MYOCARDIALINFARCTION

-Heart Attack-

Carina Amor Bernardo, RN

OPD-IM Staff

DEMOGRAPHIC DATA

Patient JCase #: 157***Age: 37 years oldSex: MaleNationality: Filipino

Diagnosis: Inferiorposterior Myocardial Infarction

PHYSICAL ASSESSMENT

Conscious and coherent Slightly weak In pain; presented by facial grimaced while

clutching his chest. Vital signs:

BP: 90/80mmHgTemp: 37°CPR: 80 bpmRR: 32 cpmSPO2: 99%GCS: 15/15

GENERAL

Cold and clammy skin. Diaphoretic.

HEAD AND NECK Hair are evenly distributed. Facial symmetry. No deformity noted. No lesions and masses palpated. Slightly sunken eyeballs, no redness, no

discharges, pupils are reactive to light.

INTEGUMENTARY

No nasal congestion or drainages noted. Lips are dry and pale but no ulcers are noted. Also no palpable lymph nodes are noted.

BODY AND EXTREMITIES

No physical deformities are noted. Good range of motion. Thorax is symmetric, slight retraction of the

intercostal muscles during inspiration. Bilateral chest movements present. No

crackles, no wheezing are noted. Soft abdomen palpated. Positive bowel sound

noted.

PAST MEDICAL HISTORYNO

DM

HTN

IHD

YES SMOKER FOR MORE THAN 10 YEARS

PRESENT MEDICAL HISTORY

Patient J was brought to the hospital by a private car with the complaint of chest pain radiating to his left shoulder and arm, pain scale results 8-9/10 in severity with sweating and nausea but no vomiting. Pain started one hour before he came to our hospital. He denies dyspnea, cough, or other symptoms. Patient was diaphoretic in severe pain. ECG showed sinus rhythm (SR) and 3 mm ST elevation II, III, AVF and 2 mm ST depression in V2-V3 and I, AVL leads, heart rate 80bpm. Myocardial Infarction.

DEFINITIONMyocardial Infarction

(MI) or Acute Myocardial Infarction (AMI), commonly known as a Heart Attack, results from the partial interruption of blood supply to a part of the heart muscle causing the heart cell to be damaged or die.

BASIC ANATOMY OF THE HEART

The heart is the hardest working muscle in the human body. Located almost in the center of the chest, the adult human heart is about the size of one fist.

The cardiovascular system, composed of the heart and blood vessels, is responsible for circulating blood throughout our body to supply the tissues with oxygen and nutrients.

The heart is the muscle that pumps blood filled with oxygen and nutrients through the blood vessels to the body tissues. It is made up of:

Four chambers (two atria and two ventricles) that receive blood from the body and pump out blood to it: The atria receive blood coming back

to the heart. The ventricles pump the blood out of

the heart.  Blood vessels, which compose a network

of arteries and veins that carry blood throughout the body: Arteries transport blood from the

heart to the body tissues. Veins carry blood back to the heart.

Four valves to prevent backward flow of blood: Each valve is designed to allow the

forward flow of blood and prevent backward flow.

An electrical system of the heart that stimulates contraction of the heart muscle.

STRUCTURE OF THE HEART

Pericardium - it is a tough double layered membrane/sac which covers the heart.

Myocardium - is the muscular tissue of the heart.

Endocardium -  is the innermost layer of tissue that lines the chambers of the heart.

  BLOOD CIRCULATION

INFARCTED HEART

PATHOPHYSIOLOGYPredisposing

factors

Premature, Accelerated Atherosclerosis

Progressive narrowing of blood

vessels

Risk for excessive blood clot formation

Ischemia of the muscle

Thromboembolism

Hypoxia

Necrosis

Aerobic to Unaerobic

metabolism

Release of Lysozomal Enzyme

Myocardial Contractility

Lactic Acid formation

Altered Depolarizatio

n

Cardiac Output

Chest Pain/Muscle

Spasm

Altered Repolarizatio

n

Renal Ischemia,Oliguria

Myocardial Infarction

IMPORTANT RISK FACTORS

Previous cardiovascular disease Older age Tobacco smoking High levels of certain lipids and

low levels of high density lipoprotein

Excessive alcohol consumption and drug abuse

Diabetes High blood pressure Obesity Chronic kidney disease Heart failure Chronic high stress levels

SIGNS AND SYMPTOMS

SEEKHELP

SUDDEN CHEST PAIN

NAUSEA AND VOMITING

PALPITATIONS

SWEATING

ANXIETYSHORTNESS OF BREATH

SOME CASES . .

25% are

silent

WITHOUT CHEST PAIN OR OTHER SYMPTOMS

CLASSIFICATIONS

Transmural: associated with atherosclerosis involving a major coronary artery. It can be subclassified into anterior, posterior, inferior, lateral or septal.

Subendocardial: involving a small area in the subendocardial wall of the left ventricle, ventricular septum, or papillary muscles.

PATIENT J’S ECG

BLOOD CHEMISTRY Test Result Adult Reference

Range

SODIUM 138 135-150 mmol/l

POTASSIUM 3.8 3.5-5.0 mmol/l

CHLORIDE 106 98-111 mmol/l

CPK (CK) 275 26-308 u/l

CK-MB 64.4 7.0-25.0 u/l

AST (SGOT) 36 M: 10-38 U/L

ALT (SGPT) 74 10-41 U/L

CHOLESTEROL 6.9 3.1-5.2 mmol/L

TRIGLYCERIDES 1.38 0.34-2.30 mmol/L

HDLc 1.14 M: 0.9-1.87 mmol/L

LDLc 5.05 3.9-4.7 mmol/L

Troponin Quantitative

0.628 <0.120 ng/ml

MEDICAL MANAGEMENT

Oxygen administration is initiated at the onset of chest pain.

Cardiac Monitoring (ECG/2D Echo) Emergent Percutaneous Transluminal

Coronary Angioplasty (PTCA). Coronary Artery Bypass or Minimal

Invasive Direct Coronary Artery Bypass (MIDCAB).

Angiography

DIET: Low Salt, Low Fat.

PHARMACOLOGIC THERAPYDrugs Dose/Route/Frequency Action

Aspirin 81mg tab., PO, ODPain killer, it also thins the blood in order to lower the risk of blood clots in coronary artery.

Plavix 75mg tab., PO, ODUsed to prevent blood clots after a recent heart attack or stroke, and in people with certain disorders of the heart or blood vessels.

Crestor 20mg tab., PO, ODReduces levels of "bad" cholesterol (low-density lipoprotein, or LDL) and triglycerides in the blood, while increasing levels of "good" cholesterol (high-density lipoprotein, or HDL).

Morphine Sulfate 2mg/ml, I.V., PRN Pain killer.

Clexane 80mg/0.8ml, S.C., BIDan anticoagulant (blood thinner) that prevents the formation of blood clots.

NURSING INTERVENTIONS

Monitor and record the patient’s vital signs and ECG readings.

Assess level of consciousness. Evaluate chest pain, give analgesics as ordered. Check the patient’s blood pressure before and after

giving nitroglycerin, especially on the 1st dose. Observe urinary output and check for edema; an early

sign of cardiogenic shock is hypotension with oliguria. Assess bowel motility; mesenteric artery thrombosis is

a potential fatal complication. Provide emotional support, and help reduce stress and

anxiety. Organize patient care and activity to minimize periods

of uninterrupted rest.

NURSING DIAGNOSIS

Acute pain related to myocardial infarction.

Anxiety related to fear of death. Impaired gas exchange related to fluid

overload due to left ventricular dysfunction.

POTENTIAL COMPLICATIONS

Dysrhythmias and Cardiac Arrest. Acute Pulmonary Edema. Heart Failure. Thromboembolism. Myocardial Rupture. Pericardial Effusion and Cardiac

Tampobade.

NURSING CARE PLANASSESSMENT PLANNING IMPLEMENTATION EVALUATION

Cues/Evidence

Nursing Diagnosi

s

Goals and Desired

Outcome

Nursing Interventio

ns

Rationale Evaluation

SUBJECTIVE:

“I feels like there is a heavy object over my chest, and it cause a lot of pain.”

OBJECTIVE:

* Sweating, Cold and clammy skin.* Clutching his chest.* Facial grimaced, Pain Scale 8-9/10.

Acute Pain related to Myocardial Infarction.

After 6-8 hours of nursing interventions, patient will be relieve from pain.

*Monitor the vital signs.BP: 90/80mmHgT: 37°CPR: 80bpmRR: 32cpm

*Administer oxygen in tandem with analgesia as ordered.Aspirin 81mg,ODPlavix 75mg, OD

*Assist patient in relaxation techniques.

*Provide baseline data regarding the patient’s condition.

*To ensure maximum relief of pain.

*Assist in the reduction in the perception / response to pain. Giving control of the situation, increase positive behavior.

After 6-8 hours of nursing interventions the goals were partially met as evidenced by:

*Less facial grimaced, Pain scale 4-5/10.

*Expresses less anxiety.

*Complies with self-care program.

NURSING HEALTH TEACHING Explained the importance of totally giving up smoking,

because it is the single most effective way to reduce the risk of having a further MI. 

Suggest some changes in diet can make a big difference. People who eat a healthy diet may halve their chance of a further heart attack compared to those who do not eat healthily.

Advised to have normal physical activity and regular exercise.

Emphasized the importance of take home medications prescribed by the physician.

CONCLUSION

When someone is suffering from chest pain, an ECG should be run to assess electrical activity of the heart and initial treatment should be given. Then further tests, such as an angiography, should be run as quickly as possible to learn more about the prognosis and apply findings to distinguish a more appropriate treatment.

For any health problems, early detection is very important, even with or without any signs and symptoms persist.

The importance of healthy living, especially healthy diet is the most effective way to avoid such disease like myocardial infarction.

BIBLIOGRAPHY

Brunner & Suddarth’s Medical-Surgical Nursing Textbook 10th

Edition. http://www.patient.co.uk/health/Myocardial-Infarction-After-the-MI

.htm http://www.webmd.com/heart-disease/understanding-heart-attac

k-basics

THANK YOU^__^