Myocardial Infarction: Case Study
Instructions:-
- Students are to choose one (1) of the case studies below and answer the associated questions. The assignment is to be presented in a question/answer format NOT as an essay (i.e. no introduction or conclusion).
- Each answer has a word limit (1600 in total); each answer must be supported with citations.
- A reference list must be provided at the end of the assignment.
- Please refer to the marking guide available in the unit outline for further information.
** The following questions must be answered for your chosen case study **
The following questions relates to the patient within the first 24 hours since admission to the emergency department (ED):
1. Outline the causes, incidence and risk factors of the identified condition and how it can impact on the patient and family (400 words)
2. List five (5) common signs and symptoms of the identified condition; for each provide a link to the underlying pathophysiology (350 words) a. This can be done in the form of a table – each point needs to be appropriately referenced
3. Describe two (2) common classes of drugs used for patients with the identified condition including physiological effect of each class on the body (350 words) a. This does not mean specific drugs but rather the class that these drugs belong to.
4. Identify and explain, in order of priority the nursing care strategies you, as the registered nurse, should use within the first 24 hours post admission for this patient (500 words).
2 Case Study 1: Myocardial infarction with history of stable angina and mitral valve stenosis
Mr Tupa Savea is a 54 year old male who has been transferred to the coronary care unit (CCU) from the emergency department for management of episodic chest pain. He has a history of stable angina and mitral valve stenosis. Mr Savea is of Samoan background and has lived in regional Queensland for the last 20 years with his wife and children. He was brought in by ambulance having had chest pain and shortness of breath. He reports having similar symptoms on and off for the past two months but did not visit his GP as he assumed the discomfort was due to indigestion. Mr Savea is an ex-smoker, tobacco free for the last six months and a social drinker (approx. 10 units/week). He works full-time as an orderly at a local hospital and is active in the Samoan support community.
On assessment Mr Savea’s vital signs are: PR 90 bpm and irregular; RR 12 bpm; BP 150/100mmHg; Temp 36.9°C; SpO2 98% on oxygen 8L/min via Hudson mask. He has a body mass index (BMI) of 35 kg/m2 indicating clinical obesity. Blood test results show elevated cardiac enzymes and troponin levels and cholesterol level of 8.9mmol/L. His ECG indicates that he has a ST segment elevated myocardial infarction. Mr Savea was administered sublingual glyceryl trinitrate followed by morphine 2.5 mg IV for pain in the emergency department. He reports being pain free on admission to CCU.
3 Case Study 2: Cushing’s Syndrome
Ms Maureen Smith is a 24 year old female who presented to her GP for ongoing gastrointestinal bleeding, abdominal pain and fatigue which has been worsening, and was referred to the local hospital for further investigation. Maureen was diagnosed with rheumatoid arthritis (RA) when she was 15 years old, and has experienced multiple exacerbations of RA which have required the use of high dose corticosteroids. She is currently taking 50mg of prednisolone daily, and has been taking this dose since her last exacerbation 2 months ago. Maureen also has type 2 diabetes which is managed with metformin. She is currently studying nursing at university and works part-time at the local pizza restaurant.
On assessment, Maureen’s vital signs are: PR 88 bpm; RR 18 bpm; BP 154/106 mmHg; Temp 36.9ºC: SpO2 99% on room air. She has a body mass index (BMI) of 28kg/m2 and the fat is mainly distributed around her abdominal area, as well as a hump between her shoulders. Maureen’s husband notes that her face has become more round over the past few weeks. Her fasting BGL is 14.0mmol/L. Blood test results show low cortisol and ACTH levels, and high levels of low density lipoprotein cholesterol. She is awaiting a bone mineral density test this afternoon, and is currently collecting urine for a 24-hour cortisol level measurement.
4 Case Study 3: Decompensated Liver Cirrhosis
Mr Ronald Stone is a 47-year-old man who was brought in by ambulance to emergency department with haematemesis. According to his partner he vomited a total of 300 mL of fresh blood this morning. He reported that he has been spitting blood stained sputum for the last few weeks with no associated cough or shortness of breath. For the past 3 days he has complained of increasing abdominal pain but with no diarrhoea or black stools. Mr Stone tested positive for Hepatitis C virus (HCV) genotype 1A in June 2010. He has cirrhosis and a history of heavy alcohol use, although he no longer drinks. He ceased intravenous drug use 10 years ago, and stills smokes tobacco and marijuana on a daily basis. He used to work with City Rail but has been made redundant 13 months ago and has been unemployed since. He lives with his partner and 2 young children from a previous marriage.
On assessment Mr Stone’s vital signs are: PR 112 bpm; RR 24 bpm; BP 105/64mmHg; Temp 37.4 °C; SpO2 94% on room air. He has a body mass index (BMI) of 31.5kg/m2 . He is lethargic but orientated to time, place and person. He has a swollen and tight abdomen typical of ascites and bilateral leg oedema. Blood test results show Hb 85 g/L, decreased WBC, platelets and albumin, and a marked increase in both serum ammonia and total bilirubin levels. 6 months ago he underwent an eosophagogastroduodenostomy (EGD) which showed grade 2 oesophageal varices. He is ordered the following medications: Vitamin K 1 mg IV stat, aldactone 25mg PO TDS, lactulose 15mls PO TDS, and vitamin B12 100mg IV TDS. He is awaiting a CT abdomen scheduled for this afternoon.
Solution
Myocardial Infarction: Case Study
Q1. Causes, Incidents and Risks factors of Myocardial Infarction
Incidents
Myocardial infarction is one of the most common conditions affected thousands of Australians (Martin et al., 2014). According to the Australian Bureau of Statistics, 55,000 Australians suffer from myocardial infarction annually, a statistical reality that translates to a heart attack every ten (10) minutes. In 2012, myocardial infarction claimed the lives of 9,286 Australians (ABS, 2014).
Causes
Most cases of myocardial infarction are as a result of coronary artery disease called atherosclerosis. Atherosclerosis refers to the hardening of arteries that subsequently leads to their clogging with fatty and highly calcified plaques over time (Kelley, 2014). In most cases, a heart attack is caused or triggered by a blood clot that affects the flow of blood through the coronary artery. Other cause of myocardial infarction includes coronary artery spasm a condition that results from a temporary constriction of the heart artery.
Risk factors
Several risks factors can predispose a person to suffer from an incident of myocardial infarction. These risks factors include genetic predisposition, stress, a diet made up of fatty and cholesterol-packed meals, smoking, alcohol intake, age, high blood pressure, diabetes, lack of physical activity, history of the autoimmune condition, history of preeclampsia and high blood cholesterol (Lu, Liu, Sun, Zheng, & Zhang, 2015). Myocardial Infarction is life threatening, stressful and its onset is sudden, unanticipated and uncontrollable (Zodpey, Shrikhande, Negandhi, Ughade, & Joshi, 2015; Dabiran, Manesh, & Khajehnasiri, 2015). As such, it means that the life of a person who has been diagnosed with the illness will take a drastic change. The individual will live a stressful life as opposed to a more relaxed and free life that he lived before the diagnosis. This might lead to the development of complications and reoccurrence of cardiac events that might eventually result in death. The life of the individuals will change as a result of the traumatic nature of the illness. Management of the stress levels can lead to the safeguarding of the health of the heart. Diet changes can reduce risks of myocardial infarction.
Myocardial Infarction brings about a change in an individual’s lifestyle; this includes cholesterol intake, smoking, activity levels and much more. Myocardial Infarction is caused by the buildup of plaque from cholesterol. Nutritious diets can lead to blood pressure, cholesterol, body weight within ranges that are healthy. This means that an individual will reduce as much as possible their cholesterol intake.
Q2. Signs, Symptoms and related Pathophysiology of Myocardial Infarction
| Signs and Symptom | Pathophysiology |
| Anxiety/ sense of impending doom | This is caused by the brain signals or red flags that are activated when fewer than normal amount of blood and oxygen reaches the brain and the rest of the body (Sayols-Baixeras, Lluís-Ganella, Lucas, & Elosua, 2014). |
| Pain and discomfort in various parts of the body such as chest, arms, neck, stomach, and jaw | Pain during a heart attack can be associated with increased sympathetic, parasympathetic, diastolic and pressures as well as increased toxins metabolites in the victim’s heart tissue. Additionally, when heart tissue starts running out of oxygen during a myocardial infarction event, the blocked artery prevents oxygenated blood from reaching the muscles and tissues and in response, the tissue cells begins to transmits pain signals to the brain (Pandie, Hellenberg, Hellig, & Ntsekhe, 2016). The brain might then confuse the nerve signals from the heart with those emanating from the arm, shoulder, neck, elbow and upper back due to nerve proximity (Zarifeh, Mulder, Kerr, Chan, & Bridgman, 2012). |
| Cough | A cough is the body’s natural reaction to induce a cardiac compression to jump start the cardiac system following a myocardial infarction (Lu et al., 2015). |
| Light-headedness | Light-headedness is caused by the perception of the brain of the reducing oxygen content of the little blood reaching the brain cells (Steg et al., 2012). |
| Nausea | Myocardial infarction patient feels nausea due to the contamination of their bloodstream and bodies with chemical metabolites (Steg et al., 2012). |
| Wheezing | Wheezing is caused by the constriction of airwaves during a heart attack (Steg et al., 2012). |
| Heavy sweating | Constricted flow through arteries confuses the brain that the body is overheating the sweating occurs (Steg et al., 2012). |
| Irregular/rapid heart beat | This is caused by the blockage affecting the patient (Steg et al., 2012). |
Q3. Two common classes of drugs used to treat Myocardial Infarction, and their physiological effects
The main aim of pharmacotherapy when it comes to myocardial infarction is to decrease morbidity as well as prevent any potential complications. At the same time, the primary objectives of emergency medical therapy are a rapid referral for PCI (percutaneous coronary intervention), reduction of cardiac workload, oxygenation optimization and pain control.
Two Common Classes of Drugs Used for The Treatment of Patients with this Condition.
Morphine falls in the class of Opiates which basically are pain depressors especially in the case of massive pain. They are intensive pain suppressors with several effects especially its abuse or over use which could result to high sensitivity to pain and depression to respiratory which is deadly. The Nitro glycerin, GTN, belong to the Organic nitrate vasodilators which reduce the pulmonary vascular resistance. Classified in a similar category by the condition of the body, they are quite stereospecific in their functioning. However, there are other classes under the same condition which in most cases are prescribed according to the sensitivity of the person in response to the drugs. The concept of this condition is critical in the sense of the basic utility of the heart and therefore defining the pharmacological formation of the drugs prescribed to each patient. This is critical in regard to the lifestyle of the patient which reassesses any possibility of use of drugs like heroin, tobacco, and cannabis Sativa by the patient (Choudhry et al., 2014).
Physiological Effects of Each Class.
The GTN, in this case, works on the arteries of the patient by reducing the pressure on the arteries with the subsequent reduction in the resistance of the vascular, accordingly. The Morphine on the hand works by reducing the pain caused by the infection to the patient immediately they are infused into the blood stream and therefore suppressing the pain for at least six hours.
Q4. Priority of nursing care used 24 hours’ post-admission of the MI patient
The main aim of emergency admission of an MI patient is to limit the damage caused by the blockage by restoring blood flow as soon as possible. The other objective of the process is to decrease the ensuing remodeling which may have dangerous effects on both prognosis and ventricular functions. The priority of the in-charge RN is to arrest the situation by to limiting the damage caused by the blockage by restoring blood flow as soon as possible. The other aim of the process is to decrease the ensuing remodeling which may have dangerous effects on both prognosis and ventricular functions (Royal College of Nursing, 2010)
.
Initial management
The initial management involves the admission of the patient with constant cardiac monitoring. During the initial 90 minutes of admission, priority should be on rapid revascularization with PCI as well as the thrombolysis in the initial 12 hours. These actions can significantly reduce the extent of myocardial damage while also reducing mortality and morbidity significantly.
The RN must enforce a strict bed rest during the initial 12-24 hrs after admission. If oxygen levels are less than 94%, the supplemental oxygen must be administered. Aspirin must also be given as soon as possible. Glyceryl trinitrate must also be administered immediately. For haemodynamically unstable patients, emergency revascularization must be performed within the initial 24 hours so as to reduce MI mortality. Should revascularization fail, then an urgent coronary artery bypass graft (CABG) must be performed. Patients having low cardiac output states coupled with cardiogenic shock must be given dobutamine infusion. Intra-aortic balloon pump or any other suitable ventricular mechanical circulatory support devices must be used if the state is not quickly improved by pharmacological interventions.
The primary role of an RN during the first 24 hrs is in the management and supervision of the patient to ensure that their medical and social needs are met. The nurse can also be in communication with both the patient and relatives by addressing their worries as well as concerns through the provision of support. The role of a nurse, in this case, involves the improvement of the quality of life, improvement of education, provision of individualized care as well as the administration of the appropriate medication (Royal College of Nursing, 2010).
The RN must ensure that there is the early administration of antiplatelet agents
like Asprin as instructed by the physician. Such drugs have been shown to reduce cardiac mortality by close to 23%
during the first month. Clopodogrel administration for instance selectively
leads to the inhibition of the binding process of adenosine diphosphate (ADP)
to platelet receptors and ultimately prevents platelet aggregation (Ali et al., 2014). This specific
drug has significant physiological
effects such as inhibition of the function of platelets. Ticagrelor, on
the other hand, has a major metabolite that interacts irreversibly with
platelet receptor (P2Y12 ADP-receptor) to
prevent both platelet activation and prevent signal transduction.
Antithrombotic agents must also be administered
so as to prevent thrombi formation during myocardial infarction event as well
as inhibition of platelet function.
References
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Alquwaizani, M., Buckley, L., Adams, C., & Fanikos, J. (2013). Anticoagulants: A Review of the Pharmacology, Dosing, and Complications. Current Emergency and Hospital Medicine Reports, 1(2), 83–97. https://doi.org/10.1007/s40138-013-0014-6
Australian Bureau of Statistics (2014). Causes of death 2012 (3303.0). March 2014, Available
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Dabiran, S., Manesh, B. K., & Khajehnasiri, F. (2015). Risk Factors of First Acute Myocardial Infarction: Comparison of Elderly and Non-Elderly: A 24-Year Study. Advances in Aging Research, 4(1), 13–17. https://doi.org/10.4236/aar.2015.41002
Kelley, D. (2014). Heart Disease: Causes, Prevention, and Current Research. JCCC Honors Journal, 5(2). Retrieved from http://scholarspace.jccc.edu/honors_journal/vol5/iss2/1
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Martin, L., Murphy, M., Scanlon, A., Naismith, C., Clark, D., & Farouque, O. (2014). Timely treatment for acute myocardial infarction and health outcomes: An integrative review of the literature. Australian Critical Care, 27(3), 111–118. https://doi.org/10.1016/j.aucc.2013.11.005
Pandie, S., Hellenberg, D., Hellig, F., & Ntsekhe, M. (2016). Approach to chest pain and acute myocardial infarction. South African Medical Journal = Suid-Afrikaanse Tydskrif Vir Geneeskunde, 106(3), 239–45. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/27303759
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