Apsara paudel Student ID: 220191405

FINAL DRAFT

Name: Paudel Apsara

Student No.: 220191405

Teacher’s name: Dr.SumatiChakravarti- Cook

Class: EAP ( 4C )

Due date:

Word count:1520

Research Question: What is the role of the nurse in the management of Myocardial

Infarction?
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Table of contents:

1 Abstract..............……………………………………………………….. (ii)

2 List of Illustrations……………………………………………………… (iii)

3 Introduction………………………………………………………………. 1-3

4 Classification ……………………………………………………........... . 3

5 Risk Factors……………………………………………………………… 3-4

6 Pathophysiology…………………………………………………………. 4-5

7 Clinical Manifestations……………………………………………………. . 5

8 Diagnostic Evaluations………………………………………………...……5

9 Medical Management………………………………………………………..6

10 Nursing Management...............................................................................6-9

11 Post Surgery Care....................................................................................10-11

12 Conclusion................................................................................................11-12

13 References...............................................................................................13-14

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ABSTRACT

The research is about the role of nurse’s in the management of Myocardial Infarction

(MI). Myocardial Infarction is one of the life-threatening, pathological condition of the

heart. Various factors pose a risk of MI in an individual,and these can be either

modifiable or non-modifiable. MI is characterised by a sudden onset of constricting,

stabbing and squeezing type of pain followed by other symptoms such as

diaphoresis, syncope, cool and cyanotic extremities and so on. The treatment

requirement in MI depends upon its nature. In severe cases, the patient might

require an emergency surgical intervention. The case of MI is managed by a doctor

or cardiac surgeon. Moreover, nurses play a significant role in the management of

vital issues such as pain reduction, meeting oxygen need, anxiety management and

identifying and preventing complication before and after the surgery.

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List of illustrations

Fig 1…………………………………………………………………………………...1

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INTRODUCTION
Myocardial Infarction in general term is known as Heart Attack. Myocardial Infarction

is classified under Coronary Artery Disease (CAD) related to the blood supply to the

heart. Decreased blood supply to the heart is the main cause that leads to tissue

death of heart muscle, and the condition is named as Heart Attack or Myocardial

Infarction. Myocardial Infarction is stated as a pathological condition that can be

characterized by either increase or decrease in the level of cardiac biomarkers

responsible for the evidence of myocardial tissue death Ibrahim, Riddell &Devireddy

(2014).

Fig1: healthy and infracted heart, retrieved from https:/thetechauthor.com/myocardial infarction-mi(2014)

The Fig (1) illustrates the difference in the normal heart and infracted heart. The first

diagram is a healthy heart with a normal artery whereas the second diagram

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indicates an infracted heart. The bluish portion in the second diagram is the

infarction resulted from the decreased blood supply to the myocardium. The artery in

the first diagram shows the free blood circulation when the second artery is

demonstrated with an atherosclerotic plaque which is causing the disturbance in

blood supply. The overalllayout provides a clear picture of how the infarction is

developed. “MI refers to the process by which areas of myocardial cells in the heart

are permanently destroyed. Like unstable angina, MI is usually caused by reduced

blood flow in a coronary artery due to atherosclerosis and occlusion of an artery by

an embolus or thrombus”. Brunner & Suddarth,(2010).pg 725. Angina is the chest

pain that is similar to MI. Angina is the first the first symptom that can be detected

during the progression of myocardial infarction.

Boateng & Sanborn (2013) explains an Acute Myocardial Infarction (AMI) as a result

of the acute coronary syndrome, that can be associated or non-associated with the

elevation of ST segment. The AMI can be confirmed by investigating the levels of

cardiac biochemical markers.According to the research done by BHF (2010), death

in the UK caused due to myocardial infarction was more common where 1 out of 5

men and 1 out of 8 women die as the result of heart attack. Bucher &Johnson( n.d.)

discovered that around 7 million of the Australian population was evidenced with

CAD and every day 15 of new Zeeland people die because of ischemic heart

disease in the year,2012. In the US, above 8 million peoplesuffer from AMI out of

which 27% die before they reach the hospital Boateng& Sanborn (2013). Myocardial

infarction (MI) can be diagnosed by clinical findings,that includes

electrocardiographic (ECG) reports, estimated levels of biochemical markers

(biomarkers), imaging, and also can be evidenced by pathology. It has become a

significant cause of mortality as well as disability throughout the world. MI might be

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the first symptom of coronary artery disease (CAD) or may repeat in patients who

experienced the disease earlier. Thygesen et al. (2016)Cited in(Journal of the

American College of Cardiology; New York Vol. 60, Iss. 16)

“Heart failure (HF) is responsible for worsening of the outcome of patients after

myocardial infarction1-4. Left ventricular systolic dysfunction occurs in about 40%

cases of acute MI, out of which 25% of patients develop heart failure

Babar,M.Z.M.,Baig,M.AR.,Azam,H.,&Azam,S.M.(2017)”. The heart failure following

myocardial infarction can be the reason of deteriorating in patient’s condition.

CLASSIFICATION

Depending upon the cause-specific, MI has been classified into five groups.

(Akram,W., Thomas,C. & and Chandan,M.) Cited in( Journal of Critical Care

Clinics.30.Iss 3). They are (MI type 1) which is of spontaneous type and is related to

a problem in a coronary artery that can result in thrombus formation. The second

type is (MI type2) that is related to increased demand of oxygen supply to the heart

muscles. Next is (type 3) associated with unavailability of biochemical markers in the

blood that can lead to sudden cardiac death. Other types of MI (MI type 4 and type

5) is associated with the procedures related to the treatment of other cardiac

diseases.

RISK FACTORS

Various risk factors for myocardial infarction has been detected. Depending on the

nature of risk factor they are grouped as modifiable factors, non-modifiable

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factors,and emerging risk factors. Modifiable factors include the changeable factors

such as habits and lifestyle of the individual. Smoking is known to be a potent cause

of vasoconstriction which impacts the blood flow. Alcohol consumption is another risk

factor for alcohol is responsible for the increase in HDL ultimately resulting in

atherosclerosis of coronary artery. Physical inactivity or the lack of exercise also

threats to myocardial infarction. It provokes the other risk factors such as obesity,

diabetes,and hypertension which places an individual at higher risk. These factors

such as smoking and alcohol consumption habit of an individual can be changed, but

the non-modifiable factors that include age gender and genetic history cannot be

modified. People above the age of 45 are known as risk population for heart attack.

Gender wise, the male population are at higher risk as compared to females. The

person with a known family history of the cardiovascular disease has a higher

chance of experiencing a heart attack. It is assumed (Erdmann,J;Linsel-Nitschke,P;

and Schunkert,H;2010) that the proteins those are involved in the progress of

atherosclerosis carry mutations. Emerging risk factors includeC-Reactive Protein

(CRP) which increases with the pathological condition of the heart. Other risks are

the Coronary Artery Calcification (CAC) that causes the hardening of the coronary

artery.

PATHOPHYSIOLOGY

The progression of myocardial infarction starts with the formation of atherosclerotic

plaque that is formedby the accumulation of lipid and cholesterol in the inner lining of

a coronary artery. Due to any physical pressure on the atherosclerotic plaque it

disrupts or erodes from its original form. The ruptured particle of the plaque then

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flows in blood and lodges in any significant blood vessels resulting in

vasoconstriction. The ruptured particlewhich moves along in blood vessels is called a

thrombus. If the thrombus is lodged in the coronary artery (the main artery supplying

oxygenated blood to the heart) which affects the blood flow to the cardiac muscle it

ends up with the death of cardiac tissues and results in the signs and symptoms of

myocardial infarction (Bassand ;et al,2007)Cited in( Marshall, Kathy; Nursing

Standard 2013).

CLINICAL MANIFESTATION

The primary symptom of myocardial infarction is the chest pain especially on the left

side as the neural pathway through thoracic,and the cervical nerves are involved in

it. Even the chest pain suggesting heart attack is of unique nature. The chest pain in

myocardial infarction is characterized by a feeling of squeezing, heaviness and

tightness and sometimes stabbing or burning type of pain. The main feature of chest

pain is it radiates to epigastrium, then to the left shoulder and follows to lower jaw

and neck Baoteng & Sanborn,( 2013).

DIAGNOSTIC EVALUATION

Various methods canbe used in the detection or confirmation of myocardial

infarction. The primary measure is the history taking and physical examination of the

patient. In auscultation, the muffled sound is heard in S1 and S2,and pericardial

friction rubs are noticed. Systolic murmurs are common. The specific investigations

include ECG findings and Serum Biochemical Markers, sometimes imaging also

aids. ECG findings reflect J-point elevation and ST-segment elevation where hyper-

acute T-waves is observed in case of Hyperkalemia. Serum Biochemical Markers

plays a significant role in the detection of a heart attack. A typical increase or

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decrease in serum biomarkers related to cardiac death especially cytokines and

troponin are found. (Akram,W., Thomas,C .and Chandan,M.) Cited in( Journal of

Critical Care Clinics.30.Iss 3).

MEDICAL MANAGEMENT

The emergency management of myocardial infarction focuses on relieving the chest

pin of the patient. Nitroglycerine is contraindicated in cases such as hypotension and

severe bradycardia. Next drug of choice is Morphine which is a potent analgesic and

venous dilator. 2-4 mg of intravenous morphine is given over 5 min. The drug dose

can be repeated every 5-15 min as per the need of the patient. The drug used for the

long-term use include anti-platelet drugs, among all the anti-platelet drugs aspirin,is

best preferred with minimum side effects. Another group of medicineis the

anticoagulant medication where unfractionated heparin and low molecular weight

heparin are frequently administered in case of emergency.

NURSING MANAGEMENT

Beside all the medical and surgical management, nursing management plays a

significant role in a hospital setting. The first and foremost thing a nurse need to do

as soon as patient reaches hospital is the assessment of airway breathing and

circulation. The patient should be placed in sitting or upright position until

contraindicated and administer the suggested volume of oxygen by the help of

oxygen mask or nasal prongs. Obtain the vital signs i.e. temperature, heart rate,

blood pressure and oxygen saturation of the patient. It is necessary to ascultate for

the heart sound and note if any murmurs are noted. Obtain an electrocardiograph
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with 12 leads. Open the IV line to administer the medication. Assess the pain level

using pain scale and administer the prescribed analgesics. Connect to ongoing ECG

monitor and record the changes in ECG. Assess for the drugs used by the patient in

routine basis and mark the contraindicated drugs. Administer aspirin for pain relief

until contraindicated. Asses for the reactions of the drug and response of disease

condition toward the treatment record the progress and failure. Provide an assurance

and emotional support to both the patient and family member. Make clear about all

the process of treatment and possible procedure in simple manner. Be ready with all

the emergency equipments such as defibrillator, pacemaker and a set of instrument

required for the Tracheostomy. Anticipate the need for emergency procedure and

report the doctor (Bucher.S and Johnson.S; n.d.).

According to Brunner and Suddarth, (2010) the most basic part in care of patient with

myocardial infarction is the assessment and general examination of the patient. This

provides a baseline information related to the patient’s condition and helps to identify

and prioritize the needs of patient. The symptoms need to be evaluated in relation to

the time, duration of onset and the aggravating factors of the disease The conditions

that need to be managed immediately include chest pain or discomfort , breathing

difficulty, palpitation, unusual fatigue, syncope and diaphoresis. Humphrey (2011)

also emphasize the importance of physical examination (inspection, palpation and

auscultation) in the patient with myocardial infarction. Humphrey also signifies the

history taking in managing existing signs and symptoms of the patient. Nurses

responsibilities are to plan care on the basis of the recognized problem and the

diagnosed condition. The main concern regarding the management of myocardial

infarction is pain reduction. Pain during MI progression is the result of progressing

tissue damage due to reduced blood supply. Brunner and Suddarth,(2010) describes

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the nature of pain as sudden chest pain that is crushing and constricting type,

typically in the anterior chest and radiating to jaw face and shoulder blades. The

main problems of patient where nurses can help them are:

• Chest pain

• Ineffective breathing pattern

• Decreased perfusion of peripheral tissues

• Anxiety

• Knowledge deficit regarding their condition

Chest pain related to myocardial infarction is severe, therefore the first priority should

be the pain management. As the MI pain is resulted from the tissue ischemia, the

nurses should focus on relieving the symptoms of ischemia. The first step can be the

meet the oxygen need of the patient. The oxygen can be delivered through nasal

prongs or nasal canula. The amount of oxygen generally delivered to the client

varies from 2-4litres/min. the nurses need to report the arterial blood gases value to

the doctor and administer the oxygen as advised by the doctor. Prior to this, it is

important to collect a detailed information about the nature, onset, severity and

location of the pain and report to the doctor because the chest pain might be

associated with various other factors. The next is to connect the patient with cardiac

monitor and 12 lead ECG to detect and record the changes of segments. The client

should be allowed to rest in sitting position or heat elevated position because this

eases breathing, allowing lungs to expand easily. MI pain is severe and medication

is alike compulsory to relieve the pain as per the prescription of physician. The

analgesics prescribed by the doctor should be administered carefully and recorded.

Humphrey (2011) suggests that he patient under the analgesics should be monitored
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continuously as the drugs are likely to cause respiratory distress as their side effects.

Another important nursing care includes providing patient with adequate rest by

limiting the physical activity. After all these nursing care, the reduction in chest pain

is expected by the health team and outcome is evidenced by the verbalization of

client and the pain scale.

After the management of chest pain, the higher significance is towards in maintaining

active respiratory function. The careful assessment and physical examination related

to the respiratory system provides the nurses adequate information about the

respiratory status of the client. It is fundamental to record and report all

theinformation of patient condition to the doctor. To maintain well respiratory function

adequate amount of oxygen must be regulated. The patient should be advised to

adhere to the diet pattern as suggested by the doctor. For example, low sodium diet.

Brunner and Suddarth (2010) mention that the higher level of sodium in the blood

can lead to fluid retention resulting in overloading of lungs and heart.

MI patient experiences the decreased perfusion on the peripheral body parts such as

upper extremities. The symptoms of reduced tissue perfusion include cool and

cyanotic extremities, marked hypotension and tachycardia, reduced urine output as

well as activity intolerance. The nurses should assess the peripheral skin and

temperature more frequently to detect the deterioration or progress on the patient’s

condition. The symptoms can be managed by the oxygenation therapy to maintain

the level of oxygen in the blood.

The patient with MI, are usually anxious related to the severe pain which leads to

fear of death. This can be the reason why painis taken as a critical concern in case

of MI patient. According to, Donges, Moorhouse & Murr (2014), the first step should

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be taken to identify the perception of the client towards the trauma and the effect of a

health condition can lead to various levels of depression in the patient. The nurses

can provide emotional support to the patient which can be helpful to the patient in the

reduction of the anxiety. Brunner and Suddarth (2010) emphasize about the

sympathetic stress response in relation with its effect on cardiac workload. The

stimulation of sympathetic nervous system due to stress is likely to be responsible

for the increased cardiac workload and thus aggravating the pain. Hence, it is

necessary to make the patient calm by providing a caring and trustworthy

environment. A nurse can also provide the adequate information about the client’s

condition and treatment method to the client and his family members. Offering a

calm environment, encouraging in self-help activities, teaching relaxation techniques

and giving assurance of progress could be helpful in reducing the anxiety. The

nurses can administer the anti-anxiety drugs if suggested or prescribed by the

physician. The counselling and stress reduction techniques are the other options that

can be adapted to reduce anxiety.

POST SURGERY CARE

The cardiac surgery is considered as one of the major surgery. The patient after the

surgery are at risk of excess fluid volume in the body which can be life-threatening to

the patient Donges, Moorhouse&Murr (2014) and this contradicts the statement of

Brunner and Suddarth (2010) that the patient after MI is at the risk of deficit fluid

volume. Both the report can be considered as the patient can experience the fluid

volume excess due to decreased renal perfusion as well as deficit fluid volume

related to blood loss and starvation during the surgery. The nurses must necessarily

asses the level of blood pressure and maintain a strict intake and output chart to

ensure the normal body fluid level in the body. The excess body fluid increases the

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cardiac overload and symptoms such as shortness of breath and chest pain may

reoccur. Pain management must be prioritized as the patient experiences an acute

pain followed by surgery. The pain can be managed by providing a comfortable

position, ensuring proper rest and sleep and mainly by administering the analgesic

drugs.

The patient is possible to face complication of acute MI. Brunner and

Suddarth(2010) address the difficulty related to the conduction system of heart

resulted from the cessation of blood to the myocardium. The complication can be

severe and risk the life of the patient. Therefore, nurses need to carefully asses and

identify the symptoms such as changes in cardiac function that is rate, rhythm and

heart sounds. Other signs representing the complications are deteriorating

respiratory condition, variations in urine output, changing color of extremities, altered

body temperature ECG variation, change in mental status and the fluctuations in

laboratory values. Any of this variation should be reported immediately by the nurses

to the doctor.

CONCLUSION

Myocardial Infarction is a serious Coronary Artery Disease. Myocardial infarction is

resulted from the tissue damage of the myocardium as a result of decreased blood

supply. The formation of atheromatous plaque can be the main cause. MI is a

medical emergency that may require an emergency cardiac surgery. The nurse’s

role in MI is focused on pain reduction, maintaining adequate oxygen supply, helping

the patient to cope up with the trauma and give the care as directed by the physician.

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REFERENCES

Baoteng,S.& Sanborn, T.(2013) Acute Myocardial Infarction, Disease a month 59,83-

96.doi.org/10.1016/j.disamonth.2012.12.004

Ibrahim, W.A., Riddell,C.T.,&Devireddy,C.M.(2014) Acute Myocardial

Infarction,Critical Care Clinics,13(30),pg(341-364)

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Erdmann J;Linsel-Nitschke,p;Schunkert H.,(2010) Genetic Causes of Myocardial

Infarction, New Insights from Genome-Wide Association Studies.Dtsch

ArzteblInt.,107(40):694-9;DOI:10.3238/arztebl.2010.0694

Kathy,M.(2013). Nursing Standard;London,vol.25,Iss.23(2016)

Bucher,L., & Johnson,S., ClinicalKey.com.au/nursing by Elsevier

Babar,M.Z.M.,Baig,M.AR.,Azam,H.,&Azam,S.M.(2017).Risk factors of heart failure

after myocardial infarction .Journal of Postgraduate Medical Institute, 31(1),

29-32.

Donges,M.E.,Moorhouse,M.F.,&Murr,A.C.(2011).Nursing Care Plans: Guidelines for

individualizing client care,ProQuestEbookCentral,retrieved from

https://ebookcentral-proquest-

com.ezproxy.une.edu.au/lib/une/detail.action?docID=253418

Humphreys,M.Nursing the cardiac patient,Willey.(2011)

ProQuest.com.ezproxy.une.edu.au/lib/une/detail

Thygesen,Ket al. (2016),Coronary Artery Disease, Journal of the American College

of Cardiology,(2013),60 (16) DOI:10.1016/j.011.2012.11.019

Johnson,J.Y.(2004).Myocardial Infarction,Handbook for Brunner &Suddarth’s

textbook of medical-surgical nursing,10th ed.(2004).retrieved from

http://search.proquest.com.ezproxy.une.edu.au/docview/200027287?accounti

d=17227

Figure: Anatomy of infracted heart, retrieved from

https:/thetechauthor.com/myocardial infarction-mi, (2014)

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Thank You.

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