SY 2020-2021

COLLEGE OF NURSING
Silliman University
Dumaguete City

Resource Unit on Myocardial Infarction

Prepared by:
Manuel Joseph Patrimonio
Joi Owen Teves

Submitted to:
Asst. Prof. Mary Nathalie Cata-al

October 8, 2021
Time Allotment: 40 minutes

Topic: Myocardial Infarction

Topic Description: This topic deals with the nursing care for patients with myocardial infarction. It includes the discussion on different signs and
symptoms signifying the occurrence of myocardial infarction, as well as predisposing factors and complications. It emphasizes the medical and
nursing intervention that would be utilized to provide optimum care for the patient.

Central Objective: By the end of the 30 minute virtual discussion on myocardial infarction the learners shall gain sufficient knowledge with a
positive attitude on myocardial infarction and communicate effectively with the patient and the appropriate nursing actions with careful
observations with 85% level of competency.

Specific Objectives Content Teaching- Time Evaluation

Learning Allotment Method
Activities

At the end of the

presentation the learners
will be able to:
​Virtual Answer the
1. Define I. DEFINITION presentation 2 minutes questions asked
Myocardial through by the facilitator
Infarction Myocardial Infarction occurs when one of the heart's Google Meet at 85%
coronary arteries is blocked suddenly or has
competency
extremely slow blood flow. A heart attack also is
called a myocardial infarction. (Harvard Medical
level.
School, 2019).

2. Enumerate the risk II. RISK FACTORS

factors of 2 minutes
myocardial 1. Modifiable:
 infarction ● Cigarette smoking
● Alcohol Consumption
● Obesity
● Physical Inactivity
● DM
● Hypertension

2. Non- Modifiable:
● Family History/ Genetics
● Age
● Race

3. Describe the III. PATHOPHYSIOLOGY 3 minutes

pathophysiology
of Myocardial Myocardial Infarction is caused by decreased blood
Infarction flow to the coronary artery due to atherosclerotic
plaque and occlusion of artery by the thrombus.

Another cause of Myocardial infarction is

vasospasm of the coronary artery, decreased oxygen
supply in turn high demand for oxygen supply.
There is a mismatch of myocardial oxygen supply
and demand. Cells deprived of oxygen. Deprivation
of Oxygen in cells results in ischemia. When
Ischemia occurs, cell injury happens and lack of
oxygen results in Infarction.

4. Enumerate the IV. CLINICAL MANIFESTATION 2 minutes

Clinical
Manifestation of 1. Cardiovascular System:
myocardial ● Chest Pain
infarction ● Increase BP
● Pulse Deficit
● ST elevation
 2. Respiratory System:
● Tachypnea
● Dyspnea
● SOB
● Crackles

3. Gastrointestinal System:
● N/V

4. Urinary System:
● Decreased urine output

5. Integumentary System:
● Pale

6. Nervous System:
● Light headedness
● Restless

5. Enumerate V. COMPLICATIONS
complications of
Myocardial ● Sudden Death - The risk of sudden death is 8 minutes
Infarction highest at the onset of symptoms and
declines progressively over a number of
hours (Resuscitation Council UK,
2000).Death is commonly due to the
dysrhythmia, and ventricular fibrillation.

● Disturbance of rate, rhythm and

conduction. - Dysrhythmias are
experienced more frequently than any other
MI complication. Although these may be
life-threatening, many patients experience
only self-limiting dysrhythmias of minimal
 haemodynamic consequence.

● Cardiogenic shock - The term cardiogenic

shock is used to describe a complex
syndrome associated with inadequate
perfusion of vital organs, most significantly
the brain, kidneys and heart Cardiogenic
shock is caused by massive irreversible
damage to the myocardium.

● Cardiac rupture - Cardiac rupture is a fatal

consequence of myocardial infarction and
arises from excessive matrix degradation in
the early phases of remodeling, possibly
combined with a delayed or impaired
production of connective tissue in later
phases.

● Heart Failure - Heart failure is one of the

more severe complications of MI and results
from the heart’s inability to provide an
adequate cardiac output for the body’s
metabolic requirements (Thompson and
Webster, 1992).

● Angina Pectoris - Anginal pain is due to the

increased oxygen demand on the viable
myocardium.

● Pericarditis - Inflammation of the

pericardium, usually transient, benign and
self-limiting but symptoms may be
distressing. Pain is typically felt in the
region of the heart.

● Thromboembolism - This arises from the

 development of a mural thrombus in acutely
inflamed endocardium, usually following a
large Q-wave infarction, or where a
ventricular aneurysm has developed. It
generally occurs one to three weeks
post-infarct, accounting for three percent of
deaths (Swanton, 1994).

● Ventricular Septal Defect - A hole occurs

in the interventricular septum, resulting in a
left to right shunt with subsequent
cardiogenic shock, pulmonary circuit
overload and severe pulmonary edema.

● Ventricular Aneurysm - Aneurysm

formation results in 10–15 percent of cases
following extensive destruction of cardiac
muscle, and its replacement by scar tissue.
During ventricular systole the aneurysm
bulges outwards and reduces the ejection
fraction by absorbing the force of
myocardial contraction. In effect it steals
some of the left ventricular stroke volume.

● Ruptured Papillary Muscles - Rupture of

the papillary muscles occurs in the healing
stages usually complicating an inferior or
anteroseptal MI. There is a sudden onset of
mitral insufficiency and heart failure.

● Shoulder Hand Syndrome - Left shoulder

pain and stiffness is felt two to eight weeks
after MI and there may be pain and swelling
of the hand.
 ● Psychological Problems and Depression -
Up to one-third of MI patients may present
with anxiety, depression and
over-dependence. As a result, they may
develop psychological problems and
depression.

6. Discuss VI. ASSESSMENT & DIAGNOSTIC TESTS 8 minutes

Assessment and
Diagnostics of 1. Assessment
myocardial
Infarction ● Physical Exam
always done but alone does not
confirm the diagnosis

● Patient’s History
is divided into two categories: (1)
the presenting symptoms and (2) the
family history of heart disease.
Previous history includes the risk
factor for heart disease.

2. Diagnostics

● Electrocardiogram (EKG or
ECG)
ECG provides information that
assists in diagnosing Myocardial
Infarction. By monitoring ECG,
changes over time, location,
evolution and resolution of an MI
can be identified and monitored.
Classic ECG changes are T wave
inversion, ST segment elevation
 and development of abnormal Q
wave. During recovery of
Myocardial Infarction, the ST
segment often is the first ECG
indicator to return to normal.

● Echocardiogram
Is used to evaluate ventricular
function. It may be used to assist in
diagnosing Myocardial Infarction
especially when ECG is
nondiagnostic. The
echocardiogram can detect
hypokinetic and akinetic wall
motion and can determine the
ejection fraction.

● Angiogram - Involves taking an

X-ray after injecting a dye-like
substance easily seen on an X-ray
into your blood. This allows doctors
to see areas with little or no blood
flow.

● Heart computed tomography

(CT) scan - A computed
tomography (CT) scan of the heart
is an imaging method that uses
x-rays to create detailed pictures of
the heart and its blood vessels. This
test evaluates if there is narrowing
or a blockage in those arteries.

● Heart MRI - Cardiac magnetic

resonance imaging (MRI) uses a
powerful magnetic field, radio
 waves and a computer to produce
detailed pictures of the structures
within and around the heart.

● Nuclear Heart Scans - A nuclear

heart scan is an imaging test that
uses special cameras and a
radioactive substance called a tracer
to create pictures of your heart.

● Laboratory test:

Creatinine kinase and isoenzyme

Ck-MB is the cardiac- specific
isoenzyme found in cardiac cells.
Elevated Ck-MB assessed by mass
assay is an indicator of acute MI.
Its level begins to rise within a few
hours and peaks within 24 hours of
an MI.

Myoglobin
Myoglobin is a heme protein that
helps transport oxygen. It is found
in cardiac cells and skeletal muscle.
It starts to increase in 1-3hours
and peaks at 12 hours after onset
of symptoms.

Troponin - Troponin is a contractile

protein that normally is not found in
serum; it is released only when
myocardial necrosis occurs. There
are three isomers of troponin.
Troponin I and T are specific for
 cardiac muscles and these tests are
recognized as critical markers of
myocardial injury. An increased
level of Troponin serum can be
observed in a few hours of acute
Myocardial Infarction. It can
remain elevated for as long as 3
weeks and can also be used to detect
recent myocardial damage.

7. Explain Medical VII. MEDICAL MANAGEMENT 8 minutes

Management of
patients with Focuses on reducing workload of the heart, relieving
Myocardial pain, improving tissue perfusion, preventing further
Infarction complication.

1. Pharmacological Therapy

● Thrombolytics
The purpose of thrombolytics is to dissolve
the thrombus in a coronary artery which
causes reperfusion and minimize the
infarction. Thrombolytics are administered
via IV, and can be given directly into the
coronary artery in cardiac catheterization
lab. Example of a thrombolytic agent is
Aspirin.

● Analgesic
The analgesic of choice for Acute
Myocardial Infarction is Morphine Sulfate
administered via IV boluses. The purpose of
Analgesic is to reduce pain. Decrease the
workload of the heart. It also relaxes
bronchioles which allows optimum passage
 of oxygen. Administration of Morphine is
monitored closely, particularly the Blood
Pressure which can decrease and
respiratory which can be depressed.

● ACE inhibitor
The purpose of the ACE inhibitor is to
prevent the conversion of ACE1 to ACE2.
Without ACE2, the blood pressure will
decrease and the kidneys excrete sodium
and fluid which results to decrease demand
for oxygen.

● Antidysrhythmic agents
There are three types of dysrhythmia: (1)
Ventricular fibrillation, (2) Bradycardia and
(3) Tachycardia. Ventricular fibrillation is
treated with defibrillation. Bradycardia is
treated with Atropine and if needed,
temporary pacemaker. Atrial Tachycardia is
treated with digoxin or amiodrone.
Ventricular Tachycardia is treated with
lidocaine or cardioversion. For continued
dysrhythmias, Magnesium Sulphate is
given.

● Beta Blockers
The purpose of this medication is to
reduce blood pressure. Beta Blockers
should be given initially, throughout the
hospitalization and after discharge. Beta
Blockers decrease the incidence of
future cardiac events.

● Nitroglycerin
 Nitroglycerin is a vasodilatory drug. The
purpose of this drug is to provide relief from
anginal chest pain. This medication is also
used to treat hypertension and control heart
failure.

8. Explain Nursing VIII. NURSING MANAGEMENT 7 minutes

Management for
patients with Nursing Priority:
Myocardial
Infarction 1. Relieve Pain
2. Prevent/ assist in treating life threatening
dysrhythmia.
3. Reduce myocardial workload.

Nursing diagnosis

Acute Pain r/t Tissue Ischemia as evidenced by

reports of chest pain and facial grimacing

Nursing Intervention & Rationale

Independent:

Intervention: Monitor and document characteristic of pain,

noting verbal reports, nonverbal cues (moaning, crying,
grimacing, restlessness, diaphoresis, clutching of chest) and
BP or heart rate changes.

Rationale: Variation of appearance and behavior of patients

in pain may present a challenge in assessment. Most patients
with an acute MI appear ill, distracted, and focused on pain.
Verbal history and deeper investigation of precipitating
factors should be postponed until pain is relieved.
Respirations may be increased as a result of pain and
associated anxiety; release of stress-induced catecholamines
increases heart rate and BP.

Intervention: Obtain full description of pain from patient

including location, intensity (using scale of 0–10), duration,
characteristics (dull, crushing, described as “like an elephant
in my chest”), and radiation. Assist patient to quantify pain
by comparing it to other experiences.

Rationale: Pain is a subjective experience and must be

described by patient. Provides baseline for comparison to aid
in determining effectiveness of therapy, resolution and
progression of problem.

Intervention: Review history of previous angina, anginal

equivalent, or MI pain. Discuss family history if pertinent.

Rationale: Delay in reporting pain hinders pain relief and

may require increased dosage of medication to achieve
relief. In addition, severe pain may induce shock by
stimulating the sympathetic nervous system, thereby creating
further damage and interfering with diagnostics and relief of
pain.

Intervention: Instruct patient to report pain immediately.

Provide quiet environment, calm activities, and comfort
measures. Approach patient calmly and confidently.

Rationale: Decreases external stimuli, which may aggravate

anxiety and cardiac strain, limit coping abilities and
adjustment to current situation.
Intervention: Instruct patient to do relaxation techniques:
deep and slow breathing, distraction behaviors, visualization,
guided imagery. Assist patient as needed.

Rationale: Helpful in decreasing perception and response to

pain. Provides a sense of having some control over the
situation, and an increase in positive attitude.

Intervention: Check vital signs before and after narcotic

medication.

Rationale: Hypotension and respiratory depression can

occur as a result of narcotic administration. These problems
may increase myocardial damage in presence of ventricular
insufficiency.

Intervention: Administer supplemental oxygen by means of

nasal cannula or face mask, as indicated.

Rationale: Increases amount of oxygen available for

myocardial uptake and thereby may relieve discomfort
associated with tissue ischemia.

Dependent:

Intervention: Administer nitroglycerin as indicated.

Rationale: Nitrates are useful for pain control by coronary

vasodilating effects, which increase coronary blood flow and
myocardial perfusion. Peripheral vasodilation effects reduce
the volume of blood returning to the heart (preload), thereby
decreasing myocardial workload and oxygen demand.

Intervention: Administer Beta Blockers as indicated.

 Rationale: Important second-line agents for pain control
through effect of blocking sympathetic stimulation, thereby
reducing heart rate, systolic BP, and myocardial oxygen
demand.May be given alone or with nitrates.

Intervention: Administer Analgesic as prescribed by the

physician.

Rationale: Analgesics relieves pain selectively without

blocking the conduction of nerve impulses, markedly
altering sensory perception, or affecting consciousness. This
helps relieve the patient’s pain and improve comfort.

References:

Brunner, L. S., & Suddarth, D. S. (2008). Textbook of medical-surgical nursing: Brunner and Suddarth's. Lippincott Williams & Wilkins.

Choi-la, Krey, Aloma, Robin, & Mukanka, C. (2020, June 21). 7 myocardial infarction (heart attack) nursing care plans. Nurseslabs. Retrieved
October 8, 2021, from https://nurseslabs.com/7-myocardial-infarction-heart-attack-nursing-care-plans/.

Nitroglycerin. Uses, Interactions, Mechanism of Action | DrugBank Online. (n.d.). Retrieved October 8, 2021, from
https://go.drugbank.com/drugs/DB00727.

Macon, B. ( 2017, November 30). Acute Myocardial Infarction. Retrieved October 8, 2021, from
https://www.healthline.com/health/acute-myocardial-infarction

Hubbard, J. (2003). Complications associated with myocardial infarction. Retrieved October 8, 2021 from
https://cdn.ps.emap.com/wp-content/uploads/sites/3/2003/04/030415Complications-associated-with-myocardial-infarction.pdf

Zafari, A. (2019, May 7). Myocardial Infarction. Retrieved October 8, 2021 from https://emedicine.medscape.com/article/155919-overview#a1