ST.

ANTHONY’S COLLEGE
NURSING DEPARTMENT
San Jose de Buenavista, Antique

Name: Jica Marie B. Gicaro Year & Section: BSN - 3A

I. TEXTBOOK DISCUSSION

1. Definition
ST-elevation myocardial infarction (STEMI) is a type of myocardial infarction in which
there is significant damage to the myocardium. This is supported by the evidence that the patient
has acute MI with characteristic changes in two contiguous leads on a 12-lead ECG. When one
or more coronary arteries, which transport blood to the heart, become clogged, it happens.
Typically, this abrupt cessation of blood flow is brought on by plaque rupture or coronary artery
dissection that results in an obstructive thrombus. A STEMI is treated with immediate PCI
within 60 minutes. When PCI is not an option, thrombolytic therapy is advised.

1. Anatomy and Physiology of organs/systems involved

Heart - The thick and metabolically active cardiac muscle in the heart's wall requires a large
amount of blood due to its high dynamic. The blood's passage through the heart wall is made
possible by coronary arteries and coronary veins. Blood is pumped into the heart's wall by two
coronary arteries. Just above the aortic semilunar valves, at the base of the aorta, the coronary
arteries begin to circulate. The left coronary artery originates on the left side of the aorta. One of
the three layers of the heart wall is called as myocardium, which is composed of cardiac muscle
cells and is responsible for contraction of the heart chambers. Electrical currents that may be
measured at the skin's surface are created by action potentials that go through the heart during the
cardiac cycle. The record of these electrical events is an electrocardiogram. P waves, QRS
complexes, and T waves make up the standard ECG. Three distinct waves—the Q, R, and S
waves—make up the QRS complex. The beginning of the QRS complex comes before
ventricular contraction and the end of the QRS complex follows ventricular depolarization. The
onset of the T wave came before ventricular relaxation, and it symbolizes the repolarization of
the ventricles. However, a complete blockage of one of the heart's main supply arteries is
frequently indicated by an increase in the ST segment. That could indicate that the muscle of the
ventricles is dying if it occurs during a heart attack. The fact that the heart muscle is in the
process of dying implies that knowing it during a STEMI is essential knowledge for medical
professionals. Consequently, reopening that artery and resuming blood flow as quickly as
feasible may help to avoid irreversible harm or at the very least lessen its severity.
Lungs - The anatomical and physiological unity of the heart and lung cannot be separated. Both
the changes in one and the other have an impact. A heart failure syndrome arises following an
ST-elevation myocardial infarction. The syndrome is characterized by hypoxemia brought on by
passive pulmonary congestion. This hypoxemia indicates the lung's dysfunction and the disease's
hemodynamic progression. This resulted to shortness of breath, dyspnea, tachypnea, and crackles
if MI has caused pulmonary congestion. Pulmonary edema may be present.

Abdomen - Lactic acid, pyruvic acid, and other metabolites are released by necrotic, ischemic,
and damaged cardiomyocytes in infarcted regions. These metabolites activate the infarcted
regions' peripheral autonomic nerve receptors. Cardiogenic nausea and vomiting follow the
stimulation at that point.
Nervous system – The presence of the heart on the left side of the chest is the cause of the
discomfort radiating up the left side of the neck arm and down the left arm. Thus, pain radiates
along left sided cervical nerve roots.

3. Signs and Symptoms

Found in the textbook As manifested by the patient:
- Tachycardia - Shortness of breath
- Dyspnea - Skin is cool and pale
- Bradycardia - Diaphoretic
- Skin is cool, pale, clammy and - Increased blood pressure
diaphoretic in appearance - Tachycardia
- Pulmonary edema - Tachypnea
- Indigestion - Acute onset of midsternal chest pain
- Nausea that radiated down the left arm and
- Chest pain radiating to one or both radiates up the left side of the neck
arms, the neck and the back.
- Anxiety and apprehension
- Fever
- Shortness of breath
2. Pathophysiology (Schematic Diagram)

ST-elevation Myocardial Infarction (STEMI)

PREDISPOSING FACTORS PRECIPITATING FACTORS

-Age (<40 years old) -Diet and lifestyle
-Sex (usually male) -Socioeconomic factors (low income and education)
-Hereditary (family history of CAD) -Smoking and alcoholic drinking
-Abdominal obesity
-Low physical activity
-Diabetes mellitus
-High blood pressure and high blood cholesterol

Increased sympathetic activity

Increased blood pressure, Increased coagulability

increased heart rate,
increased dp/dt
Increased intravascular
pressure, increased shear
forces
Increased platelet adhesion
Coronary vasocontriction
Increased local shear
force on plaque

Rupture of an atherosclerotic plaque

Due to plaque rupture, subendothelial

adhesion molecules are exposed to Tissue factor (thromboplastin)
Primary haemostasis flowing blood released (most likely from
-platelet adhesion macrophages)
-platelet activation
-platelet aggregation Fibrin strands form a
Secondary hemostasis
meshwork around
-coagulation cascade
activated platelets

Thrombus forms

Complete occlusion of coronary artery, the LADA

(Left anterior descending artery)

Myocardial Ischemia imbalance of cardiac oxygen to meet the

demand of the myocardium
 Full thickness damage (myocardial cell
death) of cardiac muscle or it becomes
necrotic

PROGNOSIS

With medical management: Without medical management:

-Percutaneous transluminal - Myocardial ischemia
coronary angioplasty (PTCA) - Increased myocardial oxygen
-Thrombolytic treatment demand
-Abnormal heart rhythms or
Good prognosis arrhythmias

Poor prognosis
Continue therapy as indicated:
• Intravenous heparin, low-
molecular-weight heparin, -Heart failure or cardiac arrest
bivalirudin, or fondaparinux -Death of cardiac tissues
• Clopidogrel (Plavix)
• Glycoprotein IIb/IIIa inhibitor Death
• Bed rest for a minimum of 12 to
24 hoursPossible for recovery

Stable vital signs and is free of

pain

5. Management
a. Medical

- Use the hospital's rapid transit system.

- Obtain a 12-lead electrocardiogram to be analyzed within 10 minutes

- Obtain blood samples for testing that include cardiac biomarkers like troponin.
- Begin routine medical interventions:
 Supplemental oxygen
 Nitroglycerin
 Morphine
 Aspirin
 Beta-blocker
 Angiotensin-converting enzyme inhibitor within 36 hours
 Anticoagulation with heparin and platelet inhibitors
 Statin
- Check for signs that require reperfusion therapy

b. Surgical (if applicable)

- Emergency percutaneous transluminal coronary angioplasty (PTCA) also called as

percutaneous coronary intervention (PCI) may be performed to reopen an occluded coronary
artery

c. Nursing

- Promote oxygen and tissue perfusion

- Promoting adequate cardiac output

- Promoting rest and comfort

- Promote activity

- Promoting nutrition and elimination

- Promoting relief of anxiety and feeling of well-being

- Facilitate health teaching

II. PROBLEM LIST (Identified Nursing Diagnoses numbered according to priority)

• Acute pain related to myocardial ischemia as evidenced by reports of chest pain with
diaphoresis and increase in pulse rate and blood pressure.
• Risk for decreased cardiac output related to increase in heart rate and blood pressure as
evidenced by difficulty of breathing and ECG changes.
• Activity intolerance related to imbalance between myocardial oxygen supply and demand as
evidenced by alterations in heart rate and blood pressure.

III. NURSING CARE PLAN

Cues Nursing Scientific Goals/ Interventions Rationale Evaluatio

Diagnosis Basis Objectives/ n
(Rationale Outcome
) Criteria
09/22/22 Acute pain The The patient Independent: Evaluated
related to deposits, will report on
Subjecti myocardial known as pain relief - Monitor and - Symptoms September
ve cues: ischemia as plaques, and control record pain of illness, 22, 2022.
Patient evidenced constrict on chest by characteristics distraction,
complain by reports the 8:00 am , taking note and - After 1
s of chest coronary September of verbal discomfort are hour of
shortness pain with arteries 22, 2022. complaints, what the nursing
of breath diaphoresis and may nonverbal majority of interventio
and hinder the indicators people with n, the
increase in heart (such as an acute MI patient
pulse rate muscle The patient sobbing, present with. was able
Objectiv and blood from will follow crying, Prior to to
e cues: pressure. receiving prescribed restlessness, getting a improved
a typical pharmacol diaphoresis, verbal history comfort in
T: 99°F amount of ogical grasping the or digging chest, as
oxygen- regimen by chest, and deeper into evidenced
BP: rich 8:00 am on rapid the underlying by:
160/90 blood. September breathing), causes, wait
mm Hg "Angina" 22, 2022. and blood till the pain reported a
is the pressure/heart has stopped. decrease
HR: 110 name for rate Elevated in the
bpm the chest fluctuations.  breathing may chest pain.
pain The patient result from Is able to
RR: 26 brought will pain and its relax,
breaths/ on by demonstrat accompanying shows
min ischemia, e how to anxiety; heart signs of
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Skin is occurs use rate and blood less
cool, during relaxation pressure are tension,
pale, and myocardi techniques also increased and sleeps
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ely infarction. recreationa related .
sweating l activities catecholamine Requires d
as s are ecrease
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for the or
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by 8:00 am patient's - Pain is a goal was
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22, 2022. including its that the - After 1
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duration, express. nursing
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breathing, pain. way of
diversions, Increases breathing
visualization, good mood and
and guided and gives a relaxation
imagery. feeling of techniques
having some and was
control over able to
the participate
circumstance. in
activities
- Before and that could
after taking help
narcotic - Narcotic prevent
medicine, administration anxiety
check the vital may result in and
signs. hypotension/r increase
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the presence goal was
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 these issues
could
exacerbate
myocardial
- After injury.
already being
hospitalized, - to lessen the
instruct the workload and
patient on myocardial
administering oxygen
nitroglycerin demand.
SL. Teach the
patient about
changes and
restrictions to
their
activities.

Dependent:

- Take a 12-
lead ECG at
admission and
again if chest
discomfort - Serial and
reappears to stat ECGs
check for keep track of
signs of new changes that
infarction, as can reveal the
directed. site of MI and
additional
heart damage.
Collaborative:

- Apply more
oxygen using
a face mask or
nasal cannula
as necessary. - Increases the
quantity of
oxygen that
the
myocardium
can absorb,
potentially
reducing
tissue
ischemia's
- The discomfort.
following
drugs should
be
administered - Increases the
as directed: quantity of
mononitrate, oxygen that is
isosorbide available for
denitrate myocardial
(Isordil), and uptake, which
nitroglycerin may reduce
(Nitro-Bid, pain brought
Nitrostat, and on cardiac
Nitro-Dur) tissue
(Imdur) ischemia.

- Beta-
blockers
include
metoprolol
(Corgard), - diminish
propranolol myocardial
(Inderal), demand,
 atenolol lower heart
(Tenormin), rate, and
pindolol inhibit
(Visken), and sympathetic
propranolol stimulation
(Lopressor)

- Painkillers,
such as
morphine and
meperidine - Although
(Demerol) morphine is
the preferred
medication for
treating MI
pain, other
analgesics
may also be
administered
to ease
discomfort
- As directed, and lessen the
administer strain on the
calcium heart.
channel
blockers. - to improve
collateral
circulation
and coronary
blood flow in
order to lessen
ischemia-
related
discomfort.

References:

Vera, M. (2022). 7 Myocardial Infarction (Heart Attack) Nursing Care Plans. Nurseslabs.
Retrieved from: https://nurseslabs.com/7-myocardial-infarction-heart-attack-nursing-care-plans/
 Abundo, E. (2021). 12753198 Nursing Care Plan for myocardial infarction. StuDocu.
Retrieved from: https://www.studocu.com/ph/document/bicol-university/nursing/12753198-
nursing-care-plan-for-myocardial-infarction/17523581
Myocardial Infarction Nursing Care Plan. RNspeak. Retrieved from:
https://rnspeak.com/myocardial-infarction-nursing-care-plan/#Activity_intolerance

Aroesty, J., and Kannam, J. (2022). Patient education: Chest pain (Beyond the Basics).
UpToDate. Retrieved from: https://www.uptodate.com/contents/chest-pain-beyond-the-
basics#:~:text=The%20deposits%2C%20called%20plaques%2C%20cause,chest%20pain
%20caused%20by%20ischemia.