetition of the
disease condition to information or skill.
prevent acquiring
complications.
40
D. Discharge Plan (METHODS)
I. Medications
 Instructed to take home medications at the right dose, time, frequency and route.
 Clopidogrel 75mg/tab 1 tab once a day after meal (0800h)
 Trimetazidine 35mg/tab 1 tab two times a day after meal (0800h-1800h)
 Isosorbide Mononitrate (ISMN) 30mg/tab 1 tab once a day after meal
(0800h)
 Do not stop taking medication without seeking health care provider.
 Do not share medication to others without doctor’s permission.
 Medication must be taken exactly and don’t skip doses or double the doses.
II. Exercise
 Instructed patient that exercise regularly is necessary. Exercise program may
intend as the doctor prescribed and considering safety of the patient condition.
 Encourage to at least 20- 30 minutes of exercise daily or at least 3-4 times a
week such ask brisk walking.
III. Treatment
 Tell patient that medication given to him will be taken as maintenance.
 Instructed patient for compliance to treatment regimen to prevent further
complications.
IV. Health Teachings
 Advised patient to avoid strenuous activities or exercises such as push ups,
mountain climbing, running or lifting heavy object, and too much exposure to
extreme temperatures.
 Advised to avoid smoking.
 Encouraged to have adequate rest periods.
 Learn to manage stress through activities such as yoga, meditation and
counselling.
 Provided patient knowledge about his conditions and how to identify
complications that needed to be reported or see doctor as possible.
V. Out-Patient
 The patient was advised to seek health care provider or cardiologist immediately
if any unusualities, complaints or discomforts occur such as chest pain that is not

41
 relieved by medicine, shortness of breathing; discomfort in back, neck, jaw or
stomach and dizziness for further evaluation and management.
 Have regular medical check-ups.
VI. Diet
 Advised patient to avoid foods rich in sodium, fat, and cholesterol such as fish
paste and sauce, dried fish, canned goods, fried foods and red meats.
 Instructed patient to eat foods high in fiber such as fruits and vegetables.
 Advised to avoid high alcohol and caffeinated containing foods and drinks such
as chocolate, coffee.
VII. Spiritual
 The patient acknowledged the use of spiritual practices and beliefs, such as
prayer, for the purpose of affecting a cure of or an improvement in an illness but
still need to seek health care provider and ask for any medical advised.
 Encouraged to keep faith in God (Allah) and continue to have positive outlook in
life.
VIII. Sexuality
 Tell patient that there will be reduced sexual activity and increase sexual
dysfunction and may trigger cardiac symptoms during sexual activity.
 Advised to avoid vigorous sexual activity and to assume a passive position or
one that is more comfortable for sexual activity.
 Advised patient to ask health care provider before starting sexual activity again.
DO NOT take sildenafil (Viagra), or vardenafil (Levitra), tadalafil (Cialis), or any
herbal remedy for erection problems without checking first.

42
 CHAPTER V
CONCLUSION

The study allows the reader to observe the theoretical aspects of the nursing
process and the practical implications of it. It shows that there is a need to assess
the whole person in order to gain an understanding of their perceptual world. It
illustrates the need for student nurses and qualified staff alike to gain knowledge of
effective tools that can be helpful in assessment and diagnosis. It moves on to
suggest that a plan of care is dependent on the accuracy of the assessment. The
more accurate the assessment, the more effective the plan of care is. It emphasizes
the need for ethical awareness, allowing the nurse to predict problems.

This case has greatly assisted in the adequacy, appropriateness, effectiveness

and efficiency of patient care, helping in the teaching and learning aspects of nurse-
client relationships. The incidence of heart failure is increasing. It is therefore
incumbent on healthcare providers to evaluate their heart failure practices and to
incorporate the most current knowledge of the pathophysiology, assessment, and
treatment modalities for myocardial infarction into their patient care.

Proper research is the key to knowing not only what quality of care can be
achieved but also how it can be achieved. Cardiovascular diseases account for 32.4
million deaths annually worldwide. Myocardial infarction continues to be an
increasing significant problem, and this study will assist readers in gaining a basic
knowledge of what is it all about, its evident symptoms, its risk and proper
management.

Educating people about how to support a partner, family member or friend with
heart failure is also an important part of promoting self-care. Patients are more likely
to engage in beneficial self-care behaviours if they have someone to help them than
if they are socially isolated. This emphasizes the need to improve community support
for socioeconomically disadvantaged patients and those who live alone or in this
case, a patient who is far from home.

43
 This case study has provided us with an understanding of the disease process,
a guide to thorough assessment and provided necessary interventions for a patient
diagnosed with acute myocardial infarction.

44
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