Cardiology

Case Scenario #1 Myocardial Infarction

Patient Presentation
Dido, 52 year old male patient was rushed to the ER with chief complaint of chest pain and what he calls a heavy heart. He is married works as an account executive for a company in Makati, is married with 3 children. He is described to be a smoker and a heavy drinker due to the nature of his work. He had a history of past admission due to ACS (Acute Coronary Syndrome) and was admitted for two days. 2 days prior to current hospitalization he told the admitting nurse that he had an argument with his immediate supervisor and did brought the heat of the matter to his wife at home. He is not overweight but during initial blood works, had elevated triglycerides. He also described easy fatigueability 1 day prior to admission. Initial vital signs reveal an elevated pulse, respiration and blood pressure. Initial workups done resulted to no elevation of ST segment on ECG, but still the patient has persistent chest pain within 30 minutes of ER confinement but the patient remains on artificial airway, and no significant increase in troponin levels. The patient also reports to take aspirin as maintenance. He has no history of diabetes and also reports a knee injury 20 years ago. The patient was scheduled to undergo angioplasty and was concurrently transferred to the CCU for monitoring. Patient was discharged after a week and was scheduled for follow up.

Abstract

Myocardial infarction is the cessation of blood supply to the myocardium and is usually caused by a block in the artery supplying the heart muscle. This causes chest pain, dyspnea and impairment in circulation of properly oxygenate blood in the body. It is considered to be a medical emergency as to prevent irreversible damage (infarct) to the heart muscle.

Emergency Room

1. List down nursing, medical and pharmacological intervention performed during acute phase.
Nursing Intervention
Maintain proper oxygenation to aid his poor oxygen circulation. Ensure patients safety by raising the side rails for the patient is subjected to risk for fall because of impaired oxygen circulation. Prevent injury to the patient for he is taking aspirin as maintenance that subjects him to risk for bleeding/ impaired wound healing.

Emergency Room
Medical Intervention Administer Oxygen to aid his poor oxygen circulation.

Prepare ECG to monitor the patients blood circulation, heart

Emergency Room
Pharmacological Intervention

Administer nitrates to dilate the coronary artery for better blood and oxygen circulation.
Aspirin to prevent thrombus formation Give Beta-blocker to reduce and maintain normal blood pressure and heart rate. Give morphine for chest pain. Statins or other drugs to improve your cholesterol levels

Emergency Room

2. Correlate patient history with current condition of the patient.

Acute Coronary Syndrome result from a sudden blockage in a coronary artery. This blockage causes unstable angina or heart attack (myocardial infarction) depending on the location and amount of blockage.

Emergency Room
Smoking is a predisposing factor for the development of myocardial infarction because it elevates the blood pressure; decreases exercise tolerance, and increases tendency of blood clot formation. Heavy drinking of alcohol raises the levels of some fats such as triglycerides and can also lead to high blood pressure and heart failure. The effect of chronic stress can create significant damage to the cardiovascular system by increasing the risk of coronary artery disease, elevating blood pressure, increasing atherosclerosis, and thus increasing risk of myocardial infarction.

Emergency Room

3. Rationalize the immediate diagnostic procedures performed on the patient and list possible diagnostic procedures that can be used for this case.

Electrocardiography to diagnose the new myocardial infarction

Emergency Room

Laboratory:

Troponin blood test can show if you have tissue heart damage. This test can confirm that you are having a heart attack.
Creatinine Kinase are tested in persons who have chest pain to diagnose whether they have had a heart attack. It may be ordered in a person with a high CK to determine whether the damage is to the heart or other muscles.

Emergency Room
Aspartate Aminotransferase Test (AST) it is often part of initial screening for liver disease. it is an enzyme that placed a variety of important roles in the body, it is also found in many tissues throughout the body including the liver, heart, muscles, kidney and brain. Lactate dehydrogenase (LDH) it is the general indicator of the existence and severity of acute or chronic tissue damage and, sometimes, as a monitor of progressive condition such as some cancers, kidney and liver disease. It is used to be ordered to help diagnose and monitor heart attack.

Operating Room
1. Describe the procedure angioplasty (VIDEO)

Describe the procedure angioplasty

Operating Room

2. What are the nursing responsibilities before, during and after procedure?

Before Assess and correct physiological and psychological problems that may increase surgical risk. Planning for discharge and any projected changes in lifestyle Inform the patient that a catheter will pass through the artery and a vein in the groin area. Reassure the patient that the procedure lasts from one to four hours and he or she will lie flat on the operating table all the time.

Operating Room
During
Maintain sterile technique Maintain supine position and safety After Inform the patient that he or she will spend ample time in the cardiac ICU or a certain facility wherein closer monitoring will be done until he or she is stable. Check PTT before giving heparin. Monitor the heparin effects and other intravenous medications. Asses for the peripheral pulses from time to time, there is a tendency that it will be impeded due to prolonged supine position.

Operating Room

3. List down risks and contraindications for the procedure.

a. Re-narrowing of your stent b. Blood clots c. Bleeding d. Heart attack e. Kidney problems f. Stroke g. Abnormal heart rhythms h. Left main stenosis in a patient who is a surgical candidate i. Diffusely diseased small-caliber artery or vein graft

Coronary Care Unit

1. Nursing priorities immediately after angioplasty for stabilization of the patients condition
Inform the patient that he or she will spend ample time in the cardiac ICU or a certain facility wherein closer monitoring will be done until he or she is stable. Check PTT before giving heparin. Monitor the heparin effects and other intravenous medications.

Asses for the peripheral pulses from time to time, there is a tendency that it will be impeded due to prolonged supine position.

Coronary Care Unit

2. List down possible medications to be given to this patient according to symptoms that is presented by a post MI patient and post angioplasty patient

a. b. c. d. e. f.

Morphine Oxygen Nitrate Aspirin Beta-blocker Calcium channel blocker

Coronary Care Unit

3. The patient suddenly develops hypotension, what would be the possible nursing and medical management for this?

a. Health teaching on proper rise from the bed. b. Have side rails as a measure of support c. Encourage the patient to ask for any assistance d. Vasopressin for hypotension

Discharge plan

1. Prioritize health instructions to be given to this patient

When the patient goes home, emphasize that it he or she experienced complications such as bleeding or lack of sensation on the lower extremity, inform to call the attending physician immediately.
Instruct that if chest pains happen there would be a tendency for the reinsertion of the catheter.

Discharge plan

2. List down possible pharmacological management to be taken during discharge.

Nitrates to dilate the coronary artery Aspirin to prevent thrombus formation Beta-blocker to reduce BP and HR Calcium Channel Blocker to dilate the coronar artery and reduce vasospasm Oxygen for supplement of O2 in the heart

Discharge plan

3. List down possible complications after discharge and how they are prevented.

Recurring MI Change of lifestyle Smoking cessation Regular exercise Diet for someone with heart disease Limitation of alcohol intake

Discharge plan
Congestive heart failure Change of lifestyle Smoke cessation Regular exercise Diet Limitation of alcohol intake Fatigue Less activity

Thrombus formation Take aspirin to thin out the blood

Stroke Have check-up to check on any heart failure

Nursing care plan

Assessment Subjective: The patient stated that he had chest pain. Objective: Guarding behavior Facial mask of pain Diaphoresis Diagnosis Acute pain related to ischemia of myocardial tissue Planning Short Term Goal Within 30 minutes of nursing intervention, the patient will be able to verbalize nonpharamcological methods Long Term Goal Within 8 hours of nursing intervention the patient will be able to express the relief of pain Intervention Independent: Check the vital sign Provide comfort measure such as touching, repositioning Encourage deep breathing exercises Dependent: Use of MONA Collaborative: Encourage divertionary tactics such as distractions or Watching television Evaluation Goal met

Nursing care plan

Assessment Subjective: The patient stated that he has a heavy heart. Objective: Bp: 140/100 RR: 34 PR: 100 Diagnosis Ineffective cardiac tissue perfusion related to reduced coronary blood flow Planning Within 30 minutes of nursing intervention the patient will be able to report relief of chest Intervention Evaluation

Within 8 hours of nursing intervention the patients vital sign will be able to return to normal

Obtain a 12-lead Goal met. ECG recording during symptomatic events, as prescribed Administer oxygen as prescribed Administer medication therapy as prescribed and evaluate the patients response continuously