Nursing Care on Critically Ill Patient with Myocardial Infarction in Cardiac Care Unit

1. Introduction
This paper was aimed to concisely construct a critical case study by using critical thinking
and problem solving approaches in the nursing practice. In order to realise a
comprehensive report, this critical care case study would be started with introduction to
include demographic data of the patient, history of present or past illness and case
description. It will be followed by alteration of anatomy and physiology, and
pathophysiology of the disease, complete physical assessment and nursing care plan,
drug study, nurses responsibility and recommendation to nursing practice

Demographic Data

Name : Mr. S

Gender : Male

Age : 63 years old

Marital status : Married

Education : Diploma

Occupation : Unemployed (Pension)

Ethnicity : Chinese

Address :-

Medical Diagnosis : Myocardial Infarction

Present Illness History

3 days before admitted to the hospital, the patient has complained an intermittent pain in
the left side of chest which radiate to the hands and shoulders that don’t heal with rest,
increase during perform daily activity, shortness of breath, orthopnoea nausea and
vomiting, fever, cold sweats. As a response to this health issue, the family was send him
to the nearest clinic and got 3 types of medicines for 3 days medication. The Doctor was
informing possible hearth disease and encourages the patient to take enough rest and
take medications. However, although after 3 days rest and taken the drugs, the clinical
symptoms still does not subside. Furthermore, the family has sent him to the hospital and
currently diagnosed as myocardial infarction and treated as a critically ill patient in the
cardiac intensive care unit.
 Past illness history

Since 15 years ago, the patient has suffered from uncontrolled hypertension and his feet
sometime swollen. The patient had never experienced chest pain before. Sometime,
patients feels a heavy sensation on the chest particularly when perform physical exercise,
stiff neck and dizziness when his blood pressure rises.

2. Altered anatomy and physiology, and / or pathophysiology

Etymologically, myocardial infarction also recognized as heart attack is a heart disease
characterized by die or necrotic of the myocardial tissue (middle layer of the heart tissue).
It occurs when blood flow to the coronary artery of the heart partially or totally blocked by
thrombus or fat (Ojha, N. Dhamoon, AS. 2021). The disease characterized by clinical
manifestation mostly left chest pain or discomfort which radiate to the shoulder, arm,
back, neck or jaw. It followed by discomfort which occasionally feel like heartburn,
shortness of breath, nausea, feeling faint, a cold sweat or feeling tired (Frangogiannis,
NG. 2015). Accordingly, Hinkle, J.L. and Cheever, K.H. (2018) have highlighted that the
disease can be caused by cigarette smoking, abnormal lipid profile, hypertension,
diabetes mellitus, abdominal obesity (waist/hip ratio) greater than 0.90 for males and
greater than 0.85 for females. On the other hand, Jacquelyn L. B. (2021) stated that the
disease occurrence also influenced by lack of daily consumption of fruits or vegetables,
insufficient physical activity and alcohol consumption.

Pathologically, myocardial infarction can be described as a multiple processes of

cardiovascular diseases. The direct cause of the disease is obstruction of coronary artery
by fat or thrombus that produces myocardial ischemia signed by chest pain or called as
angina pectoris. Unresolved blockage and ischemia tissue lead to damage of myocardial
layer or necrotic or infarction of myocardial tissue (Amin, S., & Shah, P. K. (2008)..
Furthermore, these pathological change will alternate the heart electricity and produce the
common classic ECG change included T wave inversion, ST segment elevation and
development of an abnormal Q wave (Smit, M., Coetzee, A. R., & Lochner, A. 2020)..
Finally, the ischemic area, injury and the infarction zone can be demonstrate in the
following Dixon, J. A., & Spinale, F. G. (2015) remodelling image:
 The pathological pathway of the disease was described by Tibaut, M., Mekis, D., &
Petrovic, D. (2017) in the following diagram chart:

3. Complete physical assessment

General health status
Consciousness compos mentis or fully conscious, speech sounds often mumble, blood
pressure 140/95 mmHg, body temperature 36.7 °C, respiratory rate 30 times/minute,
pulse rate 111 times/minute.
Airway = Airway clear without sputum and obstruction
Breathing = Spontaneous breathing, short and shallow of breath
Circulation = BP and pulse normal, intravenous fluid, blood vessel intact
Disability = Fully conscious without any disability
Exposure =-

Cardiovascular System
Apex beat normal, Jugular Venous Pressure 5 – 2 = 3 cm (normal), capillary refill 2-3
seconds, heart sounds S1, S2 and murmur, no bruit auscultated over right carotid artery
ECG shown sinus tachycardia, incomplete right bundle branch block, antero septal
infarct, ST wave elevation. Echocardiogram has shown an injury in cardiac antero-septal.
Chest X ray interpretation: cardio thoracic ration > 50% indicates heart enlargement.

Respiratory System
Chest shape and movement symmetric, shortness of breath, dyspnea, tachypnea, and
crackles indicate pulmonary congestion, there is additional sounds such rhonchi, pleural
friction rub without wheezing. Receive 2 L/minute nasal prong Oxygen therapy.
Gastrointestinal System
Abdomen clean, symmetric, convex shape without any injury and pain, peristalsis 10
times/minutes, mild ascites, no tenderness, no palpable liver enlargement of the kidneys,
spleen or liver, nausea especially in the morning, loss of appetite, anorexia, tympanic
sounds on percussion, bowel open 1 time a day without complain, no constipation, faint
abdominal bruit auscultated, no pain on palpation, diet provided 1/3 taken.

Musculoskeletal System
There is no injury and pain on the musculoskeletal system, muscle strengthen of upper
and lower extremities were normal (5/5 = full strengthen), no swollen or oedema, no
redness, warm on palpation.

Genitourinary System
Under folley catheter, urine amount 1500 cc /24 hours, urine colour yellowish without
sedimentation, no bloody, sedimentation, there is no prostate enlargement, no pain on
palpation, kidney impalpable.

Nervous System
• There are no issues with 12 cranial nerve functions
• Glasgow Coma Scale (GCS) : 15 (fully Conscious)
• Eye movement : Spontaneous (4)
• Verbal : Good orientation (5)
• Motoric : by order (6)
• Alert and oriented
• Cranial nerves II–XII intact (including good visual acuity)

Laboratory Findings
Haematology
- Hb : 13,1 (13 – 16 g/dl)
- Leuko : 19.500 (5.000 – 10.000 /ul)
- Hematokrit : 42 (40 – 48 %)
- Trombosit : 433.200 (150.000–400.000 /ul)
- MCV : 90 (82 – 92 fl)
- MCH : 30 (27 – 31 pg)
- MCHC : 35 (32 – 36 g/dl)
Blood Chemistry Electrolyte
- Ureum : 13 (20 – 40 mg/dl) - Natrium : 145 (135 – 147 meq/l)
- Creatinine : 0,9 (0,5 – 1,5 MG/DL - Kalium : 4,1 (3,50 – 550 meq/l)
- SGOT : 342 (< 25 u/l) - Chloride : 104 (100 – 106 meq/l)
- SGPT : 89 Duplo (< 20 u/l)
- Albumin : 4,3 (4 – 5,2 gr/dl)
- Blood glucose : 155(70 – 200 mg/dl)
4. Nursing Care Plan

Nursing
Data Diagnosis Goal Intervention Rational Evaluation
Subjective: Chest pain Chest pain Assess, document and report: These data help determine Chest pain reduce,
- Left chest pain related to subside or lost a. Complaints of chest pain the causes and effects of appear comfortable
radiating to the myocardial within 8 hours include location, radiation, chest pain and provide a and pain free, get
hand, shoulder and ischemia duration of pain and factors that baseline for comparing post- enough rest, warm
chin intermittently seconder to influence it therapy symptoms and dry skin
does not reduced coronary artery
with rest blockage b.Effects of chest pain on
- Patient said the cardiovascular hemodynamic
attack occurred perfusion—on heart, brain,
repeated with the kidneys and skin
same pain and
characteristics. Recording a 12-lead ECG during
pain, as instructed to determine
Objective: the extent of infarction
- Grimace face
expression ECG examination during pain
- BP: 140/95 mmHg, is very useful in diagnosing
Administer oxygen 2-3 l/min the extent of infarction or the
- Pulse:111x/minute
- Pain score : 6 presence of an episode of
angina

Administer drugs heparin, lasix, Oxygen therapy can increase

ascardia, pethidine, diazepam as oxygen supply to the heart
prescription when the actual oxygen
saturation is below normal

Drug therapy is a defence to

maintain cardiac tissue. Side
effects (attached)
 Nursing
Data Diagnosis Goal Intervention
Advise and facilitate the client for
complete rest, provide adequate
protection such as installing a
handrail on the side of the bed,
elevating the head of the bed to
provide comfort, providing a calm
& comfortable atmosphere to
reduce the client's anxiety & fear
with an attitude of being ready to
help. Reduce visiting hours for
clients.
Rational Evaluation
Rest can reduce the heart's
oxygen consumption. Fear
and anxiety can trigger a
stress response; This results
in increased levels of
endogenous catecholamines,
which increase the heart's
oxygen consumption. With
increasing epinephrine, the
pain threshold will also
decrease and pain will
increase the heart's oxygen
consumption

Increase physical comfort by Physical comfort improves

providing basic nursing care to patient well-being and
clients reduces anxiety

Subjective: Tissue perfusion Maintain/ Assess, document and report the These data are very useful in - Blood pressure
- Patient feel fatigue alteration achieve following to the doctor every 4 determining the state of low remains within
and easily tired related to adequate hours cardiac output. ECG normal range
- Patient feel chest decreased blood tissue - hypotension examination at the time of - Ideally, a normal
pain flow and perfusion - tachycardia and other pain is very useful in sinus rhythm, the
- Patient feel dizzy thromboembolic dysrhythmias diagnosing the extent of patient's baseline
formation - tired easily ischemia, injury, and rhythm should be
Objective: - mental changes (with input from myocardial infarction and maintained
- Blood pressure family) variant angina. between 60 and
140/95 mmHg, - decreased urine output (less 100 beats/minute
- Body temperature than 250 ml/8 hours without
36.7◦C, - cold, clammy and cyanotic dysrhythmias.
 extremities
Nursing
Data Diagnosis Goal Intervention Rational Evaluation
Objective: Provide comfort and rest to the Physical comfort will improve - No complaints of
- Breathing patient by providing individualized the patient's well-being and fatigue with the
30X/minute, pulse nursing care reduce anxiety. Rest reduces recommended
111X/minute, myocardial oxygen activities
regular consumption - Stay fully aware
- JVP 5 – 2 cm, and oriented and
- Heart sound S1 and without
S2 with additional personality
murmur changes
- Pale, capillary refill 2 - Looks
– 3 seconds comfortable
- Looks well rested
- Urine output
more than 40
ml/hour
Subjective: Anxiety related Anxiety Independent Intervention: These data provides - Anxiety was
- Patient said some to lack of reduced or lost Identify and know the patient's information on general health reduced
time anxious and do knowledge within 8 hours perception of the threat/situation, and psychological feelings so - Patients and
not know about about disease note the presence of anxiety, that post-therapy symptoms families discuss
disease and it and it rejection, and examine the can be compared. Causes of their anxieties
treatment treatments verbal/non-verbal signs of anxiety anxiety are vary among and fears about
- Before admitted to and examine the coping individual and may include death
the hospital, the mechanisms of the patient and acute illness, hospital stay, - Anxiety of
patient almost never family. pain, discontinuation of daily patients and
exercise, easily activities at home and work, families is
angry, had irregular changes in role and self- reduced
rest and smoking 3 image due to chronic illness, - Appears to be
packs a day, and reduced financial well rested,
consume alcohol support. Because anxious respiratory rate
and coffee drink. family members can transmit less than
anxiety to patients, nurses 16x/minute,
must reduce family anxiety
 and fear
Nursing
Data Diagnosis Goal Intervention Rational Evaluation
Objective:
- Patient look Maintain a trust and openness of Providing support and an - Heart rate less
restlessness the patient, take action when the attitude of being ready to help than 100x/minute
- Patient and family patient shows destructive and assist from service without ectopic
cooperative but behaviour, accept the patient's providers to provide a sense beats, BP within
worry about health opinion, but do not use it of security and reduce patient normal limits of
expenditure continuously, and avoid anxiety the patient, warm
- Family refuse confrontation. Orient the patient / and dry skin
possible costly person closest to the routine - Actively
interventions such procedures and expected participate in a
surgery activities. Increase participation progressive
whenever possible. Answer all rehabilitation
questions for real, provide program
consistent information, repeat as - Practice stress
indicated reduction
techniques.
Assess the need for spiritual If the patient needs religion,
guidance and referrals if religious counselling will
necessary. reduce anxiety and fear

Encourage the patient/nearest Unrelieved anxiety (stress

person to communicate with response) increases the
someone, share questions and heart's oxygen consumption
problems. Provide privacy for
patients and loved ones

Provide rest periods / Comfort and calm can reduce

uninterrupted sleep time, quiet anxiety
environment, control type and
amount of external stimulation.
 Nursing
Data Diagnosis Goal Intervention
Encourage independence, self-
care, and decision-making in
treatment. Encourage decisions
about discharge expectations.
Support active participation in
cardiac rehabilitation programs
Teach stress reduction
techniques
Collaborative Intervention
Administer anti-anxiety/hypnotics
as indicated, for example,
diazepam
Drug Study
Rational Evaluation
Cardiac rehabilitation
provided help eliminate the
fear of death and increase
psychological well-being
Stress reduction can reduce
the oxygen consumption of
the myocardium and can
improve the feeling of well-
being
Administration of the
tranquilizer drugs can reduce
the level of anxiety
No Name Dosage Drug Action Indication Contra Indication Side Effect
1. Heparin Parenterally with Heparin is a To prevent and treat Patients who have Although rare, but
(Anticoagulant) initial dose mukopolisacharide Thromboembolism. bleeding risk, gastric can produce
5,000 iu that prevent Also used for ulcer, vitamin K symptoms of
continued blood clot with MCI treatment, deficiency, kidney or nausea, vomiting
with drip 1000 iu change prothrombin CVD, unstable angina heart failure and or and skin rushes
or 20,000 – to thrombin. pectoris, dan new patient undergo
30,000 Heparin also dissemination surgery of brain or
iu/24 hours inhibit aggregation intravascular spinal cord.
platelets by thrombin coagulopathy (DIC)

2. Lasix 2 x 1 amp  Reduce fluid retention, Fluid retention Gout known to be severe diuresis
(Diuretic) Dose determine inhibits sodium and Used for fast action positive against drugs with hyponatremia,
based body water reabsorption in the increase urine production derivative of hypokalemia,
weight, kidneys Only used if thiazide is sulfonamide alkalosis,
Clinical  Antagonists to not succeed Severe functional hypochloremia and
manifestation, aldosterone. kidney disorders collapse
kidney function circulation, nausea,
vomit,
diarrhea, skin
redness, pruritus,
blur vision, postural
hypotension,
vertigo, hearing
loss.

Name
No Dosage Drug Action Indication Contra Indication Side Effect
3. Ascardia 1 x 6 mg It is NSAIDs, has anti-
(Anti- inflammatory, analgesic
inflammatory and antipyretic effect, and
drug) inhibits platelet
aggregation. Role in
controlling the
pathogenesis of
inflammation, pain and
fever
Treat and reduce risk Exacerbation phase of Nausea, vomit,
recurrence of heart erosive-ulcerative anorexia, epigastric
attack (myocardial lesions in the pain, diarrhea;
infarction) and chest gastrointestinal tract, gastrointestinal
pain (unstable angina gastro-intestinal bleeding, abnormal
pectoris); reduce the risk bleeding, history of liver function.
of recurrent attacks of urticaria, rhinitis, dizziness,
transient disruption of hemophilia, headache, visual
blood supply to the brain hemorrhagic disturbances,
due to blood clot. diathesis, dissecting tinnitus,
aneurysm pregnancy, prolongation of
lactation, bleeding time. skin
rash,
bronchospasm,

4. Pethidine 1 x 50 g Like morphine, pethidine Pethidine is indicated for Hypersensitivity to the Agitation, chest
(Analgesic) exerts its analgesic effects the treatment of active substance or to pain, constipation,
by acting as an agonist at moderate to severe pain. any of the excipients dizziness,
the μ-opioid receptor listed in section 6.1 drowsiness, dry
Severe respiratory mouth, headache,
depression, severe itchiness, loss of
obstructive airways appetite,
disease or acute hypotension,
asthma. It should not mental clouding
be administered to and sweating,
patients with severe
renal impairment or
severe hepatic
impairment.
No Name Dosage Drug Action Indication Contra Indication Side Effect
5. Diazepam Diazepam is used to treat Indications for diazepam Diazepam Side effects
(Benzodiazepin 1 x 5 mg anxiety,alcohol withdrawal, are for status contraindicated for diazepam include
es) and seizures. It is also epilepticus, anxiety or pregnant women drowsiness,
used to relieve muscle insomnia, convulsions patients with muscle weakness,
spasms and to provide due to poisoning, febrile myasthenia gravis, ataxia, mental
sedation before medical seizures, and for muscle severe respiratory disturbance,
procedures. This spasms. insufficiency, severe amnesia,
medication works by hepatic insufficiency, dependence,
calming the brain and and sleep apnea respiratory
nerves. syndrome depression,
confusion,
sometimes
headache, vertigo,
and hypotension.
6. Nurses responsibility in discharge planning included assessing standardized discharge
criteria
a. Stabil haemodynamic
b. No chest pain, signs of failure, ischemia or dysrhythmias
c. Able to perform daily activities independently
d. Demonstrate understanding to provided self-care education and follow up information

7. Recommendation for nursing practice

Based on the critical care study can be recommended that
a. Nurses required to conduct thorough assessment and concisely construct the
assessment findings
b. Nurses required to conduct holistic critical care not only focused to the physical need
but include psychosocial care
c. Patient and family required to contribute positively in critical care nursing

References
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