1

I. INTRODUCTION

The heart requires its own constant supply of oxygen and nutrients, like any muscle in the
body. The heart has three coronary arteries, two of them large, branching arteries that deliver
oxygenated blood to the heart muscle. If one of these arteries or branches becomes blocked
suddenly, a portion of the heart is starved of oxygen, a condition called "cardiac ischemia."
If cardiac ischemia lasts too long, the starved heart tissue dies. This is a heart attack,
otherwise known as a myocardial infarction -- literally, "death of heart muscle."

Symptoms of myocardial infarction include shortness of breath, dizziness, faintness, or

nausea. The pain of a severe heart attack has been likened to a giant fist enclosing and
squeezing the heart. The pain may be constant or intermittent. Also, women are less likely to
experience the classic symptoms of chest pain; rather, they may feel a sense of fullness in
their chest or pain in their arm, neck, back or jaw.

When diagnosing myocardial infarction the doctor will most likely ask for laboratory
studies like that of cardiac biomarkers/enzymes, Troponin levels, complete blood count,
comprehensive metabolic panel, and lipid profile. The diagnosis may also include ECG and
cardiac imaging.

The initial therapy for myocardial infarction would be to decrease myocardial workload
and to restore perfusion as soon as possible. This may be accomplished through medical or
mechanical means, such as percutaneous coronary intervention (PCI), or coronary artery
bypass graft (CABG) surgery. Medications such as narcotics, vasodilators, anti-arrythmic
drugs, beta blockers, thrombolytic/fibrolytic agents, ACE inhibitors, anticoagulants, and
antiplatelets can be administered as ordered.

Patient T.P. a 72 year old male diagnosed with myocardial infarction.This case was
assigned to our group during our exposure in the 4th floor Medical ward of CLMMRH West
Tower, and we have chosen this case because we think that it will be able to help us deepen
and widen our knowledge on the disorders of the cardiovascular system and as third year
students it allows us to practice our nursing skills in the different aberrant concurrences in the
cardiovascular functions of a person. This medical condition can be prevented with the
correct intake of the indicated medication and changing one’s lifestyle, but if you notice that
the signs and symptoms are already occurring and has been going on continually it is best
that you check with your doctor right away. As a group we tend to present to our Clinical
Instructors on the gathered information on Myocardial Infarction.
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II. OBJECTIVES

General Objective:

After four days of exposure at the 4th floor Medical Ward of Corazon Locsion Montelibano
Memorial Regional Hospital - West Tower, the student nurses will be able to acquire knowledge,
skills, and attitudes related to the disease process and assume the proper role of a nurse in
rendering care for a client with Myocardial Infarction.

Specific Objectives:

Patient-centered

After four days of student-nurse patient interaction, the patient and his significant others will be
able to:

1. State adequate information to the student-nurse regarding the patient’s history, health
condition, concerns and other relevant data.
2. Participate actively in the nursing discussion and interventions implemented by the
student-nurse.
3. Verbalize his understanding and acceptance towards his condition.
4. Appreciate challenges in life that he is currently facing.
5. Demonstrate gradually improved capability in performing activities of the daily living.

Student-centered

After an hour of case study presentation, the student nurses will be able to:

1. Discuss the anatomy and physiology of Myocardial Infarction

2. Determine the etiology, risk factors, causes, symptoms, treatment and possible nursing
interventions of Myocardial Infarction.
3. Illustrate the pathophysiology of Myocardial Infarction.
4. Recall the client’s health status and lifestyle prior to admission and how it influenced the
development of the said condition.
5. Present the drug study on the medications used for the patient along with its therapeutic
effects and nursing responsibilities.
6. Formulate Nursing Care Plans that address the specific needs of the client.
7. Interpret the laboratory and diagnostic tests in order to determine the deviations on
laboratory tests and its significance to the condition.
8. Conduct a health teaching regarding the client’s condition.
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III. ANATOMY AND PHYSIOLOGY

Circulatory System
Also called the cardiovascular system or the vascular system, is an organ system that
permits blood to circulate and transport nutrients (such as amino acids and electrolytes), oxygen,
carbon dioxide, hormones, and blood cells to and from the cells in the body to provide
nourishment and help in fighting diseases, stabilize temperature and pH, and maintain
homeostasis. The study of the blood flow is called hemodynamics. The study of the properties of
the blood flow is called hemorheology.

Pericardium
The heart sits within a fluid-filled cavity called the pericardial cavity. The walls and
lining of the pericardial cavity are a special membrane known as the pericardium. Pericardium is
a type of serous membrane that produces serous fluid to lubricate the heart and prevent friction
between the ever beating heart and its surrounding organs. Besides lubrication, the pericardium
serves to hold the heart in position and maintain a hollow space for the heart to expand into when
it is full. The pericardium has 2 layers—a visceral layer that covers the outside of the heart and a
parietal layer that forms a sac around the outside of the pericardial cavity.

Structures of Heart Wall:

 Epicardium
The epicardium is the outermost layer of the heart wall and is just another name for the
visceral layer of the pericardium. Thus, the epicardium is a thin layer of serous membrane
that helps to lubricate and protect the outside of the heart. Below the epicardium is the
second, thicker layer of the heart wall: the myocardium.

 Myocardium
The myocardium is the muscular middle layer of the heart wall that contains the cardiac
muscle tissue. Myocardium makes up the majority of the thickness and mass of the heart
wall and is the part of the heart responsible for pumping blood.

 Endocardium./ Endocardium
Is the simple squamous endothelium layer that lines the inside of the heart. The
endocardium is very smooth and is responsible for keeping blood from sticking to the inside
of the heart and forming potentially deadly blood clots.
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Chambers of the Heart

The heart contains 4 chambers: the right atrium, left atrium, right ventricle, and left
ventricle. The atria are smaller than the ventricles and have thinner, less muscular walls than the
ventricles. The atria act as receiving chambers for blood, so they are connected to the veins that
carry blood to the heart. The ventricles are the larger, stronger pumping chambers that send
blood out of the heart. The ventricles are connected to the arteries that carry blood away from the
heart.

Conduction System of the Heart

The heart is able to both set its own rhythm and to conduct the signals necessary to
maintain and coordinate this rhythm throughout its structures. About 1% of the cardiac muscle
cells in the heart are responsible for forming the conduction system that sets the pace for the rest
of the cardiac muscle cells.

The conduction system starts with the pacemaker of the heart—a small bundle of cells known as
the sinoatrial (SA) node. The SA node is located in the wall of the right atrium inferior to
the superior vena cava. The SA node is responsible for setting the pace of the heart as a whole
and directly signals the atria to contract. The signal from the SA node is picked up by another
mass of conductive tissue known as the atrioventricular (AV) node.

Systole
During systole, cardiac muscle tissue is contracting to push blood out of the chamber.

Diastole
During diastole, the cardiac muscle cells relax to allow the chamber to fill with blood.
Blood pressure increases in the major arteries during ventricular systole and decreases during
ventricular diastole. This leads to the 2 numbers associated with blood pressure—systolic blood
pressure is the higher number and diastolic blood pressure is the lower number. For example, a
blood pressure of 120/80 describes the systolic pressure (120) and the diastolic pressure (80).

Cardiac Cycle:

 Atrial systole
During the atrial systole phase of the cardiac cycle, the atria contract and push blood into
the ventricles. To facilitate this filling, the AV valves stay open and the semilunar valves
stay closed to keep arterial blood from re-entering the heart. The atria are much smaller than
the ventricles, so they only fill about 25% of the ventricles during this phase. The ventricles
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remain in diastole during this phase.

 Ventricular systole
During ventricular systole, the ventricles contract to push blood into the aorta and
pulmonary trunk. The pressure of the ventricles forces the semilunar valves to open and the
AV valves to close. This arrangement of valves allows for blood flow from the ventricles
into the arteries. The cardiac muscles of the atria repolarize and enter the state of diastole
during this phase.

 Relaxation phase
During the relaxation phase, all 4 chambers of the heart are in diastole as blood pours into
the heart from the veins. The ventricles fill to about 75% capacity during this phase and will
be completely filled only after the atria enter systole. The cardiac muscle cells of the
ventricles repolarize during this phase to prepare for the next round of depolarization and
contraction. During this phase, the AV valves open to allow blood to flow freely into the
ventricles while the semilunar valves close to prevent the regurgitation of blood from the
great arteries into the ventricles.

Blood Flow through the Heart

Deoxygenated blood returning from the body first enters the heart from the superior
and inferior vena cava. The blood enters the right atrium and is pumped through the tricuspid
valve into the right ventricle. From the right ventricle, the blood is pumped through
the pulmonary semilunar valve into the pulmonary trunk.

The pulmonary trunk carries blood to the lungs where it releases carbon dioxide and absorbs
oxygen. The blood in the lungs returns to the heart through the pulmonary veins. From the
pulmonary veins, blood enters the heart again in the left atrium.
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IV. DEFINITION OF TERMS

1. Myocardial infarction (MI) - commonly known as a heart attack, occurs when blood flow
decreases or stops to a part of the heart, causing damage to the heart muscle. The most common
symptom is chest pain or discomfort which may travel into the shoulder, arm, back, neck, or jaw.
2. Burburismus - stomach sounds produced when air or fluid is moving around the small and
large intestines. During a process called peristalsis, stomach muscles and the small intestine
contract and move contents forward in the gastrointestinal tract
3. Skin Turgor - The degree of elasticity of skin, sometimes referred to as skin turgor. The
assessment of skin turgor is used clinically to determine the extent of dehydration, or fluid loss,
in the body. The measurement is done by pinching up a portion of skin (often on the back of the
hand) between two fingers so that it is raised for a few seconds. The skin is then released to
observe how fast it returns to its normal (flat) position.
4. Pulse Oximetry - is a technology used to measure the oxygen level in your blood and your
heart rate. A finger pulse oximeter is equipped with technology to rapidly detect changes in your
blood oxygen level.
5. KILLIPI I - system used in individuals with an acute myocardial infarction (heart attack),
taking into account physical examination and the development of heart failure in order to predict
and stratify their risk of mortality. Individuals with a low Killip class are less likely to die within
the first 30 days after their myocardial infarction than individuals with a high Killip class.
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V. BASELINE DATA

Name of Patient: P.L.T.

Age: 74 years old

Date of Birth: November 5, 1944

Birthplace: Bacolod City

Gender: Male

Address: Prk. Tanigue, Brgy. 1, Bacolod City

Civil status: Married

Religion: Roman Catholic

Nationality: Filipino

Educational Attainment: Vocational Course Graduate

Source of history: Patient

Ward: Medical Ward

Attending Physician: Dr. Aurelio

Date and Time of Admission: November 13, 2017 12:10 PM

Chief complaint: Chest Pain

Admitting Diagnosis: Acute Coronary Syndrome, ST Elevation, Myocardial Infarction (Inferior

wall), KILLIP I

Final Diagnosis: Acute Coronary Syndrome, ST Elevation, Myocardial Infarction (Inferior wall),

KILLIP I
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VI. NURSING HISTORY (GORDON’S)

A. Pattern of Health Perception & Health Management

Whenever the patient experiences illness, he stated that he rarely visits a doctor to have check-
up.
B. Nutritional-metabolic Pattern
Before his hospitalization, the patient’s daily meal usually included rice, fish and vegetables. He
said that they seldom eat meat. His water intake is usually 6 glasses a day. During the stay in the
hospital, the patient followed the diet ordered by the doctor.
C. Elimination Pattern
Patient defecates every other day. Stool is often brown; sometimes with a tinge of green, but
well-formed. Client urinates every 2 hours though sometimes he would feel a little pain while
urinating.

D. Activity-Exercise Pattern
Prior to admission, he used to jog every 15-30 minutes every morning at their area. While
staying in the hospital, however, he is restricted to leave bed as ordered by the doctor.
E. Sleep- Rest Pattern
The client’s usual sleeping pattern is from 8 pm-11 pm. He stated that he usually only sleeps for
around three hours as he is easily awakened by even small noises and movements. He also has
difficulty in getting back to sleep after being awaken.
F. Cognitive –Perceptual Pattern
The patient was able to finish high school at NOHS batch 1968 and was also able to take up a
vocational course at Progressive Technical Institute. During the interview, the patient was
oriented to time, place and responsive in answering questions. He has a good memory as he can
recall past events without difficulty.
G. Self-Perception/Self-Concept Pattern
The client perceives himself as a fulfilled person as all his children are living their respective
lives happily with their own families. Also, he views himself as a very understanding person
especially towards his children.
H. Role-Relationship Pattern
He is a father of four and husband to a loving wife. He is extremely close with his children and
wife. However, his children and wife are currently having a misunderstanding between them,
leading him to distress over their situation. He has also stated that he is deeply saddened with the
current happenings between his wife and children.

I. Sexuality- Reproductive Pattern

The client married at the age of 28 years old while his wife was only 16 years old back then.
They have five children altogether—one of whom died in his young adult years. As of today, the
client is not sexually active, but is still sweet and intimate with his wife in some other ways.
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J. Coping/Stress Tolerance Pattern

Playing instruments, listening to music and reading books is usually the client’s form of coping
mechanism to stress. He loves listening to and playing classical music and is fond of reading
encyclopedias. Despite his current family problems, he finds comfort in doing the things that he
loves and enjoys doing.

K. Value-Belief Pattern
He is a Roman Catholic and he highly believes that God will be able to heal his infirmities. He
goes to mass every Sunday and he prays regularly. The client has stated that he is very open-
minded when it comes to spiritual matters and that he does not judge other religions.
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VII. HEALTH HISTORY

A. History of present Illness

Earlier this year, the patient was rushed to the emergency room of CLMMRH
because of angina attacks. However, he was discharged shortly after being consulted
by the doctor with corresponding medications. Until November 10, 2017, he thought
all the while that it was just a simple chest pain. However, while bundling up some
wood for construction at the seaside, he suddenly felt hot all throughout his body. His
chest started to ache almost beyond bearable point, as was verbalized by the patient.
He was then rushed to the emergency room of CLMMRH and was admitted
consequently to the Medical Ward.

B. Past Health history

I. Childhood Illness

Client could not recall any illnesses from his childhood.

II. Past hospitalization

Client has been hospitalized before because of leptospirosis. His second

hospitalization was due to angina attack.

III. Serious/Chronic Illness

The client claimed that he doesn’t have any chronic illness.

IV. Previous Surgery

He underwent surgery once to excise a cyst growth on his left arm.

C. Family/Social history

The father of the client also suffered from a coronary syndrome. It ultimately
resulted to his death. Aside from that, the client claims that he does have a history of
serious/chronic diseases on his mother’s side.
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VIII. ASSESSMENT

General Appearance
- Patient is generally normal
- Responsive to verbal, non-verbal and painful stimuli
- On complete bed rest
- Face is symmetric, no involuntary movements and no lesions
- With moderate body weakness on arms and legs

Vital Signs:

Date and Time Blood Pressure Temperature Pulse Rate Respiratory

Rate

November 14,2017 90/60 35.6˚C 60 20

(8:00 am)
November 14,2017 80/60 35.8˚C 53 22
(12:00 nn)
November 15,2017 120/70 37.2˚C 63 21
(8:00 am)
November 15,2017 110/70 36.5˚C 64 26
(12:00 nn)

November 14 ,2017

Cephalo - Caudal Examination

NEUROLOGIC

- Patient is conscious
- Oriented to time, place and date
- Responsive to verbal, non-verbal and painful stimuli
- Good eye contact
- Affect and facial expression appropriate to situation
- Recalls events with little difficulty
- Clear speech manifested
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HEENT

- Hair is thick and equally distributed

- PERRLA
- Hair color is a mixture dark brown and gray
- Eyes are equally symmetric
- No lesions were present
- Able to hear clearly; no presence of ear discharges
- Normal throat
- Teeth are not complete with decay

CARDIOVASCULAR

- BP of 90/60 mmHg taken at the left arm

- Cardiac rate of 60
- With IVF infusing well at right cephalic vein
- Peripheral pulses all present and normal
- Neck vein slightly distended when lying down
- Heart sounds slightly weak

RESPIRATORY

- Respiratory of 20 cpm
- Breathing pattern is normal with no abnormal sounds

GIT

- Borborygmus sound in the stomach

- Defecated to a well formed stool
- Urine slighlty dark yellow in color
- on LSLF (Low salt low fat diet)
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MUSCULOSKELETAL

- Patient is in complete bed rest

- Shoulders, arms and elbows are symmetrical, no redness or deformity present
- Hands and fingers are symmetric

GUT

- Able to void slightly dark yellow urine

INTEGUMENTARY

- Temperature of 35.6˚C
- With good skin turgor
- Lips are slightly dry
- Nails are short and dirty; nail bed is pink; nail base is thick
- Capillary refill within 2 seconds
- Presence of moles in the skin
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November 15,2017
NEUROLOGIC

- Patient is conscious
- Oriented to time, place and date
- Responsive to verbal, non - verbal and painful stimuli
- Good eye contact
- Affect and facial expression appropriate to situation
- Recalls events with no difficulty
- Clear speech

HEENT

- Hair is thick and equally distributed

- PERRLA
- Hair color is a mixture dark brown and gray
- Eyes are equal symmetric
- No lesions were present
- Able to hear clearly; no presence of discharges
- Normal throat
- Teeth are not complete with decay

CARDIOVASCULAR

- BP of 120/70 mmHg taken at the left arm

- Cardiac rate of 63 bpm
- With heplock at right cephalic vein
- Peripheral pulses all present and normal
- Neck vein slightly distended when lying down
- Heart sounds clear
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RESPIRATORY

- Respiratory of 21 cpm
- Breathing pattern is normal with no abnormal sounds

GIT

- Borborygmus sounds auscultated in the stomach

- Defecated to a well formed stool
- Urine yellowish in color
- on LSLF (Low salt low fat diet)

MUSCULOSKELETAL

- Patient is in complete bed rest

- Shoulders, arm and elbows are symmetrical, no redness and deformity
- Hands and fingers are symmetric

GUT

- Able to void yellow urine

INTEGUMENTARY

- Temperature of 37.6˚C
- Patient is slightly warm
- With good skin turgor
- Lips are slightly dry
- Nails are short and dirty; nail bed is pink; nail base is thick
- Capillary refill within 2 seconds
- Presence of moles in the skin
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IX. LABORATORY

A. CLINICAL CHEMISTRY

Date: November 13, 2017

EXAM NAME RESULT NORMAL INTERPRETA IMPLICATION

VALUES TION
Calcium 4.56 mg/dl 4.56 - 5.4 Normal Serum calcium is an
(Ionized) mg/dl independent, prospective risk
factor for MI in middle-aged
males suggesting a role for
extracellular calcium levels in
the atherosclerotic process.
Creatinine 1.14 mg/dl 0.6 - 1.3 mg/dl INCREASED Increased creatinine levels
indicate reduced kidney
function, which is a risk factor
for cardiovascular disease.
Magnesium 1.70 mg/dl 1.70 - 2.4 Normal Indicates normal metabolic
mg/dl and kidney function.
Potassium 4.50 mEq/L 3.5-5 mEq/L Normal Normal cardiac function.

B. CARDIAC MARKER

DATE: 11/13/17

EXAM NAME RESULT NORMAL INTERPRETA IMPLICATION

VALUE TION
CARDIAC Elevated cardiac troponin
MARKER: 139.36 10-50 ng/L INCREASE levels in the blood indicates a
TROPONIN I ng/L damaged heart muscle.
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DATE: November 14, 2017

EXAM NAME RESULT NORMAL INTERPRETA IMPLICATION

VALUE TION
CARDIAC Elevated cardiac troponin
MARKER: 49228.54ng 10-50 ng/L INCREASE levels in the blood indicates a
TROPONINP /L damaged heart muscle.
I

C. HEMATOLOGY - Coagulation

DATE: 11/13/17

EXAM NAME RESULT NORMAL INTERPRETA IMPLICATION

VALUE TION
Prothrombin 10.9 9.4-12.5 Normal No bleeding disorder.
Time seconds
% Activity 115 70 - 100 % INCREASED
INR 0.92  2.0-3.0 (
for patient
on
anticoagul
ant
therapy)
 2.5 -3.5 (
for
patients on
anti
coagulant
therapy
with heart
valve
prosthesis)

EXAM NAME RESULT NORMAL INTERPRETA IMPLICATION

VALUE TION
Prothrombin
Time 15 9.4-12.5 INCREASED
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seconds
% Activity 71 70 - 100 % Normal
INR 1.25  2.0-3.0 ( DECREASED Prolonged bleeding time
for patient induced by anticoagulant.
on
anticoagul
ant
therapy)
 2.5 -3.5 (
for
patients on
anti
coagulant
therapy
with heart
valve
prosthesis)

D. HEMATOLOGY

DATE: November 13, 2017

EXAM NAME RESULT NORMAL INTERPRETA IMPLICATION

VALUE TION
Hematocrit 0.40 L/L 0.40-054 L/L Normal
Hemoglobin 131 g/L 130 - 180 g/L Normal
RBC Count 4.33 4.5-5.5 DECREASED Indicates anemia, the body
10^12/L 10^12/L may not be getting the oxygen
it needs.
WBC Count 12.2 10^9/L 4.5-11.0 INCREASE Infection or inflammation
10^9/L
Segmenters 84 % 50-70 % INCREASE Represents an ongoing
infection, an inflammation, or
malignancy.
Lymphocytes 10% 25-35% DECREASE Increased susceptibility to
viruses, bacteria and fungi.
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Monocytes 5% 0-15% Normal

Eosinophils 1% 1-5% Normal
Platelet 195 10^9/L 150 - 400 Normal Normal blood clotting.
10^9/L

DATE: November 14, 2017

EXAM NAME RESULT NORMAL INTERPRETA IMPLICATION

VALUE TION
Hematocrit 0.30 L/L 0.40-054 L/L DECREASED Indicates too little iron, the
mineral that helps produce red
blood cells.
Hemoglobin 115 g/L 130 - 180 g/L DECREASED Indicates anemia.
RBC Count 3.43 4.5-5.5 DECREASED Indicates anemia, the body
10^12/L 10^12/L may not be getting the oxygen
it needs.
WBC Count 4.3 10^9/L 4.5-11.0 Normal
10^9/L
Segmenters 54 % 50-70 % Normal
Lymphocytes 28% 25-35% Normal
Monocytes 15% 0-15% Normal
Eosinophils 3% 1-5% Normal
Platelet 136 10^9/L 150 - 400 DECREASED High risk for bleeding if he or
10^9/L she has an injury or a
complicating condition that
affects blood coagulation
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E. ECG READING

P/PR QRS QT/QTc P/QRS/T axis HEART RATE

- / - ms 122 ms 514/469 ms -/-27/83 deg 50

Warning: artifact in ( part of) recording - use interpretation with caution

Warning: age not available, assumed 35 yrs. Old

Warning: Sex not available, assumed males accelerated AV junctional rythm with aberrant
ventricular conduction or accelerated idioventricular rhythm ( no atrial activity detected);
premature ventricular complexes; inferior infact; slight intraventricular conduction delay;
inferior ST elevation, consider infract or acute occurence; high lateral ST depression, probably
reciprocal; Abnormal ECG; Unconfirmed report.
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X. PATHOPHYSIOLOGY

Precipitating Factors:
Heavy work load
Predisposing Factors:
Physical and emotional stress
Sex: Male
Physical overactivity
Age: 73 years old
Increased total cholesterol
Family History of
Atherosclerotic disease

FATTY STREAKS FORMATION in the intimal

layer of the coronary artery.

Atheroma
MONOCYTES ingest lipids in the area of
deposition

Narrowing of the
REDUCED coronary blood flow Arterial Lumen

MYOCARDIAL ISCHEMA

ANAEROBIC METABOLISM of myocytes

Lactic Acid production

STIMULATION OF SENSORY afferent nerve

endings in the coronary vessels and in the
myocardium

ANGINA PECTORIS (Chest Pain)

PERMANENT Malocclusion

NECROSIS and scarring of the heart muscles

HEART ATTACK

Myocardial Infarction

Reference: Lippincott Williams and Wilkins (2006) Pathophysiology an Incredibly Easy