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MYOCARDIAL INFARCTION -Heart Attack- Carina Amor Bernardo, RN OPD-IM Staff DEMOGRAPHIC DATA Patient J Case #: 157*** Age: 37 years old Sex: Male Nationality: Filipino Inferiorposterior Myocardial Infarction Diagnosis: PHYSICAL ASSESSMENT GENERAL Conscious and coherent Slightly weak In pain; presented by facial grimaced while clutching his chest. Vital signs: BP: 90/80mmHg Temp: 37°C PR: 80 bpm RR: 32 cpm SPO2: 99% GCS: 15/15 INTEGUMENTARY 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. 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 HISTORY NO 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. DEFINITION Myocardial 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 PATHOPHYSIOLOGY Predisposing 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 Lactic Acid formation Altered Depolarization Cardiac Output Altered Repolarization Renal Ischemia, Oliguria Chest Pain/Muscle Spasm Myocardial Infarction Myocardial Contractility 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 SUDDEN CHEST PAIN SHORTNESS OF BREATH ANXIETY SEEK HELP SWEATING PALPITATIONS NAUSEA AND VOMITING 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 THERAPY Drugs Aspirin Plavix Dose/Route/Frequency Action 81mg tab., PO, OD Pain killer, it also thins the blood in order to lower the risk of blood clots in coronary artery. 75mg tab., PO, OD Crestor 20mg tab., PO, OD Morphine Sulfate 2mg/ml, I.V., PRN Clexane 80mg/0.8ml, S.C., BID Used to prevent blood clots after a recent heart attack or stroke, and in people with certain disorders of the heart or blood vessels. Reduces 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). Pain killer. an 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 PLAN ASSESSMENT Cues/Evidence Nursing Diagnosis SUBJECTIVE: Acute Pain “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. related to Myocardial Infarction. PLANNING IMPLEMENTATION EVALUATION Goals and Desired Outcome Nursing Interventions Rationale Evaluation After 6-8 hours of nursing interventions, patient will be relieve from pain. *Monitor the vital signs. BP: 90/80mmHg T: 37°C PR: 80bpm RR: 32cpm *Provide baseline data regarding the patient’s condition. After 6-8 hours of nursing interventions the goals were partially met as evidenced by: *Administer oxygen in tandem with analgesia as ordered. Aspirin 81mg,OD Plavix 75mg, OD *Assist patient in relaxation techniques. *To ensure maximum relief of pain. *Assist in the reduction in the perception / response to pain. Giving *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-theMI.htm http://www.webmd.com/heart-disease/understanding-heart-attackbasics THANK YOU^__^