CU7 Cruz Paola Luz

Paola Luz Cruz
Course Task CU7
Answer the following questions base on the cited situation. Answer will be submitted through
CANVAS.
Consider the scenarios and answer the following questions:
Scenario 1: Angina Pectoris

Lita a 65 year-old retired secretary, is admitted to the medical surgical area for management of chest
pain caused by angina pectoris. (20 points)
1. The patient asked the nurse “What is causing this pain?” What is the best response by the
nurse?
 Whenever the heart does not receive enough blood, you get an angina attack To perform
well, one has to have a healthy heart, and to have a healthy heart, it is imperative to stay
emotionally calm and relaxed. The hardening of the arteries prevents the heart from
obtaining sufficient oxygen. Narrowing and hardening of the arteries occurs through a build-
up of plaque (composed of fat, collagen, other compounds, and cholesterol) in the vessel
walls. Because of this, they will even obstruct the blood supply to the heart and reduce the
distribution of oxygenated blood.
2. The patient is diagnosed with chronic stable angina. The nurse can anticipate that her pain
may follow what type of pattern?
 More frequently, the pain in the middle of a stable angina is characterized as intense,
constricting, or as a tightness in the chest. It may feel like a vice around the ribcage or like a
tremendous burden on the chest. Another possible effect is that this discomfort can travel
down your chest and arms and through your neck and shoulders.
3. Lita has nitroglycerin at her bed side to take PRN. The nurse knows that nitroglycerin acts in
what ways?
 Nitroglycerin assists in the relaxing of coronary blood arteries. This improves oxygen
pressure into blood arteries and alleviates angina symptoms.
4. Lita took a nitroglycerin tablet at 10:00 AM, after her morning care. It did not relieve her pain,
so 5 minutes later, she repeated the dose. 10 minutes later, and still in pain, she calls the nurse.
What is the priority intervention of the nurse?
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 Give 1 dose of nitroglycerin immediately at the onset of an angina attack. If the symptoms
get a little better after the first dose but do not go away completely, a second dose may be
taken 5 minutes later as advised by physician. Give a third dose 5 minutes after the second
dose. It is important to note that it is needed to use more than 3 doses in a 15-minute
period.
Emergency services should be summoned if any of the following occurs:
 Symptoms do not improve substantially within 5 minutes or if they worsen after the first
dose.
 Symptoms do not continue to get better after the second dose.
 Chest pain/discomfort does not go away completely 5 minutes after taking the third
dose.
 Symptoms of an overdose may include headache, confusion, dizziness, slow or pounding
heartbeat, nausea, vomiting, fainting, shortness of breath, sweating, flushing, cold and
clammy skin, loss of ability to move the body, loss of consciousness for a period of time,
or seizures.
Scenario 2: Decreased Myocardial Tissue Perfusion

Mr. Santos, a 46 year-old teacher, is brought to the ER by ambulance with a suspected diagnosis of MI.
He appears ashen, is diaphoretic, and tachycardic, and has a severe chest pain. The nursing diagnosis is
Decreased Cardiac Output related to Decreased Myocardial Tissue Perfusion. (20 points)
1. The nurse is aware that there is critical time period for this patient. When should the nurse be
most vigilant in monitoring this patient?
The nurse should closely monitor the patient for a complication of an MI that leads to
sudden death during the first 48 hours.
2. The nurse is interpreting the result of the ECG. What findings does the nurse understand are
indicative of initial myocardial injury?
The World Health Organization (WHO) had defined the term myocardial infarction by the
presence of 2 of the 3 following characteristics:
 i) Symptoms of acute ischemia (chest pain)

 ii) Development of Q waves in electrocardiogram (ECG)
 iii) Increase of enzymes in the blood [combination of total creatine kinase (CK), CK-
myocardial band (MB), aspartate aminotransferase (AST) and lactate dehydrogenase
(LDH)].
Cardiac enzymes is a broad term encompassing several intracellular myocyte components

that can be found in serum and measured under certain circumstances such as myocardial
ischemia, trauma, myocarditis. In the proper clinical setting, elevation in the level of
enzymes present in serum is key in the diagnosis of myocardial infarction. While troponin is
the most commonly used cardiac enzyme for diagnosis of myocardial infarction, others exist
and may be helpful in some situations. Cardiac troponins (ctn) are considered as the golden
standard.
Cardiac biomarkers should be measured in all patients who present with chest discomfort
consistent with acute coronary syndrome (ACS). Elevations of cardiac enzyme levels should
be interpreted in the context of clinical and ECG findings.
 Cardiac troponins T and I are the preferred markers for myocardial injury as they
have the highest sensitivities and specificities for the diagnosis of acute myocardial
infarction.
 Patients with negative cardiac biomarkers within six hours of the onset of symptoms
that are consistent with ACS should have biomarkers remeasured in the timeframe
of twelve hours after the onset of symptoms.
 Peak circulating enzyme levels tend to occur earlier and are often higher following
successful thrombolytic therapy.
 Cardiac troponins T and I are highly sensitive and specific for cardiac damage.
Troponin I and T are of equal clinical value.
 Serum levels increase within 3-12 hours from the onset of chest pain, peak at 24-48
hours, and return to baseline over 5-14 days.
 Troponin levels may not be detectable for six hours after the onset of myocardial cell
injury. The most sensitive early marker for myocardial infarction is myoglobin.
 Troponin levels should be measured at presentation and again 10-12 hours after the
onset of symptoms. When there is uncertainty regarding the time of symptom
onset, troponin should be measured at twelve hours after the presentation.
 The risk of death from an ACS is directly related to troponin level and patients with
no detectable troponins have a good short-term prognosis.
 Elevated troponin levels can occur in patients without an ACS and are associated
with adverse outcomes in many other clinical situations, including congestive heart
failure, sepsis, acute pulmonary embolism and chronic kidney disease. Other cardiac
causes include myocarditis and aortic dissection.
Creatine kinase
o Myocardial muscle creatine kinase (CK-MB) is found mainly in the heart.

o CK-MB levels increase within 3-12 hours of onset of chest pain, reach peak values
within 24 hours, and return to baseline after 48-72 hours.
o Sensitivity and specificity are not as high as for troponin levels.
Myoglobin levels
o Myoglobin is found in cardiac and skeletal muscle.

o It is released more rapidly from infarcted myocardium than troponin and CK-MB and
may be detected as early as two hours after an acute myocardial infarction.
o Myoglobin has high sensitivity but poor specificity. It may be useful for the early
detection of myocardial infarction.
Natriuretic peptides
o Studies in several types of ACS have shown that elevated levels of natriuretic
peptides - eg, B-type natriuretic peptide (BNP) - are independently associated with
adverse outcomes - especially mortality.
Other findings
o Leukocytosis may be seen within several hours after an acute myocardial infarction.
It peaks in 2-4 days and returns to normal levels within one week.
o Patients without biochemical evidence of myocardial necrosis but with elevated C-
reactive protein (CRP) level are at increased risk of a subsequent ischaemic event.
o Erythrocyte sedimentation rate (ESR) rises above reference range values within
three days and may remain elevated for weeks.
3. What laboratory test are positive indicators of MI?
Criteria
A myocardial infarction, according to current consensus, is defined by elevated cardiac biomarkers

with a rising or falling trend and at least one of the following:
 Symptoms relating to ischemia
 Changes on an electrocardiogram (ECG), such as ST segment changes, new left bundle branch
block, or pathologic Q waves
 Changes in the motion of the heart wall on imagingDemonstration of a thrombus on angiogram
or at autopsy.
Cardiac biomarkers
 There are a number of different biomarkers used to determine the presence of cardiac muscle
damage.Troponins, measured through a blood test, are considered to be the best, and are
preferred because they have greater sensitivity and specificity for measuring injury to the heart
muscle than other tests. A rise in troponin occurs within 2–3 hours of injury to the heart muscle,
and peaks within 1–2 days. The level of the troponin, as well as a change over time, are useful in
measuring and diagnosing or excluding myocardial infarctions, and the diagnostic accuracy of
troponin testing is improving over time.One high-sensitivity cardiac troponin is able to rule out a
heart attack as long as the ECG is normal.
 Other tests, such as CK-MB or myoglobin, are discouraged. CK-MB is not as specific as troponins
for acute myocardial injury, and may be elevated with past cardiac surgery, inflammation or
electrical cardioversion; it rises within 4–8 hours and returns to normal within 2–3 days.
Copeptin may be useful to rule out MI rapidly when used along with troponin.
Electrocardiogram
 The taking of an ECG is an important part in the workup of an AMI, and ECGs are often not just
taken once but may be repeated over minutes to hours, or in response to changes in signs or
symptoms.
 ECG can readouts product a waveform with different labelled features. In addition to a rise in
biomarkers, a rise in the ST segment, changes in the shape or flipping of T waves, new Q waves,
or a new left bundle branch block can be used to diagnose an AMI.In addition, ST elevation can
be used to diagnose an ST segment myocardial infarction (STEMI). A rise must be new in V2 and
V3 ≥2 mm (0,2 mV) for males or ≥1.5 mm (0.15 mV) for females or ≥1 mm (0.1 mV) in two other
adjacent chest or limb leads. ST elevation is associated with infarction, and may be preceded by
changes indicating ischemia, such as ST depression or inversion of the T waves. [83] Abnormalities
can help differentiate the location of an infarct, based on the leads that are affected by changes.
[
Early STEMIs may be preceded by peaked T waves. Other ECG abnormalities relating to
complications of acute myocardial infarctions may also be evident, such as atrial or ventricular
fibrillation.
Imaging
 Noninvasive imaging plays an important role in the diagnosis and characterisation of myocardial
infarction. Tests such as chest X-rays can be used to explore and exclude alternate causes of a
person's symptoms.
 Tests such as stress echocardiography and myocardial perfusion imaging can confirm a diagnosis
when a person's history, physical examination (including cardiac examination) ECG, and cardiac
biomarkers suggest the likelihood of a problem.
 Echocardiography, an ultrasound scan of the heart, is able to visualize the heart, its size, shape,
and any abnormal motion of the heart walls as they beat that may indicate a myocardial
infarction. The flow of blood can be imaged, and contrast dyes may be given to improve
image. SPECT may also be used to determine viability of tissue, and whether areas of ischemia
are inducible.
4. The nurse should closely monitor the patient for a complication of an MI that leads to sudden
death during the first 48 hours. Which complication should the nurse monitor for?
 Complications may occur immediately following the myocardial infarction or may take time to
develop. Disturbances of heart rhythms, including atrial fibrillation, ventricular tachycardia and
fibrillation and heart block can arise as a result of ischemia, cardiac scarring, and infarct
location. Since the electrical characteristics of the infarcted tissue change, arrhythmias are a
frequent complication. The re-entry phenomenon may cause rapid heart rates (ventricular
tachycardia and even ventricular fibrillation), and ischemia in the electrical conduction system of
the heart may cause a complete heart block (when the impulse from the sinoatrial node, the
normal cardiac pacemaker, does not reach the heart chambers).
 Stroke is also a risk, either as a result of clots transmitted from the heart during PCI, as a result
of bleeding following anticoagulation or as a result of disturbances in the heart's ability to pump
effectively as a result of the infarction.
 Regurgitation of blood through the mitral valve is possible, particularly if the infarction causes
dysfunction of the papillary muscle. Acute mitral regurgitation Causes severe mitral regurgitation
within the first week after infarction and is a life-threatening complication. It is most often seen
with inferior infarctions.
 Cardiogenic shock as a result of the heart being unable to adequately pump blood may
develop, dependent on infarct size, and is most likely to occur within the days following an acute
myocardial infarction. Cardiogenic shock is the largest cause of in-hospital mortality.
 Rupture of the ventricular dividing wall or left ventricular wall may occur within the initial
weeks. Dressler's syndrome, a reaction following larger infarcts and a cause of pericarditis is also
possible.
 Heart failure may develop as a long-term consequence, with an impaired ability of heart
muscle to pump, scarring, and increase in the size of the existing muscle.
 Aneurysm of the left ventricle myocardium develops in about 10% of MI and is itself a risk
factor for heart failure, ventricular arrhythmia and the development of clots.
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Paola Luz Cruz

Course Task CU7

Scenario 1: Angina Pectoris

Emergency services should be summoned if any of the following occurs:

Scenario 2: Decreased Myocardial Tissue Perfusion

 i) Symptoms of acute ischemia (chest pain)

Cardiac enzymes is a broad term encompassing several intracellular myocyte components

o Myocardial muscle creatine kinase (CK-MB) is found mainly in the heart.

o Myoglobin is found in cardiac and skeletal muscle.

3. What laboratory test are positive indicators of MI?

A myocardial infarction, according to current consensus, is defined by elevated cardiac biomarkers

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