TABLE OF CONTENTS

I. INTRODUCTION..

II. PHYSICAL ASSESSMENT.

III. PATHOPHYSIOLOGY..

ETIOLOGY..

RISK FACTORS..

SYMPTOMATOLOGY..

SCHEMATIC DIAGRAM..

DISEASE PROCESS..

IV. MANAGEMENT.

A. DIAGNOSTICS..

B. PHARMACOLOGICAL.

C. SURGICAL.

D. NURSING DIAGNOSIS..

V. PROGNOSIS..

VI. DISCHARGE PLANNING..

VII. RELATED NURSING THEORIES..

VIII. REVIEW OF RELATED LITERATURE..

REFERENCES:
I. INTRODUCTION

Emergency Nursing is a specialized field in professional nursing that plays one of

the most critical roles in a hospital setting. When it comes to emergency room nurses,
they are considered the ace of hearts in a deck stacked with a whole team of medical
professionals as they are the frontline of triage and treatment for patients with
everything from mild colds to extreme conditions. Working in a fast-paced setting and
often stressful environments, an emergency room nurse's duties are vast and cover a
lot of ground which requires them to execute quickly and cohesively. An emergency
room nurse prioritizes care based on the critical nature and severity of a patient's
conditions. It is essential for an emergency room nurse to think critically and quickly,
have an immense amount of knowledge, pays attention to details, comprehensively
assess patients, have strong decision-making abilities, and an efficient multi-tasker as
they face life-threatening conditions they seek to improve and save a life.

One of the conditions that an emergency room nurse often encounters are
patients experiencing a "heart attack," or also known as a myocardial infarction.
Myocardial infarction where "myo" means muscle, "cardial" refers to the heart, and
"infarction" means death to tissue due to lack of blood supply, is a condition where one
of the heart's coronary arteries is suddenly blocked or has extremely slow blood flow
(Harvard Health Publishing, 2019). The sudden blockage of blood flow in the heart will
result in an inadequate blood flow, where the heart muscles will not be able to get
enough nutrients and oxygen that it needs to function.

Myocardial infarction has two clinical settings- ST-segment elevation myocardial

infarction (STEMI) and non-ST-segment elevation myocardial infarction (NSTEMI)
(Chadwick Jayaraj, J., Davatyan, K., Subramanian, S., & Priya, J., 2019). STEMI results
form complete and prolonged occlusion of an epicardial coronary blood vessel and are
defined based on ECG criteria, while NSTEMI usually results from severe coronary
artery narrowing, transient occlusion, or microembolization. Our case analysis focused
on tackling non-ST-segment elevation myocardial infarction (NSTEMI), which is defined
as an elevation of cardiac biomarkers in the absence of ST-elevation and accounted for
around 30% of all heart attacks (Ali, Y., 2020).

Globally, myocardial infarction is responsible for over 15% of mortality each year,
among the vast majority of people suffering from non-ST-segment elevation myocardial
infarction than ST-segment elevation myocardial infarction where the prevalence of
myocardial infarction is higher in men in all age-specific groups than women (Chadwick
Jayaraj, J., Davatyan, K., Subramanian, S., & Priya, J., 2019). In the United States,
approximately 1.5 million cases of myocardial infarction occur annually; the yearly
incidence rate is approximately 600 cases per 100,000 people. The proportion of
patients diagnosed with NSTEMI compared with STEMI has progressively increased
(Zafari, A., 2019). According to the latest WHO data published in 2018, the Philippines
reached 120,800 or 19.83% of total deaths caused by coronary heart diseases. Locally,
in 2017, Davao City held the highest number of heart disease cases in the Philippines'
Davao Region, amounting to nearly 1,700 (Statista Research Department, 2021).

This case analysis can bring about several implications. For nursing education,
the case analysis will hopefully provide the student nurses sufficient knowledge about
Myocardial Infarction, specifically non-ST-segment elevation myocardial infarction
(NSTEMI), especially its management and treatments. Hopefully, this case analysis will
also help the student nurses provide clear, concise, complete, and accurate health
teachings not only to the patient but also to their families. For the nursing practice, may
this case analysis broaden and hone the student nurses' skills in acting in emergency
situations, particularly in dealing with patients experiencing a myocardial infarction.
Additionally, may it serve as a guide in delivering outstanding services, management,
and intervention in patients to help them meet their needs and also provide an
opportunity to perceive the role of an emergency nurse in delivering quality nursing care
and interventions that are suitable and appropriate to the patients experiencing the
same condition. Lastly, for nursing research, may this case analysis serve as a guide in
conducting future related studies and finding related concepts. Furthermore, may this
case analysis serve as a reference for future research in the pursuit of elevating the
standards of nursing care.
Goals and Objectives

General Objective:

At the end of Emergency Nursing Rotation, we will be able to have a

comprehensive case analysis that will enable us to broaden our knowledge about the
factors affecting the client’s condition and acquire new skills to apply to our clients with
the same condition in the future.

Specific Objectives:

In order to achieve the general objectives, we specifically aim to:

a. Present the concept and the statistical data of myocardial infarction

through the introduction;
b. Determine the general and specific objectives of the case analysis;
c. Provide the definition of the disease;
d. Present the anatomy of the affected site;
e. Determine the etiology of the disease;
f. Identify the signs and symptoms;
g. Illustrate the pathophysiology of non-ST-segment elevation myocardial
infarction through a schematic diagram;
h. Examine the disease process;
i. Specify the laboratory and diagnostic procedures;
j. Enumerate the possible medical management of myocardial infarction;
k. Discuss the surgical management of the disease;
l. Propose nursing management of the disease;
m. Determine the prognosis of non-ST-segment elevation myocardial
infarction;
n. Discuss the discharging plan for the patient;
o. Relate nursing theories to the disease;
p. Gather the review of related literature; and
 q. Cite references in APA format.

II. PHYSICAL ASSESSMENT

Physical Assessment I

General

Patients with myocardial infarction, may have varying symptoms present. Some
patients may exhibit normal diagnostic results while others may experience pressure-
like substernal pain that occurs while they’re at rest or with slight exertion. The pain may
radiate towards the patient’s neck, the shoulder, jaws, and the left arm. Their vital signs
may exhibit increases in heart rate, blood pressure, respiratory rates, and temperature.
Paleness and diaphoresis is also noted on patients with ongoing symptoms.

Skin

The patient’s become cold and clammy during a circulatory crisis due to the
decrease in blood flow to the peripheries because the body redirects more blood
towards the vital organs.

Nails

Nails may appear cyanotic due to the lack of oxygen circulating upon the occurrence of
myocardial infarction.

Physical Assessment II

Thorax

Rales or wheezes may be heard upon auscultation, indicating the occurrence of

secondary to pulmonary venous hypertension. Unilateral or bilateral pleural effusions
may also produce egophony at the base of the lungs.

Abdomen
 Tricuspid incompetence may develop, along with hepatojugular reflux that may
be elicited. Moreover, a detectable pulse may be palpated in the abdominal mass,
indicating the presence of an abdominal aortic aneurysm.

Heart

Due to portal hypertension, increased heart rate and increased blood pressure may be
manifested by the patient as the cirrhosis puts stress on the portal vein.

Back and Extremities

Peripheral cyanosis, edema, pallor, diminished pulse volume, delayed rise, and
delayed capillary refill may occur due to vasoconstriction, diminished cardiac output,
and right ventricular failure.

Physical Assessment III

Depending on the amount of time before a patient is revived after a myocardial

infarction, the longer it is before resuscitation is performed, the more likely brain
damage is likely to occur due to the stasis and halt in oxygen supply to the organs,
especially the brain. Patient may become confused, paralyzed (temporary or
permanent), or worse, death if no due intervention is done.

ANATOMY AND PHYSIOLOGY

HEART - The heart is the key organ of the

cardiovascular system – the body’s
transport system for blood. A muscle that
contracts rhythmically and autonomously, it
works in conjunction with an extensive
network of blood vessels running
throughout the body. Basically, the heart is a pump ensuring the continuous circulation of blood
in the body.

PARTS OF THE HEART

AORTA - The aorta is the largest artery in the body. The aorta begins at the top of the left
ventricle, the heart's muscular pumping chamber. It takes oxygenated blood from the left
ventricle to the body.

SUPERIOR VENA CAVA – The superior vena cava is one of the two main veins bringing
deoxygenated 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 a large vein that carries deoxygenated
blood from the lower body to the heart.

PULMONARY ARTERY – Carries deoxygenated blood from the right ventricles to the lungs.

PULMONARY VEIN – Takes oxygenated blood from the lungs to the left atrium.

LEFT ATRIUM – Oxygen-rich blood from the lungs enters the left atrium through the
pulmonary vein.

RIGHT ATRIUM – Receives deoxygenated blood from the body

LEFT VENTRICLE – Receives oxygenated blood from the left atrium via the mitral valve and
pumps it through the aorta

RIGHT VENTRICLE – The chamber within the heart that is responsible for pumping oxygen-
depleted blood to the lungs

TRICUSPID VALVE – The function of the tricuspid valve, or right atrioventricular valve, is to
prevent backflow of blood into the right atrium.
BICUSPID VALVE - The bicuspid valve, or mitral valve, permits blood to flow one way only,
from the left atrium into the left ventricle.

PULMONARY VALVE – This valve is opened by the increased blood pressure of the ventricular
systole (contraction of the muscular tissue), pushing blood out of the heart and into the artery. It
closes when the pressure drops inside the heart.

AORTIC VALVE – The aortic valve functions to prevent the regurgitation of blood from the
aorta into the left ventricle during ventricular diastole and to allow the appropriate flow of blood –
the cardiac output – from the left ventricle into the aorta during ventricular systole.

III. PATHOPHYSIOLOGY..

ETIOLOGY

Predisposing Factors Rationale

Aging comes with physiological changes. This

Age
includes changes in the heart and blood vessels.

(>65 years old) Overtime, fatty deposits accumulate in the walls of

arteries causing blockage of blood flow to the heart.
Moreover, as people age, large arteries also tend to
stiffen resulting in high blood pressure which is also a
factor in developing myocardial infarction (National
Institute on Aging, 2018).

According to the American Heart Association (AHA),

Race and ethnicity
 research has shown that they are more sensitive to
(African-American)
salt thus they easily develop high blood pressure.
Moreover, they have greater prevalence of other
factors for heart diseases such as obesity and high
cholesterol, as compared to other races hence they
are more susceptible to develop heart attack (Black
Women’s Health Imperative, 2021)

Family History/ A study in The New England Journal of Medicine has

Genetics traced 50 known genetic markers of heart disease
risk. It also revealed that individuals with these genes
have a 50% chance of having a heart attack. As we
know, genes are passed on to families. However, it is
also likely that people with a family history of heart
disease share common environments and other
factors thereby increasing risk (Tischler, 2017).

Precipitating Factors Rationale

It is a condition wherein the coronary arteries are

History of coronary
blocked by cholesterol or other fatty substances. Since
artery disease
the coronary arteries supply blood to the myocardium,
any blockage or narrowing can reduce blood flow
resulting in insufficient blood supply to the heart
muscles. Consequently, it will not function accordingly
(Newman, 2021).

According to the American Heart Association (2016),

High blood pressure
high blood pressure exhausts the arteries and
 accelerates the buildup of plaque. Furthermore, blood
clot formation is possible as the arteries continue to
harden. Because of these accumulations, there will be
an interruption in the blood flow to the heart depriving
its muscles of nutrients and oxygen leading to
myocardial infarction.

High cholesterol level Cholesterol, specifically the low-density lipoproteins

(LDL) have a tendency to adhere to the arterial walls.
This would result to a buildup of fatty deposits
eventually obstructing circulation to the heart muscles
(Pietrangelo, 2020).

Diabetes According to Centers for Disease Control and

Prevention (2020), high blood sugar can damage the
inner linings of the arteries. Eventually, this can harden
the arteries which would make it harder for the blood to
reach the different parts of the body including the heart.

Obesity can exacerbate low-density lipoproteins and

Obesity
triglyceride levels and it is also highly associated with
diabetes. In addition, they are prone to increased blood
pressure because they need more blood to supply
oxygen and nutrients to their bodies which requires
more pressure to the circulation (Penn Medicine, 2019).

A cigarette has more than 4,000 harmful chemicals;

Lifestyle
one of its effects is the narrowing of the blood vessels

(Smoking, alcohol) which eventually impedes blood flow to the cardiac

muscles. Moreover, heavy alcohol consumption can
cause high blood pressure. In the long run, both can
 worsen the vasculature of the heart increasing risk for
myocardial infarction (Stanley, 2017).

Sedentary lifestyle Being physically inactive slows down the circulation

leading to build up of fatty materials in the arteries.
Furthermore, it significantly reduces the body’s ability to
break down fat in the blood, increasing risk for several
heart diseases including heart attack (Beaumont
Health, 2018).

SYMPTOMATOLOGY

Signs and Symptoms Rationale

The coronary arteries supply blood to the cardiac

Chest pain (Angina)
muscle. When the blood flow is blocked by a blood
clot or plaque, it will lead to heart attack. Chest pain
in a heart attack is the direct result of the death of
cardiac muscle due to loss of blood supply
(Stoppler, 2021).

Oxygen exchange happens in the lungs. In the

Dyspnea
case of myocardial infarction, since the cardiac
muscle is deprived of blood supply, its pumping
action is also decreased hence it cannot pump
blood well to the lungs for oxygen exchange
(Krans, 2020). Moreover, it can cause decreased
cardiac output and increased pulmonary venous
pressure. This results to the leakage of fluid into
 the interstitial space and lung alveoli causing
pulmonary congestion which reduces pulmonary
compliance and impairs the ease of breathing
(Kupper et al., 2016).

The diaphragm and accessory nerves nearby can

Pain or irritation in the
become irritated during a myocardial infarction,
neck , jaw, stomach,
thus discomfort or pain radiating to the areas near
and shoulders or back
the heart (Spader, 2021).

As portions of cardiac muscles die, it releases

Nausea and vomiting
chemicals. The part of the vagus nerve attached to
the heart becomes stimulated by these chemicals.
Moreover, the vagus nerve also runs through the
gastrointestinal tract, hence a possibility of a signal
being passed to the hindbrain to produce nausea.
Furthermore, since the hindbrain was stimulated
that something must be expelled from the digestive
tract, it will send a signal to several parts of the
digestive system resulting to vomiting (Cheprasov,
2018).

During myocardial infarction, the heart cannot

Dizziness
pump blood adequately resulting in poor circulation
to various parts of the body including the brain
hence changes in consciousness (Nunez, 2019).

Diaphoresis When the arteries supplying the heart are blocked,

pumping requires extra effort. To keep the body
temperature down during this excessive exertion,
the body sweats profusely (Krans, 2020).
 The heart is put under a lot of stress due to the
Fatigue
excessive effort of pumping blood despite a
blocked coronary artery. Moreover, since the heart
cannot pump blood efficiently to the rest of the
body, the tissues and muscles cannot get enough
oxygen depriving them of energy, causing
weakness (Krans, 2020).

Since an artery supplying the cardiac muscle is

Rapid irregular
blocked, the heart will receive less blood, thus less
heartbeat
cardiac oxygen supply. To compensate, the heart
will beat faster to meet the high cardiac demand
(Roland, 2020).

SCHEMATIC DIAGRAM

DISEASE PROCESS

IV. MANAGEMENT

A. Laboratory Tests

Laboratory tests are medical devices intended for use on samples of blood,
urine, or other substances taken from the body (FDA, 2018). Some of the laboratory
tests that are indicative of Myocardial Infarction includes:

1. Cardiac Troponin Test (Troponin T and Troponin I)

Cardiac Troponins are regulatory proteins within the myocardium that are
released into the circulation when damage to the myocyte has occurred. Serum
troponin is an exquisite sensitive marker of myocardial injury and is necessary for
establishing the diagnosis of myocardial infarction. Troponin I is extremely
specific for the cardiac muscle and absolute specificity makes it an ideal marker
of myocardial injury. They are released into the circulation 6-8 hours after
 myocardial injury, peak at 12-24 hours, and remain elevated for 7-10 days
(Mythili and Malathi, 2015). These High-Sensitivity troponin assays improve the
diagnostic accuracy and rapid detection of myocardial infarction. Early
identification of myocardial infarction is vital to the management of MI to limit
myocardial damage and the preservation of cardiac function (Daubert &
Jeremias, 2010).

Definition/ Rationale Usual Findings Nursing Responsibilities

A Troponin Test measures Cardiac troponin levels for Pre-procedure:

the levels of troponin T or
troponin I proteins in the
blood. These proteins are
released when the heart
muscles have been
damaged, such as with a
heart attack. The more
damage there is to the
heart, the greater the
amount of Troponin T and I ng/mL
there will be in the blood.
Troponin T and Troponin I 1. Explain the
are normally so low that most procedure to the
blood tests are not able to client
detect it. 2. Inform the client
that a slight sting
Normal Values : may be felt from
Cardiac troponin T: < 0.1 the needle
ng/mL
Cardiac troponin I: < 0.03 Post procedure:
3. Resume to regular
activities unless
High Sensitivity cardiac
ordered by a
troponin (hs-ctn): <14ng/mL
physician.
Changes in MI:
Above 0.40 ng/ml
- Even a slight increase
in the troponin level
will often mean there
has been some
damage to the heart.
Very high levels of
troponin are a sign of
an occurrence of
 myocardial infarction
(UCSF Health, 2017)

1. Creatine Kinase- Myocardial Band (CK-MB)

CK-MB is an isoenzyme of Creatine Kinases that is a cardiac-isoenzyme.

It is found mainly in the cardiac cells and increases when there has been
damage to these cells. Elevated CK-MB is an indicator of myocardial infarction.
The level begins to increase within a few hours (4-6 hours) after symptom onset
and peaks within 24 hours of an infarct. However, it returns to normal in 48-72
hours(Hinkle, J. L., & Cheever, K. H., 2018).

Definition/ Rationale Usual Findings Nursing Responsibilities

Pre-procedure:
A significant concentration
Normal Values: 1. Explain the
of CK-MB isoenzyme is
3-5% total CK or 5-25 IU/L procedure to the
found almost exclusively in
client
the myocardium.
2. Inform the client
Disruption of cell
Changes in MI: that a slight sting
membranes due to
Peak CK-MB level ranges may be felt from
myocardial injury releases
from 15-30% CK in post- the needle
CK from the cellular
myocardial infarction.
cytosol into the systemic
Post procedure:
circulation. On this basis, 3. Resume to regular
elevated serum levels of activities unless
ordered by a
CK have been used as a physician.
sensitive but nonspecific
test for myocardial
infarction (Boditech, 2016).
3. Myoglobin Level

Myoglobin is a protein found in cardiac and skeletal muscle that is released more
rapidly from infarcted myocardium than troponin and CK-MD and may be detected as
early as two hours after myocardial infarction. It’s low molecular weight counts for its
early release profile: typically rises 2-4 hours after onset of infarction, peaks at 6-12
hours, and returns to normal within 24-36 hours (Gursahani, 2021). Myoglobin has high
sensitivity but poor specificity. Nonetheless, it is still useful for the early detection of
myocardial infarction.

Definition/ Rationale Usual Findings Nursing Responsibilities

Normal Values: Pre-procedure:

Myoglobin is a heme
25 to 72 ng/mL (1.28 to 3.67 1. Explain the
protein found in the cardiac
nmol/L) procedure to the
muscles that indicates an
client
early marker of Myocardial
Changes in MI: 2. Inform the client
Infarction and is
Increased levels of that a slight sting
considered as the most
myoglobin 25-40% over 1-2 may be felt from
sensitive early marker for
hours, more than the normal the needle
myocardial infarction (Tidy,
value of myoglobin
C., 2019).
Post procedure:
3. Resume to regular
activities unless
ordered by a
physician.
Diagnostic Test
1. 12 Leads Electrocardiogram

Electrocardiogram is a simple, painless test that measures the heart’s electrical

activity. Electrodes (sticky patches) are attached to the chest and limbs. Signals are
recorded as waves displayed on a monitor or printed on paper.

Types of ECG:

 Holter monitor - known as an ambulatory ECG monitor records the heart’s activity
over 24 to 48 hours while the client maintains a diary of activities to help the
doctor identify the cause of symptoms. Electrodes that are attached to the chest
records information on a portable, battery-operated monitor that one can carry in
his pocket, belt, or shoulder strap
 Stress Test- in stress testing, an ECG will be attached while exercising. Typically,
this test is done while on a treadmill or a stationary bicycle such that some heart
problems only appear during exercise.
 Event Recorder- is a portable device that is similar to a Holter monitor but
records only at certain times for a few minutes at a time. It can be worn for 30
days.

Definition/ Rationale Usual Findings (Myocardial Nursing Responsibilities

infarction)

Pre-procedure:
12- Lead ECG is an initial
NSTEMI is diagnosed in 1. Explain the
test that archives the
 patients who have symptoms procedure
images of the heart’s
of elevation in troponin levels 2. In the instance
electrical activity/heart
and CK-MB but without that there are
rhythms. This test aims to
changes in ST elevation hairs on the parts
identify and track the heart
consistent with STEMI (Basit, of the body where
condition such as a
Malike & Huecker, 2021). the electrodes will
myocardial infarction
ECG is used to identify the be attached,
where attached electrodes
type of myocardial infarction. shave the hair so
register the heart’s
that the patches
electrical activity that
will stick.
provides the 12
3. Once the patient
perspectives point of view.
is ready, ask the
client to lie on the
examining table or
bed.
Intra-procedure
4. During the
procedure, attach
12 sensors
(electrodes) in the
chest, wrist and
ankles.
Additionally,
remember to
connect the wires
of the electrodes
to the monitor.
5. Advise the client
that he/she can
breathe normally
during the test but
 he/she should lie
still for
movements,
talking or
shivering may
distort the results.

Post-Procedure:
6. Resume normal
activities unless
ordered by a
physician.

2. Echocardiogram

An echocardiogram allows the physician to check the valves and the four
chambers of the heart and to see certain abnormalities. It is used during and after an
episode of myocardial infarction to know how the heart is pumping and to identify what
areas of the heart are not pumping normally. The echo is also valuable to see if any
structure of the heart has been injured.

Types of Echocardiogram:

 Transthoracic Echocardiogram- a non-invasive and most common type of

echocardiogram. In this type, a transducer is placed on the chest of the patient
which then transmits ultrasound waves in the thorax. These waves bounce off
the structure of the heart, creating images and sounds that are shown on the
monitor.
 Stress echocardiogram: performed while the patient is using a treadmill or
stationary bicycle.
  Transesophageal echocardiogram: a special type of echocardiography that uses
an endoscope to assist the transducer down to the esophagus where it produces
a more detailed image of the heart compared to a transthoracic echocardiogram.
 Dobutamine stress echocardiogram: used for patients who are unable to exercise
on a treadmill. The drug dobutamine is given instead through a vein that
stimulates the heart in a similar manner as exercise. Dobutamine stress
echocardiogram measures the effectiveness of a cardiac therapeutic regimen.

Definition/ Rationale Usual Findings Nursing Responsibilities

Pre-procedure:
Echocardiogram is used to
Echocardiographic evidence 1. Explain the
evaluate ventricular
of regional wall motion procedure to the
function. It may be used to
abnormality (RWMA) is patient
assist in diagnosing a
frequently seen in patients 2. Ensure to empty
myocardial infarction,
with NSTEMI (Bergmann, I., the bladder
especially when the ECG
Büttner, B., Teut, E. et al., 3. Have the patient
is nondiagnostic. The
2018). change into a
echocardiogram can detect
hospital gown.
hypokinetic and akinetic
4. Explain that a
wall motion ( Hinkle, J. L.,
vasodilator (amyl
& Cheever, K. H. , 2018).
nitrate) may be
given.

Intra-procedure:
5. Place the patient
in a supine
position and a
conductive gel is
applied to the third
 or fourth
intercostal space
to the left of the
sternum where
the transducer will
be placed directly.
6. The transducer is
systematically
angled to direct
ultrasonic waves
at specific parts of
the patient’s heart.

Post-procedure:
7. Remove the
conductive gel
from the patient’s
skin
8. Inform the patient
that the study will
be interpreted by
the physician
9. Instruct the patient
to resume regular
diet and activities
unless ordered by
the physician.

3. Coronary Catheterization (angiogram)

 A coronary catheterization, also known as coronary angiogram, is a procedure
that uses x-ray imaging to see the heart’s blood vessels. The test is generally done to
see if there’s a restriction in blood flow going to the heart (Mayo Clinic, 2020). The
imaging procedure provides visualization of the heart that aids physicians to evaluate
and diagnose coronary heart diseases. In coronary catheterization, a liquid dye is
injected into the arteries of the heart through a long, thin tube (catheter) that is fed
through an artery (usually in the legs or groin) into the arteries of the heart.

Definition/ Rationale Usual Findings Nursing

Responsibilities/Procedure

1. Obtain an informed
Coronary Catheterization/
Blockage in the coronary consent
Coronary Angiograms
artery is common in 2. Assess for any history
provide visualization of the
patients with myocardial of allergies to contrast
arteries through the
infarction. dye/ iodinated dye.
inserted liquid dye in order
3. Explain the procedure
to reveal areas of blockage
to the client. The
in the arteries.
doctor will order the
patient to not eat or
drink anything for at
least 6 hours before
the test.
4. Make sure that the
patient’s bladder is
empty.
5. Check the blood
pressure and the
pulse of the patient.

Intra-procedure.
6. Hair from the site
 where the catheter will
be inserted will be
shaved. Before the
insertion, the patient
is given a shot of
anesthetic to numb
the area.
7. After numbing, the
catheter will be
inserted. A small cut
is made to access an
artery
8. If the patient is awake
during the procedure,
he will be asked to
take deep breaths,
hold his breath, cough
or place the arms in
various positions
throughout the
procedure.

Post procedure:
9. The patient will spend
several hours in the
recovery room until
anesthesia wears off.
Once done, he will be
transferred to a
regular hospital or
outpatient room.
 10. Advice the patient that
he/she may be able to
eat and drink after the
procedure unless
ordered otherwise.

4. Cardiovascular magnetic resonance (CMR) and Cardiac CT-Scan

Cardiovascular magnetic resonance produces detailed images of the beating

heart. The test aids doctors to study the structure and function of the heart muscle or
identify tissue damage due to myocardial infarction (UChicago Medicine, n.d.). It
provides the opportunity for a truly comprehensive evaluation of patients with a history
of myocardial infarction, with regards to characterizing the extent of disease, impact on
LV function, and degree of viable myocardium. The use of contrast-enhanced CMR is a
powerful technique for delineating areas of infarction and obtains information about the
acuity of an infarct (West, A. M., & Kramer, C. M.,2010).

Definition/ Rationale Usual Findings Nursing Responsibilities

Acute MI: wall thickening and Pre-procedure:

Cardiac MRI and CT
myocardial edema 1. Inform the patient
produce digital
about the
photographs of the heart.
Chronic MI: wall thinning and procedure.
Cardiac MRI uses a
regional wall-motion 2. Obtain an
magnetic field and radio
abnormalities in the affected informed consent
waves to create images of
territory 3. Assess for any
the heart, while Cardiac CT
history of allergies
scans use X-rays.
to contrast dye/
iodinated dye.
4. Instruct the patient
to not eat or drink
 for a period of
time especially if a
contrast material
will be used.
5. Instruct the patient
to remove any
metal objects
attached to the
body such as
jewelry and other
accessories
6. Instruct patients to
change into a
hospital gown.
Intra-procedure:
7. Instruct the patient
to remain calm
and still during the
procedure and to
report immediately
if there are
symptoms of
itching, difficulty in
breathing,
nausea, vomiting,
dizziness or
headache.
Post- Procedure:
8. Encourage the
patient to increase
fluid intake to
 promote flushing
of the dye.
9. Instruct to resume
to usual diet and
activities unless
ordered
otherwise.

B. PHARMACOLOGICAL MANAGEMENT

DRUG: ISOSORBIDE MONONITRATE

Generic Name Isosorbide Mononitrate

Brand Name Imdur, Imdur ER, Ismo,

Monoket

·
Drug
Classification PHARMACOTHERAPEU
TIC: Nitrate
· CLINICAL:
Antianginal
· Pregnancy Category
C

· Stimulates intracellular cyclic guanosine monophosphate.

Mode of Action
· Produce vasodilation (venous greater than arterial).
· Decrease left ventricular end-diastolic pressure and left
ventricular end-diastolic volume (preload). Net effect is reduced
myocardial oxygen consumption. Increase coronary blood flow
 by dilating coronary arteries and improving collateral flow to
ischemic regions.
· Therapeutic Effect: Relaxes vascular smooth muscle of
arterial, venous vasculature. Decreases preload, afterload,
cardiac oxygen demand. Prevention of anginal attacks.

Dosage and Angina

Route

· PO (Isosorbide Mononitrate) (Immediate-Release):

ADULTS, ELDERLY: 20 mg twice daily given 7 hrs apart to
decrease tolerance development. In pts with small stature, may
start at 5 mg twice daily and titrate to at least 10 mg twice daily
in the first 2–3 days of therapy.
· (Sustained-Release): Initially, 30–60 mg/day in morning as
a single dose. May increase dose at 3-day intervals to 120 mg
once daily.
· Maximum daily single dose: 240 mg.

Dosage in Renal/Hepatic Impairment

· No dose adjustment.

· Prophylactic management of angina pectoris.

Indications
· Unlabeled Use: Treatment of chronic heart failure
(unlabeled).

· Hypersensitivity to nitrates, concurrent use of sildenafil,

Contraindicatio
ns tadalafil, vardenafil.
· Cautions: Inferior wall MI, head trauma, increased
intracranial pressure (ICP), orthostatic hypotension, blood
volume depletion from diuretic therapy, systolic B/P less than
90 mm Hg, hypertrophic cardiomyopathy, alcohol consumption,
 right ventricular infarction; OB: May compromise maternal/fetal
circulation; Lactation: No data available; Pedi: Safety not
established; Geri: Initial dose decreased required due to
increased potential for hypotension.

· Frequent: Headache (may be severe) occurs mostly in

Side Effects
early therapy, diminishes rapidly in intensity, usually disappears
during continued treatment.
· Occasional: Transient flushing of face/ neck, dizziness,
weakness, orthostatic hypotension, nausea, vomiting,
restlessness. GI upset, blurred vision, dry mouth.
· Sublingual: Frequent: Burning, tingling at oral point of
dissolution.

· Discontinue if blurred vision occurs. Severe orthostatic

Adverse
Effects hypotension manifested by syncope, pulselessness,
cold/clammy skin, diaphoresis has been reported. Tolerance
may occur with repeated, prolonged therapy, but may not occur
with extended-release form. Minor tolerance with intermittent
use of sublingual tablets. High dosage tends to produce severe
headaches.

· DRUG: Alcohol, antihypertensives (e.g., Amlodipine,

Drug
Interactions lisinopril, valsartan) may increase risk of orthostatic
hypotension. Sildenafil, tadalafil, vardenafil may potentiate
hypotensive effects (concurrent use of these agents is
contraindicated).
· HERBAL: None significant.
· FOOD: None known.
· LAB VALUES: May increase urine catecholamine, urine
vanillylmandelic acid levels.
 1. Instruct patient to take medication as directed, even if feeling
Nursing
Responsibilitie better. Do not discontinue abruptly.
s R: Sudden discontinuation may lead to more severe effects.
2. Instruct patient not to take with erectile dysfunction
medicine.
R: Taking these medications together may cause a sudden and
serious decrease in blood pressure.
3. Instruct patient to rest or stay seated while taking the
medication. Advise patient to avoid activities which require
alertness such as driving.
R: May cause dizziness or fainting.
4. Tell patient not to crush, chew, or break if the medication is
an extended-release tablet. Let them swallow it whole.
R: The medication will not be as effective.
5. Caution patient to make position changes slowly.
R: To minimize orthostatic hypotension.
6. Instruct patient to take last dose of day (when taking 2–4
doses/day) no later than 7 pm.
R: To prevent the development of tolerance.
7. Doses of isosorbide dinitrate should be taken at least 2 hr
apart (6 hr with extended-release preparations); daily doses of
isosorbide mononitrate should be taken 7 hour apart. Do not
double doses.

R: To prevent overdose.
8. Instruct patient to take Aspirin or Acetaminophen for
headache.

R: Headaches may occur due to high doses.

 9. Advise patient not to take alcohol while on medication.
R: Increases hypostatic effect.
10. Monitor client’s blood pressure before and after giving the
medication.

R: Isosorbide Mononitrate is likely to cause hypotension.

DRUG: BISPROLOL

Generic Name Bisprolol

Brand Name Apo-Bisprolol, Novo

Bisprolol, Zebeta

· Beta 1-adrenergic
Drug
Classification blocker
· Antihypertensive

· Blocks beta1-adrenergic receptors of sympathetic

Mode of Action
nervous system in heart and kidney, thereby decreasing
myocardial excitability, myocardial oxygen consumption,
cardiac output, and renin release from kidney. Also lowers
blood pressure without affecting beta2-adrenergic
(pulmonary, vascular, and uterine) receptor sit
Dosage and Route Hypertension
PO: ADULTS, ELDERLY: Initially, 2.5–5 mg once
daily. May increase to 10 mg, then to 20 mg once
daily.

Usual dose: 5–10 mg once daily.

Dosage in Renal Impairment

ADULTS, ELDERLY: CrCl less than 40 mL/min:

Initially, give 2.5 mg.

Dosage in Hepatic Impairment

Cirrhosis, Hepatitis: Initially, 2.5 mg.

· Hypertension
Indications
· Renal or hepatic impairment

· Hypersensitivity to drug
Contraindications
· Sinus bradycardia

· Second- or third-degree heart block

· Cardiogenic shock

· Heart failure

· Children (safety and efficacy not established)

 · CNS: Insomnia, fatigue, dizziness CV: Bradycardia, HF,
Side Effects postural hypotension, peripheral edema, cold extremities

· EENT: Blurred vision, dry mouth

· ENDO: Hypoglycemia

· GI: Nausea, diarrhea, vomiting, constipation

· INTEG: Rash

· RESP: Dyspnea, cough

· GU: Erectile dysfunction, decreased libido, urinary

frequency

· Overdose may produce profound bradycardia,

Adverse Effects hypotension.

· Abrupt withdrawal may result in diaphoresis, palpitations,

headache, tremors.

· May precipitate HF, MI in pts with cardiac disease,

thyroid storm in pts with thyrotoxicosis, peripheral ischemia
in those with existing peripheral vascular disease.

· Hypoglycemia may occur in previously controlled

diabetes.

· Thrombocytopenia, unusual bruising/bleeding occur

rarely.
 · Increase: myocardial depression—calcium channel
Drug Interactions blockers, phenytoin (IV) verapamil

· Increase: antihypertensive effect—ACE inhibitors, α-

blockers, calcium channel blockers, diuretics, nitrates

· Increase: bradycardia—digoxin, amiodarone clonidine,

diltiazem, verapamil

· Increase: antidiabetic effect—antidiabetics; may mask

hypoglycemic symptoms

Drug/Herb
· Increase: β-blocking effect—hawthorn

· Decrease: β-blocking effect—ephedra

 1. Not to discontinue product abruptly, taper over 1 week.
Nursing
Responsibilities R: may cause precipitate angina, rebound hypertension;
evaluate noncompliance

2. Not to use OTC products that contain α-adrenergic stimulants

(e.g., nasal decongestants, OTC cold preparations) unless
directed by prescriber.

R: beta-blockers enhance the effects of α-adrenergic stimulants,

which can lead to constriction of blood vessels and an increase
in blood pressure.

3. Monitor excessive fatigue or weakness.

R: beta blockers often cause some degree of fatigue and

weakness, but any sudden or severe change in muscle strength
or energy levels should be reported

4. Instruct patient too avoid alcohol, smoking; to limit sodium

intake.

R: alcohol causes blood pressure to decrease and may cause

fainting or dizziness.

5. To avoid hazardous activities if dizziness is present.

R: dizziness or lightheadedness are the common side effects of

beta-blockers.

6. To avoid other salicylates unless directed by prescriber; not to

give to children, possibility of Reye’s syndrome.

R: salicylates reduce the effects of bisoprolol in lowering your

blood pressure.

7. If patient has diabetes, monitor closely for signs of

hypoglycemia.

R: Bisoprolol can mask the signs of low blood sugar.

 8. If patient has hyperthyroidism, watch for tachycardia and
hypertension.

R: Bisoprolol can mask the signs of low blood sugar.

9. Instruct patient to avoid sudden position changes and to rise

slowly from a lying or sitting position.

R: minimize the effects of orthostatic hypotension.

10. Advise patient to avoid driving and other activities that

require mental alertness.

R: avoid until the effects of Bisoprolol has been established.

DRUG: STREPTOKINASE

Generic Name Streptokinase

Brand Name Kabikinase, Streptase

Therapeutic:
Drug Thrombolytics
Classification Pharmacologic:
Plasminogen Activators

Mode of Action Combines with Plasminogen to form activators complexes,

then converts plasminogen to plasmin, which is then able
to degrade clot-bound fibrin. Therapeutic Effects: Lysis of
thrombi in coronary arteries, with preservation of ventricular
function. Lysis of pulmonary emboli and subsequent
restoration of blood flow. Restoration of cannula patency
and function.
Dosage and Route Pulmonary Embolism, Deep Vein Thrombosis, Arterial
Thrombosis or Embolism

· A dose of 250,000 IU of streptokinase infused into a

peripheral vein over 30 minutes

Arteriovenous Cannulae Occlusion

· Instill 250,000 IU streptokinase in 2ml of solution in

each occluded limp of the cannula slowly

· Acute Myocardial Infarction (MI), Pulmonary

Indications
Embolism (PE), Deep Vein Thrombosis (DVT), Acute
Peripheral Arterial Thrombosis and Occluded
Arteriovenous Cannulae.

Contraindications Active Internal Bleeding, recent (within 2 months)

cerebrovascular accident, intracranial or intraspinal
surgery, intracranial neoplasm, severe uncontrolled
hypertension and patients with severe allergic reaction to
streptokinase.

Vomiting, nausea, flushing, urticaria, bleeding, hemorrhage at

Side Effects injection side, phlebitis at injection site, musculoskeletal pain,
allergic reactions and fever.

Adverse Effects Intracranial Hemorrhage, epistaxis, gingival bleeding,

bronchospasm, hemoptysis, reperfusion arrhythmias,
hypotension, recurrent ischemia/thromboembolism, GI
bleeding, hepatotoxicity, retroperitoneal bleeding, GU
bleeding, ecchymosis and anaphylaxis.
Drug Interactions Use of Anticoagulant and Antiplatelet Agents
· May cause bleeding complications

Aminocaproic acid
· Reverses the action of streptokinase

1. Monitor patient’s blood pressure

Nursing
Responsibilities R: Mild changes is expected when taking streptokinase
however if there is substantial change, therapy may be
discontinued.
2. Monitor patient’s temperature during treatment
R: A slight elevation about in the temperature, perhaps
with chills can occur and high elevations should be
treated immediately.
3. Protect patient from invasive procedures such as IM
injections and undue manipulation during thrombolytic
therapy
R: To prevent unnecessary bruising and bleeding
4. Check patient’s cardiac monitor frequently
R: Changes in cardiac rhythm could happen especially
during intracoronary instillation. Dysrhythmias signals
discontinuation of therapy.
5. Advise the patient to report symptoms of major
allergic reactions.
R: Occurrence of allergy is a signal to discontinue
therapy and emergency treatment should be instituted
immediately.
6. Continuous Monitoring of vital signs until laboratory
tests confirms anticoagulant control.
R: Patient is at risk for post thrombolytic bleeding for 2-4
days after intracoronary streptokinase treatment.
 7. Avoid giving the patient aspirin.
R: Aspirin has antiplatelet action and could cause
negative interaction to streptokinase.
8. Advise the patient to report signs of potential serious
bleeding: gum bleeding, epistaxis, hematoma,
spontaneous ecchymoses, oozing at catheter site,
increased pulse and pain from internal bleeding.
R: If signs of bleeding occur, the infusion of
Streptokinase is interrupted then resumed if bleeding
stops.
9. Watch for neurological alterations such as change in
mental status, level of consciousness, seizures,
hemiparesis/hemiplegia and changes in pupils.
R: May indicate cerebral hemorrhage.
10. Assess any muscle of joint pain.
R: Assessment is done in order to rule out
musculoskeletal pathology or hemorrhage. It is also
done to determine if pain is drug induced rather than
caused by anatomic or biomechanical problems. Be
aware of back pain for it could indicate retroperitoneal
bleeding.

DRUG: MORPHINE

Generic Name Morphine

Brand Name Kadian

 ·
Drug Classification
PHARMACOTHERAPEUTIC:
Opioid Agonist
· CLINICAL: Opioid
Analgesic

Mode of Action Binds with opioid receptors within CNS, inhibiting ascending
pain pathways.

IV
Dosage and Route Reconstitution • May give undiluted. • For IV injection, may dilute in
Sterile Water for Injection or 0.9% NaCl to final concentration of 1–2
mg/ml. • For continuous IV infusion, dilute to concen- tration of 0.1–1
mg/ml in D5W and give through controlled infusion device. Rate of
Administration • Always ad- minister very slowly. Rapid IV increases
risk of severe adverse reactions (apnea, chest wall rigidity, peripheral
circulatory collapse, cardiac arrest, anaphylactoid effects).
Storage • Store at room temperature.

IM, Subcutaneous
• Administer slowly, rotating injection sites. • Pts with circulatory
impairment experience higher risk of overdosage due to delayed
absorption of repeated admin- istration.

PO
• May give without regard to food. • Mix liquid form with fruit juice to
im- prove taste. • Do not break, crush, dis- solve, or divide extended-
release cap- sule, tablets. • Avinza, Kadian: May mix with
applesauce immediately prior to administration.

Rectal
• If suppository is too soft, chill for 30 min in refrigerator or run cold
 water over foil wrapper. • Moisten supposi- tory with cold water
before inserting well into rectum.
IV INCOMPATIBILITIES
Amphotericin B complex (Abelcet, AmBi- some, Amphotec), cefepime
(Maxipime), doxorubicin (Doxil), phenytoin (Dilantin).

IV COMPATIBILITIES
Amiodarone (Cordarone), atropine, bu- metanide (Bumex),
bupivacaine (Mar- caine, Sensorcaine), dexmedetomidine

Indications Relief of moderate to severe, acute, or chronic pain; analgesia

during labor. Drug of choice for pain due to MI, dys- pnea from
pulmonary edema not result- ing from chemical respiratory
irritant. Infumorph: Use in devices for managing intractable
chronic pain. Extended- release: Use only when repeated
doses for extended periods of time are re- quired.

All Formulations: Hypersensitivity to morphine. Acute or severe

Contraindications asthma, GI obstruction, known or suspected paralytic ileus, severe
hepatic/renal impairment, severe respiratory depression. Extended-
Release: GI obstruction, acute postoperative pain, hypercarbia.
Injection: HF due to lung disease; arrhythmias, head injury, seizures,
acute alcoholism. Labor when premature birth expected. Increased
intracranial pressure. Immediate-Release (Tablets, Oral
Solution):Hypercarbia. Extreme Caution: COPD, cor pulmonale,
hypoxia, hypercapnia, preexisting respiratory depression, head injury,
increased ICP, severe hypotension. Cautions: Biliary tract disease,
pancreatitis, Addison’s disease, cardiovascular disease, morbid
obesity, adrenal insufficiency, elderly, hypothyroidism, urethral
stricture, prostatic hyperplasia, debilitated pts, pts with CNS
depression, toxic psychosis, seizure disorders, alcoholism.
 Ambulatory pts, pts not in severe pain may experience nausea, vom-
Side Effects iting more frequently than pts in supine position or who have severe
pain. Fre- quent: Sedation, decreased B/P (includ- ing orthostatic
hypotension), diaphoresis, facial flushing, constipation, dizziness,
drowsiness, nausea, vomiting. Occa- sional:
Allergicreaction(rash,pruritus), dyspnea, confusion, palpitations, trem-
ors, urinary retention, abdominal cramps, vision changes, dry mouth,
headache, de- creased appetite, pain/burning at injec- tion site. Rare:
Paralytic ileus.

Overdose results in respiratory depres- sion, skeletal muscle

Adverse Effects flaccidity, cold/ clammy skin, cyanosis, extreme drowsi- ness
progressing to seizures, stupor, coma. Tolerance to analgesic effect,
physical dependence may occur with re- peated use. Prolonged
duration of action, cumulative effect may occur in those with
hepatic/renal impairment. Antidote: Naloxone (see Appendix K for
dosage).

DRUG: Alcohol, other CNS depressants may increase CNS effects,

Drug Interactions respiratory depression, hypotension. MAOIs may produce serotonin
syndrome. (Re- duce dosage to 1⁄4 of usual morphine dose).
HERBAL: Gotukola,kavakava, St. John’s wort, valerian may increase
CNS depression.
FOOD: None known.

LAB VALUES: May increase serum amy- lase, lipase.

Nursing Baseline Assessment

Responsibilities
Pt should be in recumbent position before drug is given by
parenteral route.

Assess onset, type, location, duration of pain.

Rationale: Ensures correct route, and dose of the medication

according to the pain description, and whether if the drug is
successful in helping manage the patient’s pain.

Obtain vital signs before giving medication.

Rationale: Morphine is contraindicated in those with low BP,

HR or RR. If respirations are 12/min or less (20/min or less in
children), with- hold medication, contact physician.

Intervention / Evaluation

Monitor vital signs 5–10 min after IV administration, 15–30 min

after subcutaneous, IM.

Be alert for decreased respirations, B/P.

Rationale: Morphine can cause respiratory depression,

bradycardia or other arrhythmias, and fatigue / weakness

Check for adequate voiding. Monitor daily pattern of bowel

activity, stool consistency; avoid constipation.

Rationale: Urinary retention, and constipation is a side effect of

Morphine usage

Initiate deep breathing, coughing exercises, particularly in those

with pulmonary impairment.
Rationale: Helps determine if drug therapy is beneficial in
resolving the anxiety and apprehension associated with
pulmonary edema.

Assess for clinical improvement, record onset of pain relief.

Consult physician if pain relief is not adequate.

Rationale: Indicates drug effectivity, and whether or not further

interventions should be taken.

Patient / Family Teaching

• Discomfort may occur with injection.

Rationale: Prepares the family and patient for administration

• Change positions slowly

Rationale: Avoids orthostatic hypotension.

• Avoid tasks that require alertness, motor skills until response

to drug is established.

Rationale: Provides accurate assessment of the patients motor

function post-administration

• Avoid alcohol, CNS depressants.

 Rationale: This drug interaction may decrease CNS effects,
and induce respiratory depression and / or hypotension

• Tolerance, dependence may occur with prolonged use of high

doses.

Rationale: Health teaching to avoid the risk of possible

addiction.

• Report ineffective pain control, constipation, urinary retention.

Rationale: Allows for the medical team to intervene for

dangerous side effects, or ineffective pharmacotherapy.

DRUG: HEPARIN

Generic Name Heparin

Brand Name Heparin Lock Flush, Hepalean,

Heparin Leo
 · Anticoagulant
Drug
Classification · Pregnancy Category C

Mode of Action Prevents conversion of fibrinogen to fibrin and prothrombin to

thrombin by enhancing inhibitory effects of antithrombin III.

Dosage and Unstable Angina, NSTEMI, Acute Coronary Syndrome

Route
IV Infusion: Adults, Elderly: 80 units/kg bolus (maximum: 4,000
units), then 12

units/kg/hr (maximum: 1,000 units/hr)

Usual Pediatric/Neonatal Dose

IV Infusion: 75 units/kg bolus over 10 min, then initial maintenance

dose of 20 units/kg/hr. Adjust to maintain aPTT of 60-85 sec.

Indications Prevention and treatment of MI, Open heart surgery, disseminated

intravascular clotting syndrome, atrial fibrillation with embolization;
as an anticoagulant in transfusion and dialysis procedures; to
maintain patency of indwelling venipuncture devices; diagnosis,
treatment of disseminated intravascular coagulation (DIC)

Contraindicatio Hypersensitivity to heparin. Severe thrombocytopenia, uncontrolled

ns
active bleeding (unless secondary to disseminated intravascular
coagulation) history of heparin induced thrombocytopenia (HIT),
heparin-induced thrombocytopenia with thrombosis (HITT), or pts
who test positive for HIT antibody consumption, right ventricular
infarction; OB: May compromise maternal/fetal circulation;
Lactation: No data available; Pedi: Safety not established; Geri:
 Initial dose decreased required due to increased potential for
hypotension.

· Occasional: Pruritus, burning (particularly on soles of feet)

Side Effects
caused by vasospastic
· reaction.
· Rare: Pain, cyanosis of extremity 6-10 days after initial
therapy lasting 4-6hrs, hypersensitivity reaction (chills, fever,
pruritus, urticaria, asthma, rhinitis, lacrimination, headache).

Adverse Bleeding complications, ranging from local ecchymoses to major

Effects
hemorrhage.
(cutaneous/GI/genitourinary/intracranial/nasal/oral/pharyngeal/ureth
ral/vaginal bleeding) occur more frequently in high-dose therapy,
intermittent IV infusion, women 60 years and older.

· Drug: Other anticoagulants (e.g., dabigatran, warfarin),

Drug
Interactions platelet aggregation inhibitors (e.g., aspirin, clopidogrel),
thrombolytics (e,g., tissue plasminogen activator) may increase
risk of bleeding
· Herbal: Cat’s claws, dong quai, evening primrose, feverfew,
garlic, ginkgo, ginseng, horse chestnut, red clover have
additional antiplatelet activity
· Food: None known.
· Lab Values: May increase free fatty acids, serum ALT, AST;
aPTT. May decrease serum cholesterol
Nursing - Note for the age of client.
Responsibilitie
Rationale: A higher incidence of bleeding has been reported in
s
women over 60 years of age.

- Advise patient to report any symptoms of unusual bleeding

or bruising to health care professional immediately.
Rationale: A decrease in blood clotting factors usually causes
bleeding and bruising. Defects in blood vessels usually cause
red or purple spots and patches on the skin, rather than
bleeding.

- Instruct patient not to take medications containing aspirin or

NSAIDs while on heparin therapy.
Rationale: Heparins decrease your body's ability to make clots.
NSAIDs can have this same effect. When these two medicines
are taken together, their effects can be increased.

- Caution patient to avoid IM injections and activities leading

to injury and to use a soft toothbrush and electric razor during
heparin therapy.
Rationale: To prevent excessive bleeding or hematoma
formation.

- Advise patient to inform health care professional of

medication regimen prior to treatment or surgery
Rationale: From the medication history, it may be necessary to
advice on stopping or altering medication before an operation.

- Tell patient that product may be withheld during active

bleeding (menstruation), depending on condition.
Rationale: Blood thinners usually do not affect how often you
get your period, but they can increase the flow of blood and
 slightly increase the chance of passing clots during your period.

- Patients on anticoagulant therapy should carry an

identification card with this information at all ties.
Rationale: All patients found ID cards helpful to identify their
doctors, they improved clarity both during and after ward
consultations, patients felt more involved in their own care and
were able to direct their questions appropriately, thereby
improving overall satisfaction, and ultimately patient safety.

- Limit alcohol
Rationale: Alcohol can thin blood and interact with blood
thinners like warfarin, so the safest option is to limit or avoid
alcohol altogether when taking anticoagulant medications.

DRUG: NITROGLYCERIN PATCH

Generic Name Nitroglycerin (Glyceryl

Trinitrate)

Brand Name Nitro-Dur, Tranderm-

Nitro, Trinipatch (CAN)

Drug Nitrate, Antianginal,

Classification
Vasodilator

· The drug interacts with nitrate receptors in the

Mode of Action
vascular smooth-muscle cell membranes. This will
reduce nitroglycerin to nitric oxide, which activates the
enzyme guanylate cyclase resulting to the increase in
intracellular formation of cGMP. Increased cGMP level
 may relax vascular smooth muscle by forcing calcium
out of muscle cells, causing vasodilation. As a result,
this reduces preload and afterload, decreasing
myocardial workload and oxygen demand. It also dilates
coronary arteries, increasing blood flow to ischemic
myocardial tissue

· Transdermal: Adult, Elderly: Initially, 0.2 to 0.4 mg

Dosage and per hour worn for 12 to 14 hours.
Route · For maintenance, 0.1 to 0.8 mg per hour worn for 12
to 14 hours. To prevent tolerance, patch off for 10 to 12
hours.

· Chronic stable angina pectoris

Indications
· Prophylaxis of angina pain

· Hypersensitivity to nitroglycerin or other nitrites

Contraindications
· Allergy to adhesives
· Cardiac tamponade, cardiomyopathy, constrictive
pericarditis
· Severe anemia
· Increased intracranial pressure, cerebral
haemorrhage
· Closed-angle glaucoma

· CNS: Headache, dizziness

Side Effects
· CV: Tachycardia, orthostatic hypotension
· GI: Nausea and vomiting
· INTEG: Pallor, sweating, rash

· CNS: Anxiety, insomnia, syncope

Adverse Effects
· CV: Hypotension, arrhythmias
· GU: Dysuria, impotence, urinary frequency
· HEME: Methemoglobinemia
 · MS: Arthralgia
· INTEG: Contact dermatitis (transdermal forms),
exfoliative dermatitis

Drug Interactions Drug:

· Other antihypertensives (amlodipine, lisinopril,
valsartan), may increase risk of
· orthostatic hypotension.
· Avanafil, sildenafil, tadalafil, vardenafil may increase
risk of fatal hypotension.
· Aspirin may increase nitrate level.

Food:
· Alcohol may increase risk of severe hypotension and
collapse

Herbal:
· Ephedra, ginger, ginseng, and licorice may increase
hypertension
· Black cohosh, goldenseal, and hawthorne may
cause hypotension.

Lab values:
· May increase serum methemoglobin and urine
catecholamine concentrations.
 1. Check vital signs before and every dosage especially
Nursing
Responsibilities blood pressure and pulse.
R: It may cause hypotension that may need immediate
attention.
2. Monitor for side effects such as headache, light-
headedness, decreased B/P.
R: This may indicate a need for decreased dosage.
3. Make sure to always use gloves when applying the
patch to the patient.
R: To avoid touching the patch and being exposed to the
effects of the drug.
4. Apply to site free of hair and not subject to much
movement. Do not apply to distal extremities.
R: To obtain optimal therapeutic effect of the drug.
Moreover, increased movement may make more blood
come to that area and cause the medication to be
absorbed too fast.
5. If the patient needs cardioversion or defibrillation,
remove transdermal patch before procedure.
R: To prevent accidental thermal burns from the
delivered shock.
6. Plan a nitroglycerin-free period of about 10 hours
each day, as prescribed.
R: To maintain its therapeutic effects and avoid
tolerance
7. Advise the patient to make position changes slowly.
R: The drug may cause orthostatic hypotension that can
lead to fainting or falling.
8. Remind the patient/family not to cut or trim the patch.
R: To avoid unnecessary adjustment of dosage.
R: This is to avoid local irritation and sensitization.
 9. Teach patient to rotate sites slightly
R: This is to avoid local irritation and sensitization.
10. Urge patient to avoid alcohol and erectile dysfunction
drugs during therapy.
R: To prevent acute hypotensive episode.

C. SURGICAL MANAGEMENT

MANAGE DEFINITION NURSING

MENT RESPONSIBILITIES

1. Determine which medications

Percutaneous It is a procedure done
Coronary to open up clogged
Intervention/ arteries. It uses a
small balloon catheter
Coronary that is inserted in the
Angioplasty blocked blood vessel
to help it widen and
improve blood flow
into the heart. Most of
the time, angioplasty
is combined with a
stent which is placed
to decrease the blood
vessels chance of
narrowing again
(Mayoclinic, 2019).
were given during the procedure.
Watch out for possible bleeding.
2. Assess the puncture site for any
swelling, redness, or pain.
Hematoma may suggest the
occurrence of internal bleeding.
3. Apply manual pressure over
hematoma, followed by pressure
dressing.
4. Keep the patient lying flat for
several hours after the procedure
so that any serious bleeding may
be avoided. Patient must be on bed
rest for four to six hours.
5. Notify the doctor if the patient
presents signs of arrhythmia.
 1. Determine which medications
Intravascular Stent Coronary Intravascular were given during the procedure.
Stent Placement is a Watch out for possible bleeding.
procedure wherein a
small mesh tube is 2. Assess the puncture site for any
inserted into an artery swelling, redness, or pain.
that is narrowing due Hematoma may suggest the
to plaque. Initially, an occurrence of internal bleeding.
angioplasty will be 3. Apply manual pressure over
performed before the hematoma, followed by pressure
insertion of a stent
dressing.
(Drugs.com, 2021).
4. Keep the patient lying flat for
several hours after the procedure
so that any serious bleeding may
be avoided. Patient must be on bed
rest for four to six hours.
5. Notify the doctor if the patient
presents signs of arrhythmia.
 1. Keep the patient in supine
Atherectomy It is a procedure position for a few hours post
wherein plaque is procedure.
removed from arteries
using a small sharp 2. Apply a pressure bandage on
blade attached at the the incision to prevent bleeding.
end of a catheter 3. Antiplatelets may be
which is inserted into a administered to prevent bleeding.
small puncture in the 4. Medications to manage pain or
artery. After the nausea may be given.
plaque is removed, the
5. Notify the doctor if the patient
plaque is then
collected into the presents signs of arrhythmia.
catheter. The process
may be repeated at
the time the treatment
is performed until the
blockage is eliminated.
It is sometimes
performed on patients
that have already
undergone angioplasty
and stent insertion, but
still have plaque
blocking the blood flow
(Cleveland Clinic,
2019).
 1. Watch out for signs and
Transmyocardial Transmyocardial laser symptoms of bleeding.
Laser revascularization 2. Monitor vital signs.
Revascularization (TMLR) is a surgical
procedure wherein a 3. Inspect incision site for signs of
high-powered carbon infection.
dioxide laser is utilized
to interject high-
powered pulse into the
left ventricle, to make
smaller channels
through the muscle of
about 1-mm in
diameter. This causes
an improvement in
blood flow and
reduces chest pain
(Bhimji, 2020).

1. Monitor ECG for changes in

Cardiomyoplasty Cardiomyoplasty is a rhythm, rate, and presence of
surgical procedure in dysrhythmias. Treat as indicated.
which skeletal
muscles are taken 2. Monitor for muscle twitching or
from a patient’s back, hiccups. May indicate pacer lead had
or more specifically, dislodged and migrated to chest wall or
the Latissimus dorsi. diaphragm after perforation of the
This added muscle is heart.
then aided by ongoing 3. Monitor for sudden complaints of
stimulation from a chest pain, and auscultate for
pacemaker to boost
pericardial friction rub or muffled
the heart’s pumping
action (American heart tones. Observe JVD and
Heart Association, pulsus paradoxus. This indicates
2020). perforation of the pericardial sac
and may present an impending
cardiac tamponade.
4. Limit movement of extremity
involved near insertion site as
ordered. This prevents accidental
disconnection and dislodgement of
lead wires immediately after
placement.
5. Protect patients from microwave
 ovens, radar, diathermies, and etc.
Environmental electromagnetic
interference may impair demand
pacemaker function by disrupting the
electrical stimulus.

1. Monitor vital signs and intake

Heart According to and output.
Transplantation Beckerman (2020), a 2. Assess mental status and level
heart transplant is a
surgical replacement of consciousness. Note changes in
wherein a person’s sensorium; lethargy, confusion,
diseased heart is disorientation, anxiety, and
removed and depression.
transplanted with a 3. Monitor oxygen saturation and
healthy donor’s heart ABGs.
who has died and has
either agreed or the
family has agreed to
donate their loved
one’s organs.

1. Watch out for dysrhythmias and

Left Ventricular A left ventricular assist report to the primary physician.
Assist Device device (LVAD) is a 2. Assess the incision site where
battery-operated
mechanical pump the device was implanted for
implanted in patients bleeding, hematoma formation, or
who have reached infection.
end-stage heart 3. Observe the patient’s response
failure. This helps the to the device.
left ventricle (the main
pumping chamber of
the heart) to pump
blood more efficiently
to the rest of the body
(Cleveland, 2019).
Coronary Artery Coronary Artery 1. Maintain airway patency.
Bypass Graft Bypass Graft (CABG) Monitor the patient's pulmonary
(CABG) is a surgical procedure status closely and report any
wherein a healthy changes, such as pulmonary
blood vessel is taken congestion, dyspnea, or SpO2
from either an arm, below 92%. Follow the weaning
leg, or chest. Then, it protocol per orders.
is connected below
and above the blocked 2. Monitor vital signs and record
arteries in the heart to intake and output hourly. Note the
create a new pathway urine's color, clarity, and specific
for blood to flow, gravity. Notify the surgeon of any
creating improved signs of decreased renal perfusion.
circulation (Mayo
Clinic, 2020). 3. Assess the patient's
hemodynamic and cardiac status.
Atrial fibrillation (AF) is a common
complication of cardiac surgery,
although it's rarely life-threatening.
Treat persistent AF with medication
or synchronized cardioversion as
ordered.

4. Perform peripheral and

neurovascular assessments hourly
for the first 8 hours. Then, if the
patient is stable, perform these
checks every 2 hours for the next 8
hours and every 4 hours for the
following 8 hours.

5. Monitor his neurologic status

and notify the surgeon and
anesthesia provider if he hasn't
awakened within 8 hours after
surgery. Elderly patients and those
with liver or kidney problems,
history of stroke, or perfusion
deficits during surgery may need
more time to recover from
anesthesia.
Cardiopulmonary It is the utilization of a
Bypass heart-lung machine
during cardiac
surgery. This provides
patients with cardiac
and pulmonary
support, while bypass
on the heart and lungs
is performed. In this
procedure, the
patient’s blood is
diverted from the heart
and the lungs and
rerouted outside the
body. Herein, the
normal physiologic
functions of the heart
and lungs are taken
over by the
Cardiopulmonary
Bypass machine.
Along with this,
Cardioplegia solution
will be administered to
allow the surgeon to
operate on a non-
beating heart to
prevent loss of blood
while continuously
supplying other organs
with oxygen during its
inactive state (Cheung
& et al, 2021).

c. Non-pharmacological Management

Management Definition Nursing Responsibilities

 Oxygen therapy Myocardial infarction often
occurs when there is not
enough oxygen supply to
one or multiple areas of the
heart. Thus, oxygen
therapy is initiated to
increase the oxygen supply
and satisfy the oxygen
demand.
1. Measure cardiac output
and other functional
parameters as appropriate.
2. Review serial ECGs.
This provides information
regarding progression or
resolution of infarction,
status of ventricular
function, electrolyte
balance, and effects of
drug therapies.

3. Monitor oxygen
saturation continuously,
using a pulse oximeter.

5. Position patient with

head of bed elevated, in a
semi-Fowler’s position
(head of bed at 45 degrees
when supine) as tolerated.

5. Administer oxygen as
indicated.

d. Nursing Management

Nursing interventions are a significant part and a core action done in a patient’s stay.
Nurses perform these to help patients recover back to their optimum state if possible.
The nurse must be competent in performing such procedures through the application of
his or her knowledge, experience, and critical thinking skills in categorizing which
interventions will be most helpful to the patient’s condition. Aside from the
managements mentioned above, the following interventions listed below are also
important general nursing interventions in patients diagnosed with non-STEMI
Myocardial Infarction. These are the following:

Management Rationale
Monitor vital signs. These data are important in
determining the patient’s condition.

Obtain a 12-lead ECG recording. To observe the electrical activity of the

heart.

Administer medication as ordered. Medication therapy is the first line of

defense in preserving myocardial
tissues.

Administer oxygen as prescribed or as Oxygen therapy increases the oxygen

needed. supply needed to supply the
myocardium.

Encourage the patient to use stool To prevent straining since this may
softeners if needed. cause blood pressure to increase.

Ensure physical rest. Emphasize the Physical rest reduces myocardial

importance of planned rest periods. consumption. This also prevents undue
fatigue.

Provide a cool, calm, and quiet This is to conserve energy, promote rest
environment. and enhance coping abilities.

Provide comfort measures and diversional To promotes relaxation and help refocuses
activities. attention

Encourage to share thoughts and feelings Provide opportunity to examine realistic

 fears

Use therapeutic communication skills such Encourages realistic dialogue about

as active listening, acknowledgement and feelings and concerns
such

Assess the patient’s and family’s level Causes of anxiety are variable and
of anxiety and coping mechanisms. individual. Because anxious family
members can transmit anxiety to the
patient, the nurse must also identify
strategies to reduce the family’s fear
and anxiety.

Assess the need for social service Social services can assist with post-
referral. hospital care and financial concerns.

Assess the need for spiritual counseling If a patient finds support in a religion,
and refer as appropriate. spiritual counseling may assist in
reducing their anxiety and fear.

Possible Nursing Diagnosis

 1. Pain related to restlessness, changes in level of consciousness

2. Activity intolerance related to imbalance between myocardial oxygen supply

and demand

3. Risk for decreased cardiac tissue perfusion related to reduced coronary blood
flow

4. Risk for decreased cardiac output related to left ventricular failure

5. Risk for ineffective peripheral tissue perfusion related to interruption of blood

flow in the coronary arteries associated with thrombosis

6. Risk for excess fluid volume related to increased sodium/water retention.

7. Anxiety related to cardiac event

Deficient knowledge about post-Myocardial Infarction care.

V. PROGNOSIS

Myocardial infarction is characterized by necrosis due to an insufficient supply of

oxygenated blood. Plaques that have built up in the coronary arteries or atherosclerosis could
cause blockage of the arteries hindering the heart from efficiently pumping blood throughout the
body. This blockage can often lead to pain called angina.

According to Khan M.A et al.. the estimated incidence of Ischemic Heart Disease related
incidence per year is around 126 million people and 9 million of these people die. Myocardial
infarction's mortality rate is tallied at around 30% and 50% of these deaths happen during the
hospital stay. Around half of these survivors are readmitted to the hospital after the year and 5%
- 10% of the total patients die within a year.

The general prognosis of the patients with myocardial infarction is mostly unpredictable
and it depends on the degree of damage the infarction has caused including the residual left
ventricular activity and re-vascularization of the patient. Zafara, M. (2019), stated that an
effective early re-perfusion of patients with MI within 30 minutes preserves the left ventricular
function, short-term and long-term therapy with beta-blockers, aspirin, and ACE inhibitors lead
to good prognosis while old age, diabetes, and elevated thrombolysis can lead to poor patient
prognosis.

Patients who have had myocardial infarction should consult a dietitian because diet
plays a significant role in the development of coronary artery diseases. Low salt and low fat
diets decrease the chances of plaque deposits in the arterial walls. We should emphasize to our
clients that right exercise along with a good diet lowers the risk of cardiovascular diseases.
Smoking and alcoholic drinking patients have to be discouraged from continuing the vice due to
the effects of cigarettes and alcohol to the heart and blood circulation. Which could trigger
another episode of MI.

VI. DISCHARGE PLANNING

 Take your medication on time as

prescribed by your doctor. Know
what each of these medications do
for you.

 When you miss a dose take 1

immediately. If you forgot and the
next dose of medication is close by,
wait till then to take another
MEDICATION medication. Do not double dose.

 Separate your medication

containers and do not mix them up.

 Make sure to refill your medications

on time so that you do not miss
doses.
 Recovery is different for each individual;
the rate at which one can heal depends on
a plethora of factors. Like the extent of
damage to the heart and your activity level
before your episode. It is important to start
slow and take much needed rest. If
possible sign up for a cardiac
rehabilitation program. Start with low
impact exercise such as:

 Walking

 Cycling
EXERCISE
 Rowing

 Jogging

 Yoga

Rest whenever you feel any of the

following:

 Shortness of breath

 Lightheadedness

 Chest pain

NOTE: Do not lift objects more than 10

or 20 pounds in the
first week of discharge as it
might cause a sudden increase in
blood pressure and heart
rate.

Sexual

Talk to your doctor before continuing

sexual activity. Do not viagra, levitra or
cialis or any medications that could cause
erection without talking to your doctor first.

4 - 6 weeks
 1. If you are a smoker then smoking
cessation is one of the best solutions for
recovering MI patients. Talk to a support
group with regards to quitting cigarettes.
Quitline is available in the Philippines;
“hotline 165364.” Call this number so that
you can begin being guided how to stop
smoking.

2. Call your doctor when you experience

 Pain, pressure, tightness, or

TREATMENT heaviness in your chest, arm, neck,
or jaw

 Shortness of breath

 Gas pains or indigestion

 Numbness in your arms

 Sweaty, or if you lose color

 Good physical hygiene helps the patient
heal faster. It helps our client feel good
and it boosts confidence in themselves
especially after an episode.

Post MI patients need to be extra careful

about their health therefore. Good hand
hygiene, avoiding people with infectious
diseases, and regular use of masks help
our clients avoid illnesses that could
further complicate their health.

HYGIENE
 Follow up check ups are necessary to
monitor your heart health.
Your survival is dependent on it. So
follow the appointments your doctor has
OUTPATIENT OR FOLLOWUP set up for you, may it be weekly or
monthly.

Smoking is one of the biggest risk

factor towards atherosclerosis due
to.

 Smoking decreases the levels of

high density lipoproteins in the
bloodstream and it creates an
environment of destructive
breakdown of cholesterol in the
body causing low density
lipoproteins to be more toxic in the
blood vessels which causes an
increase in plaque deposits and
increasing inflammation.

 Nicotine can cause

vasoconstriction which can cause
high blood pressure. The amount of
carbon monoxide it produces also
reduces the levels of oxygen in the
lungs prompting the heart to pump
more blood to carry more oxygen
throughout the body.

WEIGHT MONITORING
 Monitor your weight. Losing even
10 pounds can lower your blood
pressure—and losing weight has
the biggest effect on those who are
overweight and already have
hypertension.

 Overweight and obesity are risk

factors for heart disease. And being
overweight or obese increases your
chances of developing high blood
cholesterol and diabetes—two
 more risk factors for heart disease.

 Weigh yourself in the morning

during before breakfast after you
have emptied your bladder and
defecated.
 Report any sudden increase in
weight around 5 pounds in a
week from your current
weight.
 Consult a dietitian if it can be afforded.
Generally stay away from food that
contains high salt and fat as salt causes
the body to retain water and fat contains a
lot of cholesterol which leads to plaque
build up. The salt also increases the blood
pressure due to the increased fluid volume
your body now holds causing your heart to
have to pump blood harder.

Generally avoid food such as:

 Canned Goods

 Dried Goods salted goods like

DIET
bulad

 Packaged food

Food can also be seasoned with herbs

instead of salt to add
taste. Also refrain from smoking or
drinking alcohol.

SPIRITUAL Encourage the patient to seek spiritual

support.

 Seeking spiritual support

strengthens our client’s ability to
cope with the situation.
 Even if the patient isn’t that
 religious, having someone to vent
out their fears already makes a
positive impact towards recovery.

VII. RELATED NURSING THEORIES

Faye Glenn Abdellah

According to Faye Glenn Abdellah’s

theory, “Nursing is based on an art and science
that moulds the attitudes, intellectual
competencies, and technical skills of the
individual nurse into the desire and ability to help
people, sick or well, cope with their health needs.
“The patient-centered approach to nursing was
developed from Abdellah’s practice, and the
theory is considered a human needs theory. It was formulated to be an instrument for
nursing education, so it is most suitable and useful in that field.
 The nursing model is intended to guide care in hospital institutions, and can also
be applied to emergency rooms, as well. Abdellah's “21 Nursing Problems Theory”
relates to change and anticipated changes that affect nursing; the need to appreciate
the interconnectedness of social enterprises and social problems. Health, or the
achievement of it, is the purpose of nursing services. Although Abdellah does not give a
definition of health, she speaks of “total health needs” and “a healthy state of mind and
body.” This is mentioned in one of her major concepts of 21 nursing problems theory for
people with Myocardial infarction.

The nursing theory explains about patient-centered approach which is a

significant practice and considered needs for person with myocardial infarction, since
the persons large arteries in the heart becomes blocked suddenly, a portion of the heart
is starved of oxygen if the starved tissue dies, this can cause heart attack.

Lydia Hall – Core, Care, Cure Theory

The theory of Lydia Hall consists of three independent but interconnected circles:
core, care and cure. This theory emphasizes the patient as a whole and not by just
seeing the one part of a person and also emphasizes that the three circles should be
functioning together.

In the care circle, the nurses are

focused on performing the task of nurturing
the patient. This represents the role of nurses
such as providing health teachings to the
patient and helping the patient meet their
needs and providing care and comfort to the
patient. In the core circle, the core is the
patient receiving the nursing care. The nurse helps the patient to set realistic goals and
provide emotional support and encouragement. As for the cure circle, administration of
the physician’s prescribed medicines and collaboration with other health professionals
will be the nursing intervention of the nurses.
 This model was chosen because the student nurses believe that the patient with
myocardial infarction fits in this theory. The core would be the patient himself that needs
to set goals for him and the nurses will provide care that will meet the goals set by the
patients. Patients with myocardial infarction need treatment that would help him in
managing the disease and this is where the cure circle is needed. With the help of
nurses and other medical personnel, they will provide interventions that would help the
patient with his illness.

Dorothea Orem – Self-care Deficit Theory

Dorothea Orem’s Self-Care Deficit Theory

focuses on each individual's ability to perform
self-care, defined as ‘the practice of activities that
individuals initiate and perform on their own
behalf in maintaining life, health, and well-being.

Orem’s self-care deficit theory of nursing conceptualizes self-care as the

personal care that people require each day. The theory states that human beings have
self-care agency which is the capability for self-care. However, health-related limitations
may interfere.

The theory of self-efficacy was explored as a motivating factor. MI patients are

advised to follow a heart healthy diet with reduced fat and increased fiber intake in order
to reduce the risk of recurrence, or of health complications, but many patients find
incorporation of these dietary behaviors difficult.

It is important for nurses to be able to clearly demonstrate the effectiveness of

their contribution to patient care and to be able to identify what it is about a particular
nursing approach that makes it effective. Utilization of a conceptual model of nursing
can guide strategies for planning care and contribute to explanations of why the care
produces desired patient outcomes. Orem’s model proved highly useful in guiding
strategies for planning effective care, as well as contributing to explanations of how the
intervention worked.
VIII. REVIEW OF RELATED LITERATURE

In some patients, the heart may be affected, and this can occur in individuals with
or without a prior cardiovascular diagnosis. Evidence of myocardial injury, as defined
as an elevated troponin level, is common among patients hospitalized with COVID-19,
with putative causes including stress cardiomyopathy, hypoxic injury, ischemic injury
(caused by cardiac microvascular damage or epicardial coronary artery disease), and
systemic inflammatory response syndrome (cytokine storm). A minority of patients with
an elevated troponin level present with symptoms and signs suggestive of an acute
coronary syndrome. (Pinto, 2021)

Green tea and coffee drinkers who survive a stroke or myocardial infarction have
lower all-cause mortality risk than people who don't consume these beverages, a recent
study suggests. Compared to people who didn't drink green tea and coffee, heavy tea
and coffee drinkers who enjoyed at least seven cups a day had significantly lower all-
cause mortality when they had a history of stroke. But according to the results published
in “Stroke” there was no benefit from green tea evident for people without a history of
stroke or MI, and no benefit from coffee drinking for stroke survivors. "Our study
suggests that dietary habits such as green tea or coffee consumption can contribute to
improved prognosis of CVD survivors," said senior study author Dr. Hiroyasu Iso of
Osaka University Graduate School of Medicine in Japan. However, it's not clear from
the study results whether the prognosis is prolonged if people who have never drunk
green tea or coffee before start drinking or increase the amount they drink after the
onset of cardiovascular disease. (Rapaport, 2021)

Consumption of marijuana might have adverse cardiac effects, especially in older

individuals with a history of cardiac disorders, a case report suggests. Two Canadian
physicians report the case of a 70-year-old man with stable coronary artery disease
(CAD), who consumed a lollipop containing a large quantity of delta-9-
tetrahydrocannabinol (THC) to relieve pain and aid sleep. The patient subsequently
presented to the emergency department (ED) with hallucinations and cardiac
symptoms, and was eventually diagnosed with non-ST-elevation myocardial infarction
(MI), successfully treated, and discharged. Consumption of marijuana might have
adverse cardiac effects, especially in older individuals with a history of cardiac
disorders, a case report suggests. The patient was treated for non-ST-elevation MI with
a low-molecular-weight heparin bolus, acetylsalicylic acid, and clopidogrel, and
discharged home after his hallucinations and chest pain had resolved. (Yasgur, 2019)

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