CASE ANALYSIS: MYOCARDIAL INFARCTION

A 50-year-old man arrives at the emergency room complaining of chest pain. He states
that the pain started about an hour after dinner while he was working. His pain is
described as a "crushing pressure" that begins in the middle of his sternum and
travels to his left arm and back. He rates it as a 4 out of 10. On examination, he is diaphoretic,
pale, and complains of shortness of breath (SOB).

QUESTIONS:
1. What further nursing assessments need to be performed for him?
 Vital signs
 Heart sounds
 Lung sounds
 Edema
 Skin condition
2. What interventions do you anticipate being ordered by his attending doctor?
Upon further assessment, the patient has no jugular vein distention (JVD) and no
edema. His heart sounds are normal (S1 and S2), and his lungs are clear with scattered
wheezes on auscultation. His vital signs were as follows:
 BP 140/90 mmHg SpO2 90% on Room Air
 HR 92 bpm and regular Ht. 173 cm
 RR 32 bpm Wt. 104 kg
 Temp 36.9°C
His 12-lead EKG report reads: “Normal sinus rhythm (NSR) with frequent premature
ventricular contractions (PVCs) and three- to four-beat runs of ventricular tachycardia
(VT)." ST-segment elevation in leads I, Avl, and V2 through V6 (3–4 mm). "ST-
segment depression in leads III and Avf.”

Cardiac enzymes were drawn and results are still pending. A chest x-ray was ordered
as well. The doctor orders the following: Aspirin 325 mg PO once, Nitroglycerin 0.4 mg
SL every 5 minutes for up to 3 doses, Morphine 4 mg IVP PRN for unrelieved chest
pain, and oxygen to keep SpO2 > 92%.

QUESTIONS:
1. What intervention should you, as the nurse, perform right away and why?
 Applying oxygen first can help prevent further complications due to inadequate
oxygenation because it reduces the myocardial oxygen demands and helps maintain
oxygenation. .

2. What medication should be the first one administered to this patient? Why and
how often?
 Nitroglycerin 0.4 mg S2 – A vasodilator, nitroglycerin affects the coronary arteries.
Increasing blood flow to the myocardium is the aim. In the event that this works, the
 patient only has angina. However, the patient could be experiencing a myocardial
infarction if it is ineffective. For up to 15 minutes, repeat every 5 minutes as necessary.
 Aspirin should be administered, but only to lessen mortality and the accumulation of
platelets. While it can partially assist in preventing the blockage from getting worse, it
helps little to alleviate the patient's current pain. 3 or 4 times a day, by at least 4 hours,
are necessary.
 Morphine should be administered if nitroglycerin and aspirin are ineffective in treating
the pain in the patient's chest.

1. What is the significance of the ST-segment changes on the patient's 12-lead

EKG?

His chest pain was unrelieved after three (3) doses of sublingual nitroglycerin (NTG).
Morphine 5 mg intravenous push (IVP) was administered, as well as 324 mg chewable
baby aspirin. His pain was still unrelieved at this point. His cardiac enzyme results were
as follows:
 CK 254 U/L
 CK-MB 10%
 Troponin I 3.5 ng/mL

QUESTION:
1. Based on the results of his labs and his response to medications, what is the
next intervention you anticipate and Why?

The patient was taken immediately to the cardiac catheter lab for a percutaneous
coronary intervention (PCI). The cardiologist found a 90% blockage in his left anterior
descending (LAD) artery. A stent was inserted to keep the vessel open.

QUESTIONS:
1. What is the purpose of Percutaneous Coronary Intervention (PCI), also known as
a heart catheterization?
 The purpose of percutaneous coronary intervention (PCI), which is used to treat coronary
artery blockages, widens or clears blocked or narrowed portions of the artery, allowing
blood to flow again to the heart.

2. What is the expected outcome of a PCI?

 A PCI is expected to prevent myocardial infarction, cardiac death, and other outcomes.

3. What do you expect to see in your patient after they receive a heart
catheterization?

He did well with the PCI, and he was put in the cardiac telemetry unit to be watched
over night. Four (4) hours after the procedure, he reports no chest pain. His vital signs
are now as follows:
 BP 128/82 mmHg SpO2 96% on 2L NC
 HR 76 bpm and regular RR 18 bpm
  Temp 37.1°C
He will be discharged home 24 hours after his arrival to the ER and will follow up with
his cardiologist next week.

QUESTION:
1. What topics for patient education would you need to discuss with him?
 Any dietary and lifestyle changes that could be made should be clarified to him.
 Exercise 30-45 minutes of moderate activity 5-7 days a week.
 Stop smoking and avoid caffeine and alcohol
 Medication Instructions