INTRODUCTION

Acute myocardial infarction (AMI or MI), more commonly known as a

heart attack, is a disease state that occurs when the blood supply to a part of
the heart is interrupted. The resulting ischemia or oxygen shortage causes
damage and potential death of heart tissue. It is a medical emergency, and the
leading cause of death for both men and women all oer the world.!"#
Important risk factors are a preious history of ascular disease such as
atherosclerotic coronary heart disease and$or angina, a preious heart attack or
stroke, any preious episodes of abnormal heart rhythms or syncope, older age
%especially men oer &' and women oer (', smoking, excessie alcohol
consumption, the abuse of certain illicit drugs, high triglyceride leels, high
)*) (+)ow,density lipoprotein+) and low -*) (+-igh density lipoprotein+),
diabetes, high blood pressure, obesity, and chronically high leels of stress in
certain persons.
The term myocardial infarction is deried from myocardium (the heart
muscle) and infarction (tissue death due to oxygen staration). The phrase
+heart attack+ is sometimes used incorrectly to describe sudden cardiac death,
which may or may not be the result of acute myocardial infarction.
.lassical symptoms of acute myocardial infarction include chest pain,
shortness of breath, nausea, omiting, palpitations, sweating, and anxiety or a
feeling of impending doom. /atients fre0uently feel suddenly ill. 1omen
often experience different symptoms than men. The most common symptoms
of MI in women include shortness of breath, weakness, and fatigue.
Approximately one third of all myocardial infarctions are silent, without chest
pain or other symptoms.
Immediate treatment for suspected acute myocardial infarction
includes oxygen, aspirin, glyceryl trinitrate and pain relief, usually morphine
sulfate. The patient will receie a number of diagnostic tests, such as an
electrocardiogram (2.3, 243), a chest 5,ray and blood tests to detect
eleated creatine kinase or troponin leels (these are chemical markers
released by damaged tissues, especially the myocardium). 6urther treatment
may include either medications to break down blood clots that block the blood
flow to the heart, or mechanically restoring the flow by dilatation or bypass
surgery of the blocked coronary artery. .oronary care unit admission allows
rapid and safe treatment of complications such as abnormal heart rhythms.
Acute myocardial infarction is a type of acute coronary syndrome,
which is most fre0uently (but not always) a manifestation of coronary artery
disease. The most common triggering eent is the disruption of an
atherosclerotic pla0ue in an epicardial coronary artery, which leads to a
clotting cascade, sometimes resulting in total occlusion of the artery.
Atherosclerosis is the gradual buildup of cholesterol and fibrous tissue in
pla0ues in the wall of arteries (in this case, the coronary arteries), typically
oer decades. 7lood stream column irregularities isible on angiographies
reflect artery lumen narrowing as a result of decades of adancing
atherosclerosis. /la0ues can become unstable, rupture, and additionally
promote a thrombus (blood clot) that occludes the artery8 this can occur in
minutes. 1hen a seere enough pla0ue rupture occurs in the coronary
asculature, it leads to myocardial infarction (necrosis of downstream
myocardium).
If impaired blood flow to the heart lasts long enough, it triggers a process
called the ischemic cascade8 the heart cells die (chiefly through necrosis) and
do not grow back. A collagen scar forms in its place. 9ecent studies indicate
that another form of cell death called apoptosis also plays a role in the process
of tissue damage subse0uent to myocardial infarction.!:"# As a result, the
patient;s heart can be permanently damaged. This scar tissue also puts the
patient at risk for potentially life threatening arrhythmias.
In<ured heart tissue conducts electrical impulses more slowly than
normal heart tissue. The difference in conduction elocity between in<ured and
unin<ured tissue can trigger re,entry or a feedback loop that is belieed to be
the cause of many lethal arrhythmias. The most serious of these arrhythmias is
entricular fibrillation (V-Fib$=6), an extremely fast and chaotic heart rhythm
that is the leading cause of sudden cardiac death. Another life threatening
arrhythmia is entricular tachycardia (V-Tach$=T), which may or may not
cause sudden cardiac death. -oweer, entricular tachycardia usually results
in rapid heart rates that preent the heart from pumping blood effectiely.
.ardiac output and blood pressure may fall to dangerous leels, which is
particularly bad for the patient experiencing acute myocardial infarction.
The cardiac defibrillator is a deice that was specifically designed to
terminate these potentially fatal arrhythmias. The deice works by deliering
an electrical shock to the patient in order to depolari>e a critical mass of the
heart muscle, in effect +rebooting+ the heart. This therapy is time dependent,
and the odds of successful defibrillation decline rapidly after the onset of
cardiopulmonary arrest.
?AI@T /AA) A@I=29?ITB /-I)I//I@2?
?.-CC) C6 -2A)T- ?.I2@.2?
*2/A9TM2@T C6 @A9?I@3
Patients initial, age, sex: M?, (D, female Admitting Diagnosis: -ypertension
Civil Status: Married Date of AdmissionE Fanuary "D, :''G
Date of Bit!: May "&, "DH& C!ief Com"laint: .hest /ain
Addess: Annafunan, Tuguegarao .ity Attending P!#si$ian: *r. 9. *elos santos
O$$u"ation: -ouse1ife
Religion: 9oman .atholic
ASS%SS&%NT
&%DICA' ( SOCIA' )ISTOR*: /atient experienced childhood illness such as mumps and chickenpox.
C)I%+ CO&P'AINT: .hest pain
P
The patient is a retired goernment employee of their place. ?hes the
third child of his parents who were blessed with six children. ?he has a
loing husband and caring children that they are the once who takes
good care of her during hospitali>ation and attends to her needs
including medication and financial support. The patient is non smoker
and alcoholic drinker.
*A9I@3E The client is ery weak. ?he depends on nurses interentions
regarding her condition.
%
726C92E M? defecates regularly eery morning and would oid I
times a day.
*A9I@3E M? defecates regularly and oid & times a day.
R
726C92E M? sleeps at around "' pm and wakes up at around ( am.
M? cannot do any household chores because she was paraly>ed which
started last <uly :''J and it was her first attack.
*A9I@3E 1hen she was hospitali>ed, M? sleeps all the time.
S
726C92E M? lies at Annafunan with her husband and her two
children. The patient doesnKt hace any allergies in food, medication
and in the enironment. According to the ?C, M? wears eye glasses
when she reads.
*A9I@3E The client stays at .=M.,MI.A her husband and daughter were
the oneKs staying with him in the hospital.
O
726C92E M? experienced difficulty of breathing before admitted. *A9I@3E The patient hae oxygen tank beside her and regulated at :,& lpm
N
726C92E M? hae good appetite, she eats egetables, bread and a lot
of meat in her meals. ?he takes her breakfast eery day and neer skips
meals.
*A9I@3E M? eats three times a day. ?he is not on @3T 6eeding. ?he does
takes her medications prescribed for her.
S
M? is 9oman .atholic, has a strong belief in 3od. ?he neer forgets to
pray eery day and thank 3od for the blessings she has.
*A9I@3E M? has a rosary with her.
)ealt! )isto# %limination Rest , A$tivit#
.urrent -ealth
/roblems
.hest pain
6amily 9isk 6actors
@o known family history
of illness.
?tool
The client did not pass any stool within our
shift
.urrent Actiity )eel
The client lies on her bed throughout the shift
/ast -ealth
/roblems
The patient
experiences minor
illness such as
hicken pox,
mumps,
hypertension and
meningitis.
-ealth Maintenance
/ractices
The client eats his meals on
time and neer had skipped
any. ?he also takes oer the
counter drugs when she
experience any minor
illnesses such as headache
as erbali>ed by the ?C.
Arine A*)Ks
.lient *M canKt groom her self and do her actiities of daily liing due
to body weakness but her ?CKs was there to assist her.
?urgical -istory
none
?leep
The patient was closing her eyes within our shift.
Cbstetrical -istory
3L:TL:/L'AL')
L:
Medications
Aspirin G'mg " tab$@3T
C*.
Imidapril "' mg$tab "
tab$@3T now then C*
.iticholine " g. I= 0 ":
)anoxin .:( mg C*
Mannitol "''cc I= now.
Abdomen
7owel soundsE audible (normal)
/alpationE no palpable masses
7ody 6rame
The patient is thin.
Accidents
The patient had not
been inoled in
any kinds of
accident
Toileting Ability
The client canKt ambulate.
/osture
Anable to Assesed
/atient 2ducation
@eeds
The patient needs
emphasis on
proper health
management and
how to aoid
strenuous
actiities.
3ait
Anable to Assesed
Ps#$!oso$ial )isto#
.oordination
The patient has no unnecessary moements..
?ignificant Cthers
*MKs husband and children take care of
her while in the hospital.
Cccupation$ 2ducation
The client <ust stays at home because of his old age.
.oping MechanismE
The client has a happy disposition. -e
often opens up her problem to her
husband and tries to talk it out to him
together with her children.
3eneral Appearance
The patient has fair complexion with een skin tone.
?he is thin. ?he is also conscious because she follows
our instructions.
7alance
Anable to assessed..
9eligion
The client is a 9oman .atholic.
Affect
The patient demonstrates normal affect. ?he shows
facial expressions suitable on eery situation
Muscle
ArmsE )egsE
?trengthE passie
ToneE normal
/rimary )anguage
The client speaks Ibanag.
Crientation M MemoryE
-e is oriented to the people around her because she
een calls the name of her husband.
Motor 6unction
6ineE he can hold ob<ects, touch diff. body parts
3rossE he cant ambulate due to weakness.
/rimary ?ources of -ealth
-ospital .
9ange of Motion
)egsE can extend, flex, slightly lift legs with assistance
ArmsE can extend, flex, lift arms with assistance
6inancial ?ources related to illness ?peechE
?lurred ?peech.
/ain 9elief MeasureE
@o complaints of pain
The client financialsource is her children
specially her daughter abroad.
@on =erbal 7ehaiorE
The client was calm and submissie
Mobility$ Ase of Assistie *eices
?C and -./
Safe %nvionment Ox#genation Nutition
Allergies$9eaction
MedicationsE none
6oodE none
2nironmentE none
Actiity ToleranceE ?he can moe her body with
assistance.
-ospital *iet$9estriction
C6
Airway .learanceE
@o complaints.
6luid Intake
About &'ml
2yes$=isionE
3lassesE the client uses reading
glasses sometimes
/upilsE /299)A
9espirationsE
9hythmE regular
/ositioned assumedE moderate high back rest
Ase of accessory musclesE negatie use of
accessory muscle
I=E
?iteE right arm
?olutionE /@?? ")x H'gtts$min. with side drip of *( 1 N & amp.
-ydrala>ine x "' gtts.$min.
-earing$-earing AidE
The client has good hearing and she
doesnKt use any hearing aid.
?kin integrityE
)esions$ scarsE none
3ood skin integrity
)ung ?oundsE negatie adentitious sounds -eight E (
TemperatureE HI.( . 9outeE axilla 1eightE
)aboratory Analysis .olor
?kinE brown )ipsEbrown
@ailsE light pink
?kin TurgorE
@ormal8 snaps back when pinched
Ability toE
.hewE @3T
?wallowE
Tolerate
=omitE positie
.apillary 9efillE
: seconds
/ulse Cximetry
/eripheral /ulse
)ocationE apical 9ateE G& bpm
9hythmE irregular
?trengthE strong full and then weak pulses
7lood glucose monitoring
Apical /ulse O (
T-
intercostal space )aboratory Analysis
7lood /ressureE "('$"''
2demaE no edema
-omanKs signE @A
)aboratory Analysis
M.-, hemoglobine,H& n. (:I,H:)
M.- Pcontent H" n.. (H:,HI)
17.
@eutrophils .IJ n. (.H(,I()
.reatinine &J n.. ( (H,""()
@a "HI n. ("HG,"&()
ANATO&* , P)*SIO'O-*
CARDIO.ASCU'AR S*ST%&
The heart is the pump responsible for maintaining ade0uate circulation of
oxygenated blood around the ascular network of the body. It is a four,
chamber pump, with the right side receiing deoxygenated blood from the
body at low presure and pumping it to the lungs (the pulmonary circulation)
and the left side receiing oxygenated blood from the lungs and pumping it at
high pressure around the body (the systemic circulation).
The myocardium (cardiac muscle) is a specialised form of muscle, consisting
of indiidual cells <oined by electrical connections. The contraction of each
cell is produced by a rise in intracellular calcium concentration leading to
spontaneous depolarisation, and as each cell is electrically connected to its
neighbour, contraction of one cell leads to a wae of depolarisation and
contraction across the myocardium.
This depolarisation and contraction of the heart is controlled by a specialised
group of cells localised in the sino/atial node in the ig!t atium, the
pacemaker cells.
1. These cells generate a rhythmical
depolarisation, which then spreads out
over the atria to the atrio-ventricular
node.
2. The atria then contract, pushing blood
into the ventricles.
3. The electrical conduction passes via the
Atrio-ventricular node to the bundle of
His, which divides into right and left
branches and then spreads out from the
base of the ventricles across the
myocardium.
. This leads to a !bottom-up! contraction of
the ventricles, forcing blood up and out
into the pulmonary artery "right# and
aorta "left#.
$. The atria then re-fill as the myocardium
rela%es.
The ;s0uee>e; is called s#stole and normally lasts for about :('ms. The
relaxation period, when the atria and entricles re,fill, is called diastole8 the
time gien for diastole depends on the heart rate.
T!e %C-
The 2lectrocardiograph (2.3) is clinically ery useful, as it shows the
electrical actiity within the heart, simply by placing electrodes at arious
points on the body surface. This enables clinicians to determine the state of
the conducting system and of the myocardium itself, as damage to the
myocardium alters the way the impulses trael through it.
1hen looking at an 2.3, it is often helpful to remember that an upward
deflection on the 2.3 represents depolarisation moing towards the iewing
electrode, and a downward deflection represents depolarisation moing away
from the iewing electrode. 7elow is a normal lead II 2.3.
The P wave represents atrial depolarisation- there is
little muscle in the atrium so the deflection is small.
The Q wave represents depolarisation at the bundle of
His& again, this is small as there is little muscle there.
The R wave represents the main spread of
depolarisation, from the inside out, through the base of
the ventricles. This involves large ammounts of muscle
so the deflection is large.
The S wave shows the subse'uent depolarisation of the
rest of the ventricles upwards from the base of the
ventricles.
The T wave represents repolarisation of the
myocardium after systole is complete. This is a relatively
slow process- hence the smooth curved deflection.
T!e Coona# Ci$ulation
The heart needs its own reliable blood supply in order to keep beating, the
coronary circulation. There are two main coronary arteries, the left and right
coronary arteries, and these branch further to form seeral ma<or branches.
The coronary arteries lie in grooes (sulci) running oer the surface of the
myocardium, coered oer by the epicardium, and hae many branches which
terminate in arterioles supplying the ast capillary network of the
myocardium. 2en though these essels hae multiple anastomoses,
significant obstruction to one or other of the main branches will lead to
ischaemia in the area supplied by that branch.
NURSIN- CAR% P'ANS
NURSIN-
DIA-NOSIS
D%+ININ-
C)ARACT%RISTICS
%0P%CT%D
OUTCO&%S
NURSIN-
INT%R.%NTIONS
%.A'UATION O+
%0P%CT%D
OUTCO&%S
P
%
Anxiety r$t threat of
death
9estlessness
Anxious
6acial tension
*ecreased energy
worried
At the end of " hour, the
patient will be able to
appear relaxed
Assesed patient
condition.
/roided comfort
measures.
Maintained a calm
and tolerant manner
while interacting
with patient
2stablished a
therapeutic
relationship,
coneying empathy
and unconditional
positie regard.
Informed patient
regarding her health
condition.
Informed patient
wheneer
interentions are
being done.
Ased therapeutic
touch.
The patient achieed
lower leel of anxiety as
she appeared relaxed.
R
S
O
N
Actiity Intolerance
r$t body weakness
?een patient
assisted by ?.C.
in positioning
99, :I cpm
/9 PG& bpm
/assie
moements
At the end of the shift,
the patient will hae an
improed actiity
tolerance and increased
energy within imposed
restrictions
Monitored and
recorded ital signs.
Assessed
emotional$
psychological
factors affecting the
degree of illness of
patient.
Assisted patient in
moderate high back
rest position.
2ncouraged
ade0uate rest and
sleep
2ncouraged patient
to do actiities
within leel of
energy
?cheduled actiities
around rest periods.
The patient has
slightly improed
tolerance of actiity and
increased energy within
imposed restrictions
DRU- STUD*
Dug:
Dose:
Classifi$ation
A$tion ( Uses Containdi$ations Advese effe$ts Nusing Res"onsi1ilities
+UROS%&ID%
2+RUS%&ID%3
/*iuretics
,Acute
pulmonary
edema,
2dema,
-ypertensi
on
'ANO0IN
/:( mg C*
,Inotropics
/A potent loopn diuretic that
inhibits sodium and chloride
reabsorption at the proximal
and distal tubules and
ascending loop of -enle.
/Inhibits sodium P potassium
P actiated adenosine
triphosphat2, promotin
moement of calcium from
extracellular to intracellular
cytoplasm and strengthening
,.ontraindicated in patients
hypersensitie to drug and in
those with anuria.
,Ase cautiously in patients
with hepatic cirrhosis and in
those allergic to sulfonamides.
Ase furisemide during
pregnancy only if potential
benefits to mother clearly
outweigh risks to fetus.
,.ontraindicated in patient
hypertensie to drug and in
those with digitals induced
toxicity, entricular fibrillation,
or entricular tachycardia
unless caused by heart failure.
,Ase with extreme caution in
CNS: ertigo, headache,
di>>iness, paresthesia,
weakness, restlessness, and
thrombophlebitis with I.=.
administration.
EENT:transient deafness
blurred or yellowed ision.
GI:abdominal discomfort and
pain, diarrhea, anorexia,
nausea, omiting, constipation,
pancreatitis.
GU:nocturia, polyuria,
fre0uent urination, oliguria.
-ematologicE agranulocytosis,
leukopenia, thrombocytopenia,
a>otemia, anemia,
CNS: fatigue, generali>ed
muscle weakness, agitation,
hallucinations, headache,
malaise,
di>>iness, ertigo, paresthesia.
CV: arrhythmias
To preent nocturia, gie /.C. and I.M.
preparations in the morning. 3ie
second dose in early afternoon.
AlertE Monitor weight, blood pressure
and pulse rate routinely with long,term
use and during rapid diuresis.
6urosemide can lead to profound
water and electrolyte depletion.
If oliguria or a>otemia deelops or
increases, drug may need to be
stopped.
*rug induced arrythmias may increase
the seerity of heart failure and
hypotension.
/atient with hypothyroidism are
extremely sensitie to cardiac
glycosides and may need lower doses.
Monitor 4 leel carefully. Take
Dug:
Dose:
Classifi$ation
A$tion ( Uses T!ea"euti$
effe$ts
Containdi$ations Advese effe$ts Nusing Res"onsi1ilities
.hlorproma>ine
(Thora>ine)
, (' mg eery
-? x " month
, .entral
nerous system
agent8
psychothera,
peutic8
antipsychotic8
antiemetic8
phenothia>ine
, /henothia>ine deriatie with actions at all
eels of .@? with a mechanism that produces
strong antipsychotic effects. Actions on
hypothalamus and reticular formation produce
strong sedation, hypotension and depressed
temperature regulation. -as strong alpha,
adrenergic blocking action and weak
anticholinergic effects. *irectly depresses the
hrart8 may increase coronary blood flow. 2xerts
0uinidine,like antiarrhythmic action. Antiemetic
effect due to suppression of the chemoreceptor
trigger >one (ct>). Inhibitory effect on *A
reuptake maybe the basis for moderate
2xtrapyramidal sx. Antipsychotic drugs
sometimes called neuroleptics because they
tend to reduced initiatie and interest in the
enironment, decrease displays of emotions or
affect, suppress spontaneous moements and
complex behaior and decrease psychotic sx.
?pinal reflexes and unconditioned
nocireceptie,aoidance behaiors remain
intact
, to control manic phase of manic,depressie
illness, for sx management of psychotic
disorders, including schi>ophrenia in manageent
of seere nausea and omiting, to control
excessie anxiety and agitation before surgery
and for treatment of seere behaior probles in
children. Also used for treatment of acute
intermittent porphyria, intractable hiccups and
as ad<unct in treatment of tetanus
Mechanism that
produces strong
antipsychotic
effects is unclear,
but thought to be
related to blockade
of postsynaptic
*A receptors in
the brain. Also has
antiemetic effects
due to its action on
the .TQ
-ypersensitiity to
phenothia>ine
deriaties8
withdrawal states,
brain damage, bone
marrow depression,
9eyeKs syndrome8
children RI months8
pregnancy (category
.), lactation
Body as a wholeE
idiopathic edema, muscle
necrosis, ?)2,like
syndromeE CVE orthostatic
hypotension, palpitation,
tachycardia 2.3changes,
prolonged ST and /9
interals
GIE dry mouth,
constipation, dyspepsia,
increase appetite, /A*
aggraationE MetabolicE
weight gain, enlargement
of parotid glands,
hypo$hyperglycemia
CN! sedation, insomnia,
drowsiness, di>>iness,
2/?, restlessness,
headache, weakness,
hypothermia,
"espiratory!
laryngospasm
pecial senses! blurred
ision, photophobia,
mydriasisE kin! urticaria,
dermatitis, hirsutism
ec>ema, reduce
perspirationE #ro$enital!
anoulation, infertility,
reduce libido, inhibition
e<aculation, urinary
retention
, gie with food or full glass of
fluid to minimi>e 3I distress
, ensure that oral dose is
swallowed and not hoarded.
?uicide attempt is a constant
possibility
, monitor 7/ fre0uently.
-ypotensie reactions,
di>>iness and sedation are
common during early therapy,
particularly in patients on high
doses and in the older adult
receiing parenteral doses
, periodic .7. with
differential, lier function test,
urinalysis, and blood glucose
, be alert for signs of
neuroleptic malignant
syndrome and report
immediately
, monitor IMo
, be alert to complains of
diminished isual acuity,
reduced night ision,
photophobia and a perceied
brownish discoloration of
ob<ects.
, report 2/?
, do not abruptly stop drug
Dug:
Dose:
Classifi$ation
A$tion ( Uses T!ea"euti$
effe$ts
Containdi$ations Advese effe$ts Nusing Res"onsi1ilities
6luphena>ine
*ecanoate
, '.( cc IM with
7/ precaution
, central
nerous system
agent,
psychotherapeut
ic8
antipsychotic8
phenothia>ine
, potent phenothia>ine antipsychotic agent.
7locks postsynaptic *A receptors in the brain.
?imilar to other phenothia>ines with the
following exceptions8 more potent per weight
higher incidence of extrapyramidal
complications, and lower fre0uency of sedatie,
hypotensie, and antiemetic effects
, use of the management of manifestations of
psychotic disorders
2ffectie for
treatment of
antipsychotic
symptoms
including
schi>ophrenia
4nown
hypersensitiity ro
phenothia>ines8
subcortical brain
damage, comatose
or seerely
depressed states,
blood dyscrasias,
renal or hepatic
disease
CN! 2/?, tardie
dyskinesia, sedation,
drowsiness, di>>iness
headache, mental
depression, catatonic,like
state, grand mal sei>ures
CV! tachycardia,
hyper$hypotension
GI! dry mouth, nausea,
epigastric pain,
constipation, fecal
impaction, cholecystic
<aundiceE kin! dermatitis
pecial senses! nasal
congestion, blurred ision
increased intraocular
pressure photosensitiityE
endocrine!
hyperprolactinemiaE
/eripheral edema, urinary
retention inhibition of
e<aculation
, monitor 7/
, report immediately onset of
mental depression and 2/?
, be alert for appearance of
acute dystonia
, be alert for red, hot, dry skin8
full bounding pulse, dilated
pupils, *yspnea, mental
confusion, eleated 7/
, aoid patient to too much
exposure to sun$ heat
, monitor IMC
, instruct patient to aoid
alcohol
,
a
A
Case
Study
on
Myocardial
Infarction
Submitted by:
Olivia D. Olivas
Neomy Lea Sinco
BSN 4
L! L"
Submitted to:
#ane Arcan$el% N
Clinical Instructor