case pres mi

8/4/2019 Case Pres MI

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CASE PRESENTATION

ON MYOCARDIAL

INFARCTION


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INTRODUCTION


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Acute Myocardial InfarctionAcute coronary event which

causes interruption of blood flow

from the coronary vessels to themyocardium. If prolonged it will

lead to injury and irreversible

death of myocardial tissue.


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OBJECTIVES

To describe the pathophysiology, clinical

manifestations and treatment of

myocardial infarction.Use the nursing process as a framework

for care of patients with MI.

Describe the nursing care of the patient

with myocardial infarction.


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GENERAL INFORMATION

Name: Mr. JT

Sex: male

Age:66 y/o

Wt.: 75 kg

Occupation:

BusinessmanCitizenship: Filipino

Arrived on unit by: STRETCHER

Admission date: August 30,2006

Admitting v/s:

BP: 230/110 mmHg

PR:110bpm RR:26cpm

TEMP: 36.8C

Reason for admission: chest pain

Medical diagnosis:Acute Myocardial Infarction


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ChiefComplaint:

chest pain radiating to the left arm


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HEALTHHISTORY

HISTORYOFPRESENT ILLNESS

3 days PTA

(+) dyspnea on exertion

(+) bipedal edema grade I(+) 2 pillow orthopnea

3 hrs PTA

(+) worsening dyspnea

(+) chest pain radiating to the left arm(+) restlessness

(+) easy fatigability


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FAMILYHISTORY

FATHER MOTHER

HPN (+)

DM (-)ASTHMA (+)

CANCER (-)

(-)

(+)(-)

(-)


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Past Medical History

S/P: coronary artery bypass graft 4 vessel

1988(Phil. Heart Center)

Personal/social history:(+) heavy smoker35 pack years

(+) alcoholic beverage drinker

Separated from wife for 20 yrs with 4children working abroad.


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Gordons Health Pattern

Assessment


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Health Perception and Mgt.

Pt. is uncooperative and does not follow

specific instructions for him, otherwise he

keeps on moving.


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Nutritional and Metabolic

The pt. has poor appetite and consumes 1

of rice every meal. With the onset of

disease he lost his appetite decreasing his

rice consumption from 1cup to a cup.

He is a heavy smokerand alcohol drinker.


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Elimination Pattern

He claimed that before his illness he is

experiencing constipation and usually

defecate within 2 3 days interval.

Sometimes he used supplemental fiber

which is readily available in the market,

urinates frequently usually 6 8 times a

day.


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Sleep and Rest Pattern

He has poor sleeping pattern, usually

sleeps between 11/past midnight and

wokes up from time to time. He does not

take a nap in the afternoon. With his stay

at the hospital, even though the

environment is conducive to sleeping still

he cannot sleep well because he feelsanxious.


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Mobility

In motor and physical aspect there were

slight changes, he felt weak and dizzy.

Sometimes thus limiting his activities.


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Cognitive/Perceptual

Mentally the pt. is well oriented and

coherent the pt. did not experience any

disorientation as to time, space and

personality. He worried , though, about his

condition and things like outcome of his

illness.


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ADLs

At present, slight movement causes him

fatigue and was advised CBR without

BRP. But the pt. was hesitant to follow.


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Beliefs/ Values

Pt. is Roman Catholic, however he seldom

hears mass because he is living alone.


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Health Maintenance

When he gets sick, he does not seek

medical assistance and tries to self

medicate with Isordil. He does not submit

himself to regular check up and

continues to smoke against doctors

advise.


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Coping Stress

When faced with any undertakings or

obstacles he claims that he does not want

to let a day pass without doing anything to

counter it. He goes out and attends

anything that could divert his attention

while thinking of a good solution to his

problem, he never wants to bother anyonein the family except when the problem is

way to much for him to bear.


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Role Relationship

He is married with four children,

unfortunately due to undisclosed reason

pt. got separated. At present his caregiver

is his sister in law. All of his children

are presently working abroad with

constant communication with his

caregiver.


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REVIEW OF SYSTEMS


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Review ofSystems

Constitutional : Wt. loss of5 kgs. In 1 month(+) restlessness (+) easy fatigability

(+) weakness

Skin: (+) rashes (+) ithcing

HEENT: (+) dizziness (+) lightheadedness(+) hoarseness (+) nasal flaring

(+) headache (-) nasal discharge

Chest: (+) mild chest tightness

Respiratory: (+) SOB (+) tachypneic RR:37 cpm(+) non productive cough (+) wheezes(+) chest x-ray result suggested mild to mod.

lung hyperinflation


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Cardiovascular: S/PCoronary Artery Bypass Graft 4

vessel 1988

(+) tachycardic PR:110bpm

(+) palpitation (+) hypertension BP: 230/110

(-) murmurs

Peripheral Vascular: (+) intermittent claudication

Musculoskeletal: (-) muscle pain

Extremities: (+) bipedal edema grade I (+) necrotic wound

Left big toe

Neurologic: (-) fainting (-) seizure

Hematologic: (-) bleeding (-) anemia

Endocrine: (-) heat / cold intolerance

Gastrointestinal: (+) constipation

(-) nausea/vomiting


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PHYSICAL EXAMINATION


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V/S:BP: 230/110 mmHg

RR:26 cpm

PR:110 bpm

TEMP: 36.8oC


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PHYSICAL EXAMINATION

Conscious

Coherent, in moderate cardiorespiratory distress

Pale palpebral conjuctiva

Anicteric scleraMoist buccal mucosa

(-) tonsillopharyngeal congestion

(-) lymphadenopathy

(-) Anterior neck mass Equal chest expansion

(-) retraction(-)wheezes


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(+) coarse crackles, both lung fields

(+) harsh breath sounds

(-) murmur

Flat abdomen

(-) cyanosis

(+) bipedal edema grade I

Extremity

(+) necrotic wound on L big toe

(-) neurologic deficit on PE


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EFFECTS OF ILLNESS TO

GROWTH AND DEVELOPMENT


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OLDER ADULTS (OVER 65 YEARS)

Categorizing the aging population

Young Old: 65 75 y/o

Old: 75 85 y/o Old old: 85 100 y/o

Elite old: over 100 y/o


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Theories of Aging

Wear and tear theory

Proposes that human, like automobiles have vital

parts that run down with time, leading to aging

and death.

The faster the organism lives, the quicker it dies

The cells wear out through exposure to internal

and external stressors, including trauma,chemicals and buildup of natural wastes.


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Genetic theory

Proposes the organism geneticallyprogrammed for a predetermined number

of cell divisions after which the cells/

organism dies. Immune theories

The immune system becomes less

effective with age, and viruses that hasincubated in the body become able to

damage body organs


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Psychosocial theories

Disengagement theory

Aging involves mutual withdrawal betweenthe older person and others in the elderly

persons environment.

Activity theory

The best way to age is to stay physically and

mentally active.Continuity theory

People maintain their values, habits andbehavior in olds age.


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Eriksons developmental task

Ego integrity vs. despair

Integrity

View life with a sense of wholeness andderive satisfaction from past

accomplishment

View death as an acceptable completionof life

Accept ones one and only life cycle


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Despair

Believe they have made poor choicesduring life and wish they could live life

over.


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Cognitive

Piagets phases of cognitive development

end with the formal operations phase

Memory

Short term memory

Recent memory

Log term memory


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Moral development

Kohlberg moral development is

completed in the early adult years.

HEALTHPROBLEMS

Chronic disabling illness


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THEORYOFNURSING AS A

FRAMEWORK OFTHECASE

STUDY


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OREMSGENERAL THEORYOF

NURSING

Dorothea Orems theory includes these

related concepts: self care, self - care

deficit and nursing systems.

Self care theory based on four concepts:

self care, self care agency, self care

requisites and therapeutic self care

demand.


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Self care - Refers to those activities andindividuals performs independentlythroughout life to promote and maintainpersonal well being.

Self care agency - is the individuals

ability to perform self care activities. Itconsists of two agents:

a.) a self care agent (an individual whoperforms self care independently)

b.) a dependent care agent ( a person otherthan the individual who provides care)


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Self care requisites/self care needs

> are measures/actions taken to provide

self care.


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There are 3 categories:

Universal requisites are common to all

people. They include maintaining intake

and elimination of air, water and food, and

balancing rest, solitude, and social

interaction, preventing hazard to life and

well being and promoting normal human

function.


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Developmental requisites result from

maturation or are associated with

condition or events such as adjusting to a

change in body image or to a loss of a

spouse.

Health Deviation Requisites. Results fromillness, injury, or disease or its treatment,

they include actions such as seeking

heath care assistance, carrying outprescribed therapies , and learning to live

with the effects of treatment.


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Therapeutic self care Demand. Refers

to all self care existing self care

requisites or in other words, action tomaintain health and well being.


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SELF CARE DEFICITTHEORY

SELF -

CARE

SELF

CARE

AGENCY

SELF

CAREDEMANDS

DEFICIT

NURSING

AGENCY

40 mg/dl

LDL Hi 250 mg/dl 60 80 mg/dl

VLDL 28 mg/dl 25 50 mg/dlTriglycerides 100 40 - 160 mg/dl


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X - Ray

Findings:

Pneumonitis right base

Heart size normal

Atheromatous aorta


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MEDICAL MANAGEMENT


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MEDICAL MANAGEMENT

Goal

To minimize myocardial damage.

To preserve myocardial function.

To prevent complications.


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THROMBOLYTICTHERAPY

Action: to dissolve and lyse the thrombus in acoronary artery, allowing blood to flow into thecoronary artery again, minimizing the size of theinfarction and preserving ventricular function.

Reduce the patients ability to form a stabilizingclot, so the patient is at risk for bleeding shouldbe used if the patient is bleeding or has ableeding disorder.

Must be administered as early as possible afterthe onset of symptoms that indicate acutemyocardial infarction.


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STREPTOKINASE

Classification: Thrombolytic enzyme

Action: acts with plasminogen to produce anactivator complex which enhances theconversion of plasminogen to plasmin. Plasminthen breaks down fibrinogen, fibrin clots andother plasma proteins, promoting the dissolution(lysis) of the soluble fibrin trapped inintravascular emboli and thrombi.

Indication:Acute myocardial infarction forreopening of coronary vessels


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NURSINGCONSIDERATIONS

Minimize the number of times the patients skin

is punctured.

Avoid intramuscular injections.

Draw blood for laboratory tests when startingthe IV line.

Start IV lines before thrombolytic therapy;

designate one line to use for blood draws.

Check for signs and symptoms of bleeding.


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NURSINGCONSIDERATION

Do not add other medications to streptokinase.

Assess for bleeding tendency, heart disease,

and/or allergic reactions.


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ASPIRIN/ACETYLSALICYLIC ACID

Classification:Antithrombotic,

analgesic/antipyretic

Indication:As antithrombotic for the

prophylaxis of thromboembolic disorders

in preventing myocardial infarction and

transient ischemic attack.


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LOW MOLECULAR WT. HEPARIN

Clexane 0.4 ml SQ BID

Generic Name : Enoxaparin Sodium

Classification:Anticoagulant, Low

molecular weight heparin Action: Decreases the incidence of

recurrent angina, MI and death

Indication: Treatment of unstableangina and non Q-wave myocardialinfarction, administered with aspirin


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Monitor vital signs; observe for early signs

and symptoms of bleeding.

May experience mild discomfort, irritation

and hematoma at injection site. Report

any unusual bruising, bleeding or

weakness..


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ANTITHROMBOTIC

Plavix 75 mg/cap OD

Classification:Antiplatelet drug

Action: Inhibits platelet aggregation by

inhibiting binding adenosine diphosphate

(ADP) to its platelet receptor.

Indication: prevention of

atherothrombotic events in patientssuffering from myocardial infarction.


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Watch out for signs of bleeding including

occult blood, especially during the first

weeks of treatment.


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NITRATES

Isoket drip 20cc + 90cc D5W to run at20ugtts/min.

Generic Name: Isosorbide dinitrate

Classification: Coronary vasodilator

Action: Smooth muscle relaxant, ventricularend-diastolic pressure and volume arediminished, thus reducing cardiac work andimplicitly myocardial oxygen requirements; thearterial vessels are dilated as well, which leadsin a slight drop in aortic and systemic bloodpressure relieving the myocardium from a partof its afterload.


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Side effects include headache,

hypotension, dizziness and weakness

which can be managed by slowly

increasing the dose until the required dailydose has been attained.


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ANALGESIC

Morphine 4mg IV every 6 hours

Generic Name: Morphine sulfate

Classification: Narcotic analgesic

Action: principal actions of therapeutic valueof morphine are analgesia and sedation;

reduces anxiety; reduces preload, which in turn

decreases the workload of the heart and relaxes

the bronchioles to enhance oxygenation.

Indication: severe pain of infarction

NURSING CONSIDERATION


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Check blood pressure, pulse, respirations

before and after giving morphine sulfate

DONOTGIVE morphine if respiratory rate is

less than 12 cpm.Always put bedside rails up following injection

of narcotics.

Encourage deep breathing techniques to

prevent pneumonia and atelectasis.

ANTIHYPERTENSIVE


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ANTIHYPERTENSIVE

Captopril 25 mg/tab BID

Classification:Angiotensin Converting

Enzyme Inhibitors

Action:ACE converts angiotensin I to

angiotensin II, a potent endogenous

vasoconstrictor substance.

NURSING CONSIDERATION


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Observe for precipitous drop in blood

pressure within 3 hours after initial dose if

on diuretic therapy and low salt diet.

If blood pressure falls rapidly, place on

supine; have saline solution infusion

available.

ANTIHYPERTENSIVE


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ANTIHYPERTENSIVE

Betaloc 50 mg/tablet OD

Classification: Beta-blockers

Action: Block the sympathetic nervous

system (beta-adrenergic receptors)

especially the sympathetics to the heart,

producing a slower heart rate and

lowered blood pressure.

NURSING CONSIDERATIONS


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Avoid activities that require mental

alertness until drug effects realized.

ANTIHYPERTENSIVE


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ANTIHYPERTENSIVE

Dilatrend 6.25 mg 1 tablet BID

Classification:Alpha-beta adrenergicblockers

Action: blocks alpha- and beta-adrenergic

receptors causing peripheral dilation anddecreases peripheral vascular resistance;decreases cardiac output, reduces reflexorthostatic hypotension.

Indication: reduce cardiovascular mortalityin clinically stable clients who have survived anacute myocardial infarction

NURSING CONSIDERATIONS


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Reduce the dose if bradycardia (HRless

than 55 bpm) occurs.

ANTI ISCHEMIC AGENT


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ANTI-ISCHEMIC AGENT

Vastarel 35 mg/tablet BID

Generic Name : Trimetazidine diHCL

Classification: Metabolic anti-ischemic

agent Action: Increases coronary flow

reserve, thereby delaying the onset ofexercise- induced ischemia.

Indication: prophylactic treatment ofepisodes of angina pectoris

Causes:

C th l ti h t di

Streptokinase

ASA


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Coronary atherosclerotic heart disease

Coronary thrombosis/embolism

Myocardial

ischemia

Decreased

myocardial O2 supply

Cellular hypoxia

Decreased

myocardial

tissue

perfusion

Increasedmyocardial

O2 demand

Decreased diastolic

filling

Altered cell

membrane Int.

Decreased

myocardial

contractility

Stimulation of

baroroeceptors

Stimulation of

sympathetic

receptors

Increased myocardial

contractility

Decreased arterial

pressure

Decreased cardiac

output

Increased peripheralvasoconstriction Increased afterload

Increased HR

ASA

Clexane

Plavix

Captopril

Betaloc / Dilatrend

Nitrates / Morphine

Vastarel

Oxygen

NURSINGCAREPLAN

ASSESSMENT NURSING GOAL OF CARE NURSING RATIONALE EVALUATION


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DIAGNOSIS INTERVENTION

S> Makulogang daghan ko,

as verbalized bythe patient.

> crushing,

squeezing chestpain radiating tothe left arm

O > P/S: 8/10

Levines sign

With facial

grimace

Groaning

Diaphoretic

Dyspneic

Changes inbody posture

noted

Changes inautonomic

response:

*BP-

230/110mmHg

*PR-110bpm

*RR-26cpm

Acute painrelated to

ischemia ofmyocardialtissue

Within the 8hours shift the

patient will:

SHORTTERMGOALS:

1. Report pain isrelieved and orcontrolled withappropriate timeframe for

administeredmedications.

2. Verbalizemethods thatprovide relief.

3. Demonstrate

use of relaxationtechniques anddiversionalactivities.

LONGTERMGOAL:

1. Followprescribedpharmacological

regimen.

1. Monitor anddocument

characteristics ofpain, noting verbalreports, nonverbalcues andautonomicresponses.

2. Obtain full

description of painfrom patientincluding location,intensity, duration,characteristics &

radiation. Assistpatient to quantifypain by comparingit to otherexperiences.

Variation of appearance &behavior of patients in pain

may present a challenge inassessment. Verbal history &deeper investigation ofprecipitating factor should bepostponed until pain isrelieved. Respiration may beincreased as a result of pain& anxiety; release of stressinduced catecholamines

increase heart rate & bloodpressure.

Pain is subjective and mustbe described by the patient.Provides baseline forcomparison to aid indetermining effectiveness oftherapy, resolution or

progression.

The patientreported that

pain is relieved,verbalized anddemonstratedrelaxationtechniques thatprovided relief.

ASSESSMENT NURSING

DIAGNOSIS

GOAL OF CARE NURSING

INTERVENTION

RATIONALE EVALUATION

3 Instruct patient Delay in reporting pain


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3. Instruct patientto report pain,stat.

4. Provide quietenvironment, calmactivities &comfort measures.

5. Assist/instruct inrelaxationtechnique.

6. Check v/sbefore & afternarcotic or

medication.

Delay in reporting painhinders pain relief/ mayrequire increased dosage ofmedication to achieve relief.Severe pain may induce

shock by stimulating the SNS,thereby creating furtherdamage & interfering withdiagnostics & relief of pain.

Decreased external stimuli,which may aggravate anxiety& cardiac strain, limit copingabilities & adjustment tocurrent situation.

Helpful in decreasing

perception or responses topain. Provides a sense ofhaving some control over thesituation, increase in positiveattitude.

Hypotension/ respiratorydepression can occur as aresult of narcoticadministration. Theseproblems may increasemyocardial damage inpresence of ventricularinsufficiency.

ASSESSMENT NURSING

DIAGNOSIS

GOAL OF

CARE

NURSING

INTERVENTION



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7.Position theclient on HBR

8. Administersupplemental

Oxygen bymeans of nasalcannula, 3-5LPM.

9. Administermedications asindicated.

a) ASA, (anti-

thrombotic)

b) Streptokinase

(Thrombolytics)

c) Isoket(Antianginal)

d)Betaloc

(Betablockers)

e)Analgesics

To decrease chestdiscomfort.Reducepressure from abdominalcontents on the diaphragm& better lung expansion &gas exchange, venousreturn to the heartdecreases, which reduces

the work of the heart.

Increases amount ofoxygen available for

myocardial uptake &thereby may relievediscomfort associated withtissue ischemia.

ASSESSMENT NURSING

DIAGNOSIS

GOAL OF

CARE

NURSING

INTERVENTION



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S> garomagagadan naako,asverbalized by

the pt.

O> restless

> diaphoresis

> palepalpebralconjunctiva

> easyfatigability

> RR = 26cpm

Ineffectivetissueperfusionrelated to

reducedcoronarybloodflowfromcoronarythrombusandatherosclerotic plaque

Within the 8hour shift thepatient will:

SHORTTERMGOALS:

1.Verbalizeunderstandingof condition,therapy &effects ofmedications.

2.Demonstrate

behaviors/lifestyle changes toimprovecirculation.

3.Demonstrateincreasedperfusion asindividuallyappropriate.

LONGTERMGOAL:

1. Lifestylemodification

1. Investigatesudden changesor continuedalterations in

mentation.

2. Inspect pallor,cyanosis,mottling, coolclammy skin.Note strength ofperipheral pulse.

3.Monitorrespirations,note work ofbreathing.

4.Monitor intake,

note changes Iurine output.Record urinespecific gravity,as indicated.

Cerebral perfusion isdirectly related to cardiacoutput and is alsoinfluenced by electrolyte

acid base variations,hypoxia 7 systemic emboli.

Systemic vasoconstrictionresulting from diminishedcardiac output may beevidenced by decreasedskin perfusion & diminishpulses.

Cardiac pump failureand/or ischemic pain mayprecipitate respiratorydistress; howeversudden/continued dyspneamay indicatethrombolembolic pulmonarycomplications.

Decreasedintake/persistent nauseamay result in reduced

circulating volume, whichnegatively affects perfusion& organ function. Specificgravity measurementsreflect hydration status &

renal function.

The patientverbalizedunderstandingof condition

anddemonstratedlifestylechanges.

ASSESSMENT NURSING

DIAGNOSIS

GOAL OF

CARE

NURSING

INTERVENTION



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3.Asses GIfunction, notinganorexia,decreased/absen

t bowel sounds,N&V, abdominaldistension,constipation.

4.Encourageactive/passiveleg exercises,avoidance of

isometricexercises.

5.Assess forHomans sign,

erythema,edema.

Reduced blood flow tomesentery can produce GIdysfunction, e.g. loss ofperistalsis. Problems may

be potentiated/aggravatedby use of analgesics,

decreased activity, anddietary changes.

Enhances venous return,reduces venous stasis, anddecreases ris ofthrombophlebitis; however,

isometric exercises canadversely affect cardiacoutput by increasingmyocardial work & oxygenconsumption.

Indicators of DVT,although DVT can bepresent without positive

Homans sign.

ASSESSMENT NURSING

DIAGNOSIS

GOAL OF

CARE

NURSING

INTERVENTION



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S: Madalion

akongmapagal, asverbalized by

the patient.

O:> withcardiopulmonary distress

with Dyspnea

on exertion 2 pilloworthopnea

restless

easyfatigability

AbnormalECG result

Vital signs:BP 230/110mmHg

PR 110bpm

RR 26cpm

Activity

intolerancer/t:

a)Imbalance

betweenmyocardialoxygensupply &demand

b) Presenceof ischemia

Within the 8

hours shift thepatient will:

SHORTTERMGOALS:

1.Identifynegative factorsaffecting activitytolerance &eliminate/reduc

e their effectswhen possible.

2.Use identifiedtechniques toenhance toactivity

tolerance

3.Participatewillingly in

desired

activities4.Reportmeasurableincrease inactivitytolerance.

1.record/docume

nt HR & rhythm& BP changesbefore, during &

after activity, asindicated.Correlate withreports of chestpain/SOB.

2.Encourage rest(bed/chair)initially.Thereafter, limitactivity on basisof pain/ adversecardiacresponse.Provide non-stress

diversional

activities.

3.Instruct patientto avoidincreasingabdominalpressure.

Trends determine

patients response toactivity & may indicatemyocardial oxygen

deprivation that mayrequire decrease in activitylevel/return to bed rest,changes in medicationregimen or use of thesupplemental oxygen.

Reduces myocardialworkload/oxygen

consumption, reducing riskof complication.

Activities that requireholding the breath &bearing down (Valsalvamaneuver) can result tobradycardia & reboundtachycardia with elevatedBP.

The patient

identifiednegativefactors

affectingactivitytolerance,used identifiedtechniques,participatedwillingly and

reportedmeasurable

increase inactivity.

ASSESSMENT NURSING

DIAGNOSIS

GOAL OF

CARE

NURSING

INTERVENTION



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5. Demonstrate

a decrease inactivitytolerance.

LONGTERMGOAL:

1. PerformADLs,independently.

4.Explain pattern

of gradedincrease ofactivity level, e.g.

getting up tocommode/sittingin chair,progressiveambulation, andresting aftermeals.

5.Review s/s

reflectingintolerance ofpresent activitylevel/requiringnotification ofNOD/MD.

6.EmphasizedCBRwith NBP,as ordered.

Progressive activity

provides a controlleddemand on the heart,increasing strength &

preventing overexertion.

Palpitations, pulse

irregularities, developmentof chest pain, or dyspneamay indicate need forchanges in exerciseregimen/medication.

Reduces myocardial

workload/oxygenconsumption, reducing riskof complications.

Discharge plan


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Discharge plan

Outcome Evaluation - Decreased DOB as felt by the pt.

RR: 19cpm

Decreased severity of chest pain as verbalized by the pt.

Reduced orthopnea to 1 pillow

Increased appetite

Stable v/s: BP: 130/90 PR:82 RR:19 TEMP: 36.9C

Health teaching


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Health teaching

1. Diet low fat/ low salt; (DASH) diet2. Medications instructed

3. Exercise PROM/AROM/ deep breathing exercise;avoid valsalva maneuver, running, brisk walking

4. Avoid stressful activities/ stop smoking, alcohol

5. Minimize stair climbing to 1 flight stair then rest periodsof 5 mins

6. Sleep with 1 pillow

7. Avoid lifting more than 5 kls

8. Meditations and biofeedback exercises instructed9. Follow up check up after a week then asinstructed.

case pres mi

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