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Case Study

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Case Study

Introduction

Arterial blockages cause myocardial infarction, a heart disease. The heart's ability to

absorb oxygen and blood flow through its ventricles is hampered. Myocardial infarction is the

most common cause of atherosclerosis. The ST segment of an ECG used to identify MI is

usually high. The purpose of this case study is to show the strong collaboration between nursing

and other therapies as an excellent example of the clinical strategy for treating myocardial

infarction patients in a hospital setting. As well as the actions that the nursing team must take,

the effects of MI on a patient are also covered in this case study. This case study is important

since, to precisely diagnose the problem, the ECG’s morphology might be studied in conjunction

with other diagnostic procedures. Coronary occlusions may be treated with thrombolytic

treatment. The degree of occlusion determines the MI’s severity (Reed et al., 2017).

Case

The patient is a 42-year-old white male with a smoking history, type 2 diabetes,

hypertension, obstructive sleep apnea, and obesity. Complex hereditary factors contribute to

coronary artery disease. After some time, the patient started to experience the effects of

myocardial infarction. The patient had a sudden, intense right-sided chest pressure event at home

that persisted for more than an hour and a half. At home, the discomfort subsided on its own. The

same discomfort was still present the following morning, but this time it was external and

radiating to the patient's left arm and jaw. These are the typical heart attack symptoms and

warning indications.

Assessment
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A 42 years old male visited an emergency room following him experienced two episodes of

chest pain on rest, second one being more severe. Upon taking his vital signs, he had an elevated

blood pressures of 167/86mmhg, on 3litre oxygen saturating at 93%, blood sugar of 310mg/dl.

The subjective data was acquired from the patient where he verbalized he experienced acute

onset of severe right sided chest pressure at rest, lasted about an hour and half. He added, ‘Pain

went away without medications at home and experienced a similar reoccurrence of similar pain

the next morning, now sub-sternal and radiation to the left jaw and arm. Further assessment was

done regarding past medical history and reported he has untreated diabetes type 2, hypertension,

hyperlipidemia, obstructive sleep apnea, obese and he is a Tabaco user. Cardiac markers to

include serial troponin, BNP and CK-MB for further assessment (Saleh & Ambrose, 2018).

The nurse looks over the patients presenting symptoms and complains and notes that his

blood pressure is elevated. Acute pain and ineffective tissue perfusion related to occlusion as

patient report that he has experienced chest pains specifically sub sternal radiated to arm and jaw

and shortness of breath at rest before visiting the hospital. The nurse determines that patient is

experiencing myocardial infarct, and also having progressively increase in levels of troponin,

elevated CK-MB and BNP which confirmed the diagnosis. The nurse is also concerned that the

patient most of the predisposing factors of myocardial infarction. Higher blood pressure indices,

smoking intensity, body mass index, and the presence of diabetes were associated with an

increased risk of MI in men and women (Millett, Peters & Woodward, 2018).

Medications

Heparin: an Antithrombotic Agents. It prevent the formation of thrombi associated with

myocardial infarction and inhibit platelet function by blocking cyclooxygenase and subsequent

platelet aggregation.
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Aspirin: an antiplatelet. Inhibits synthesis of prostaglandin by cyclooxygenase; inhibits platelet

aggregation; has antipyretic and analgesic activity.

Nitroglycerin: causes systemic vasodilation, decreasing preload

Zofran HCL: binds to 5-HT3 receptors both in periphery and in CNS, with primary effects in GI

tract. Has no effect on dopamine receptors and therefore does not cause extrapyramidal

symptoms. According to Reed et al. (2017, these symptoms develop over time instead of

suddenly.

Time Lab results

1600hrs Serial troponins (troponin) 0.06

2000hrs Troponin 0.08

0000hrs Troponin 0.53

BNP 7.9

Ck-MB 51.1

The initial troponin level on admission were slightly elevated form normal (0-0.04) and 4 hours

later they continued to raised up to 0.53 within 8 hours of admission. An elevated levels of

troponins is an indication of myocardial infarction. Furthermore, CK-MB levels are also elevated

to 15.1, normal ranges (5 to 25 IU/L) which suggest likelihood of damage of heart muscles.

Vital signs

Temperature 98.6

HR 91bpm
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RR 20b/min

B/P 167/86mmhg

SPO2 93% on O2 3l

Blood Glucose 310mg/dl

Patient blood pressures is elevated suggestive the heart is straining to pump the blood secondary

to occlusion in the major arteries supplying the myocardial muscles. Patient is also in

dependency on O2 supplement to meet the body O2 demands. Cardiac enzymes and other

indications of heart health are studied. They are crucial in determining a variety of disorders that

may increase cardiac biomarkers, but they are especially helpful when analyzing myocardial

infarction (Thygesen et al., 2018). Myocardial infarction severity must be assessed using cardiac

enzymes like creatine kinase-MB. The quantity of cardiac proteins in the patient’s blood tells us

how severe the myocardial infarction is. Finding these enzymes makes it simpler to categorize

myocardial infarction patients according to risk. The nurses' job in the CCU is to monitor vital

signs such as blood pressure, heart rate variations, and breathing rates. An electrocardiogram

(ECG), which frequently reveals the presence of anomalies in the left ventricle, is the most

frequently utilized test to diagnose suspected myocardial infarctions. It is possible to identify

myocardial cell degeneration through laboratory testing of blood proteins associated with the

heart. Less oxygen is delivered to the heart due to aging cardiac cells brought on by MI. As a

result, the heart may have trouble getting oxygen from the blood. The importance of using

oxygen to increase red blood cell oxygen saturation compensates for the heart's decreased ability

to collect oxygen.

Care Plan
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After thorough head to toe assessment of patient, I came up with the following three priority

nursing diagnosis related to myocardial diagnosis

Nursing diagnosis

1. Acute pain

Acute pain related to tissue ischemia and coronary arterial occlusion as evidenced by

patient reporting of substernal pain radiating to the left jaw and arm. Elevated blood

pressures of 167/86.

Expected outcome after interventions

By the end of one hour of interventions, patient will verbalize relief/control of chest pain. He will

also will display reduced tension, relaxed manner, ease of movement and demonstrate use of

relaxation techniques.

Nursing interventions and rationale

1. Monitor and document characteristic of pain, noting verbal reports, nonverbal cues

(moaning, crying, grimacing, restlessness, diaphoresis, clutching of chest) and BP or

heart rate changes.

Rational: patients with an acute MI appear ill, distracted, and focused on pain. Verbal

history and deeper investigation of precipitating factors should be postponed until

pain is relieved. Respirations may be increased as a result of pain and

associated anxiety, release of stress-induced catecholamines increases heart rate and

BP.

2. Obtain full description of pain from patient including location, intensity (using scale

of 0–10), duration, characteristics. Assist patient to quantify pain by comparing it to

other experiences (Reed et al., 2017).

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Rational: Pain is a subjective experience and must be described by patient. Provides

baseline for comparison to aid in determining effectiveness of therapy, resolution and

progression of problem.

3. Administer supplemental oxygen by means of nasal cannula or face mask, as

indicated. Rational: Increases amount of oxygen available for myocardial uptake and

thereby may relieve discomfort associated with tissue ischemia.

4. Administer nitroglycerin as prescribed. Rational: useful for pain control by coronary

vasodilating effects, which increase coronary blood flow and myocardial perfusion

Evaluation

Patient demonstrated relieve of chest pain after administration medications. He also displayed

reduced tension, relaxed manner, ease of movement.

2. Ineffective tissue perfusion

Risk of ineffective tissue perfusion related to reduction and interruption of blood flow to

myocardial muscles.

Expected outcome

Demonstrate adequate tissue perfusion by patient’s vital signs reading within normal range,

patient alert/oriented, free of pain and discomfort.

Nursing interventions and rationale

1. Administer antiplatelet and anticoagulant that is aspirin and heparin respectively

as prescribed. Rationale: Aspirin reduces coronary reocclusion and heparin reduce

risk of thrombophlebitis or mural thrombus formation.

2. Inspect for pallor, cyanosis, mottling, cool and clammy skin. Note strength of

peripheral pulses. Rationale: Systemic vasoconstriction resulting from diminished

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cardiac output may be evidenced by decreased skin perfusion and diminished

pulses.

Evaluation

Patient demonstrated adequate perfusion through vital signs within patient’s normal range,

patient alert/oriented and free of pain/discomfort

3. Activity intolerance

 Activity intolerance related to imbalance between myocardial oxygen supply and demand

as evidenced by patient only saturating better on oxygen and reporting of extertional

angina at rest.

Expected outcome

Patient will demonstrate measurable and progressive increase in tolerance for activity with 12

hours of interventions. Within 4 hours of interventions patient will report absence of angina

Nursing interventions and rationale

1. Encourage rest initially. Thereafter, limit activity on basis of pain and/or adverse

cardiac response. Provide non-stress diversional activities. Rationale: Reduces

myocardial workload and oxygen consumption, reducing risk of complications.

2. Document heart rate and rhythm and changes in BP before, during, and after activity.

Correlate with reports of chest pain or shortness of breath. Rationale: Trends

determine patient’s response to activity and may indicate myocardial oxygen

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deprivation that may require decrease in activity level and return to bedrest, changes

in medication regimen, or use of supplemental oxygen.

Atherosclerotic plaque accumulation, which encourages intracoronary thrombus

formation, is the primary cause of MIs. An intracoronary thrombus causes the coronary artery to

narrow. As a result, the ventricles receive insufficient blood supply, which leads to myocardial

infarction. A myocardial infarction can result from several uncommon diseases impeding

coronary arteries. They include unusual coronary artery inflammation, blood clots that form

outside the ventricles, such as those that do so in the heart chamber, stabbing wounds that are

close to the heart, the spasmodic effects of cocaine on the coronary artery, post-heart surgery

complications, and other strange heart conditions (Reed et al., 2017).

The heart's ventricular activity can be compared using an ECG. The ECG's ST segment

elevation is used to infer. The ST-segment elevation in leads II, III, and all of the patient's ECG

signals indicated MI. However, myocardial infarction cannot be accurately detected by the ECG

alone. It is important to remember that the ECG examines several heart disorders. As a result,

there might be discrepancies between the fundamental elements of the signal and the diagnosis

offered by morphology. For instance, the ST segment's characteristics are utilized to evaluate

myocardial infarction. The presence of an expanded segment suggests a myocardial infarction.

However, the genetic cardiac arrhythmia of Brugada Syndrome increases the likelihood of an

ST-segment elevation. More testing is therefore necessary, including lab tests and urine and

blood sample analysis.

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Conclusion

Acute myocardial infarction, often known as a heart attack, is a dangerous condition that

necessitates immediate medical attention because it cuts off the heart's blood supply. Fortunately,

there are many methods to diminish the effects of this condition and its long-term detrimental

effects on health. You can speed up your recovery from a heart attack and lower your risk of

having another by changing your diet and lifestyle. The myocardium is oxygen-deprived by

coronary artery occlusion. If the myocardium is persistently denied oxygen, myocardial necrosis

and cell death may happen. Patients may experience neck, jaw, shoulder, or arm pain or tightness

in their chest. In addition to the history and physical examination, abnormalities in the ECG and

an increased cardiac troponin level may be signs of myocardial ischemia. The pathophysiology,

diagnosis, and management of myocardial infarction are covered in this exercise, which also

stresses the value of an interprofessional team in improving patient care.

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References

Millett, E. R., Peters, S. A., & Woodward, M. (2018). Sex differences in risk factors for

myocardial infarction: cohort study of UK Biobank participants. bmj, 363.

Reed, G. W., Rossi, J. E., & Cannon, C. P. (2017). Acute myocardial infarction. The

Lancet, 389(10065), 197-210.

Saleh, M., & Ambrose, J. A. (2018). Understanding myocardial infarction. F1000Research, 7.