MYOCARDIAL INFARCTION

MYOCARDIAL INFARCTION

Myocardial infarction, commonly known as a heart attack, is the irreversible necrosis of heart muscle secondary to prolonged ischemia. This usually results from an imbalance in oxygen supply and demand, which is most often caused by plaque rupture with thrombus formation in a coronary vessel, resulting in an acute reduction of blood supply to a portion of the myocardium.

RISK FACTORS:

NON MODIFIABLE FACTORS:

Age -Men: The risk increases after age 45 -Women: The risk increases after age 55 Hereditary

-Family history of early heart disease- a father or brother diagnosed before ager 55; or mother or sister diagnosed before age 65.

 MODIFIABLE FACTORS: Diabetes Mellitus Family history of coronary heart disease Smoking or tobacco use

Hypertension
Hypercholesterolemia

SIGNS AND SYMPTOMS

Pain Dyspnea Extreme pallor Nausea and vomiting Tachyarrythmias Initial hypotension but may be hypertension afterwards Pyrexia Fear

Biographic Data and Assessment

BIOGRAPHIC DATA

Name: Patient Y Address: Brgy. Paiisa Tiaong Quezon Age: 59 years old Sex: Male Status: Married Occupation: Currently None; he was a farmer before. Religion: Roman Catholic

SOURCE OF INFORMATION: The information is willingly given by the eldest daughter and by the wife of the patient. Patient's chart is our primary source of information. CHIEF COMPLAINT: Epigastric pain and chest pain

HISTORY OF PRESENT ILLNESS

Two days prior to admission the patient started to experience epigastric pain. Few days prior to admission the patient experienced chest pain. > According to his eldest daughter, the pt. Consulted a doctor regarding his epigastric pain, and they were told that the patient has esophageal irritation. But then this finding turned irrelevant because what might the pt feels is just referred pain.

ACTIVITY OF DAILY LIVING > According to relatives, the patient has no difficulty walking, bathing, eating, and performing ADL.

PAST HEALTH HISTORY > The patient had typhoid fever during his early teens. > He also had kidney stones 20 years ago, he did not undergo to any medical treatment, according to his wife, they just used herbal medicine in treating it, surprisingly a stone was excreted with his urine.

> The patient has history of asthma. > The patient has DM for 12 years. FAMILY HISTORY > His father had hypertension.

LIFESTYLE > The patient drinks wines occasionally. > He is a chain smoker since his teens. He consumes 2 packs of cigarette per day.

PSYCHOLOGICAL DATA >The patient is pessimistic, he easily get nervous when talking about his health status.

SPIRITUAL ASPECT > His whole family go to church every Sunday.

Physical Assessment

Skin: Scaly skin on lower extremities, dry and with scars and bruises found on the limbs. Head: normocephalic Eyes: Pale conjunctiva Ears: Good hearing, no discharges Nose: with NGT, no nasal discharges Mouth: dry lips and mucous membranes Lungs: w/ tachypnea and cough, w/ chest heaviness and crackles Abdomen: abdominal tenderness Extremities: good ROM; nail beds: capillary refill <5

Gordons functional health pattern

HEALTH PERCEPTION/HEALTH MGT.

Patient

is cooperative with the medical regimen as well as family members is currently receiving tube feeding via

NUTRITIONAL AND METABOLIC PATTERN

Patient

NGT. Has decreased bowel sounds due to poor peristaltic movement brought by immobility.

ELIMINATION PATTERN
The

patient has foley catheter and the amount of urine output is normal. (30-60 cc/hour)

ACTIVITY/EXERCISE
Currently

on bed rest. Altered ADL.

SLEEP/REST PATTERN
The

patient is resting well and is quite lethargic.

COGNITIVE/PERCEPTUAL PATTERN
GCS

Score: 11 (Spontaneous eye opening:4, motor:6, verbal response:1 (due to ET)) exhibits signs of dismay regarding his condition. Patient has become irritable and demanding.

SELF-PERCEPTION PATTERN
He

ROLE RELATIONSHIP PATTERN

The

family of the patient is very supportive towards the treatment of their relative. He has good relationship w/ them as exhibited by the presence of family members everyday. patient has five (5) children.

SEXUALITY/REPRODUCTIVE PATTERN
The

COPING/STRESS TOLERANCE PATTERN

The

patient has poor coping/stress tolerance. He had become demanding and irritable after knowing of his condition. values/belief of the patient doesnt hinder w/ the treatment process.

VALUES/ BELIEF
The

Anatomy and Physiology of the Heart

The heart is the organ that helps supply blood and oxygen to all parts of the body. It is divided by a partition or septum into two halves, and the halves are in turn divided into four chambers. The heart is located in the chest cavity between two pleural cavities, which surround the lungs. The heart lies obliquely in the mediastinum, with its base directed posteriorly and slightly superiorly and the apex is also directed to the left so that approximately 2/3 of heart's mass lies to the left midline of sternum. The base of the heart is located deep to the sternum and extends to the level of second intercostal space. The apex is located deep to the left fifth intercostal space, approximately 7-9 cm to the left of the sternum near the midclavicular line, which is a perpendicular line that extends down from the middle of the clavicle. It is surrounded by the pericardium which consists the fibrous and serous pericardium.

HEART CHAMBERS:
Atria-

upper two chambers of the heart. Ventricles- lower two chambers of the heart.

HEART WALL:
Epicardium-

the outer layer of the wall of the

heart. Myocardium- the muscular middle layer of the wall of the heart. Endocardium- the inner layer of the heart.

CARDIAC CONDUCTION:
It is the rate at which the heart conducts electrical impulses. The following structures play an important role in causing the heart to contract: Atrioventricular bundle- located in the lower portion of the atrium which carries cardiac impulses.Atrioventricular node- section of nodal tissue that delays cardiac impulses. Purkinje fiber- fiber branches that extend from AV bundle. Sinoatrial node- section of nodal tissue that sets the rate of contraction for the heart,it is the physiological pace maker of the heart, which is located in the junction of atrium and superior vena cava.

VALVES:
Aortic

valves- prevent the back flow of blood as it is pumped from the left ventricle to the aorta. Mitral valve- prevents the backflow of blood as it is pumped from the left atrium to the left ventricle. Pulmonary valve- prevents backflow of the blood as it is pumped from the right ventricle to the pulmonary artery. Tricuspid valve- prevents back flow of blood as it is pumped from the right atrium to the right ventricle.

BLOOD VESSELS General Structure of Blood Vessel Walls All blood vessels, except the very smallest, have three distinct layers or tunics. The tunics surround the central blood-containing space - the lumen.

1. Tunica Intima (Tunica Interna) - The innermost tunic. It is in intimate contact with the blood in the lumen. It includes the endothelium that lines the lumen of all vessels, forming a smooth, friction reducing lining. 2. Tunica Media - The middle layer. Consists mostly of circularlyarranged smooth muscle cells and sheets of elastin. The muscle cells contract and relax, whereas the elastin allows vessels to stretch and recoil. Tunica Adventitia (Tunica Externa) - The outermost layer. Composed of loosely woven collagen fibers that protect the blood vessel and anchor it to surrounding structures.

Blood vessels are classified as arteries, veins and capillaries. Arteries are vessels that transport blood away from the heart. Because they are exposed to the highest pressures of any vessels, they have the thickest tunica media. The elastin allows them to stretch and recoil and the smooth muscle allows them to constrict and dilate. Arteries are classified as elastic, muscular and arterioles.

Capillaries are the smallest vessels, the link between arteries and veins in the pathway of blood. Capillary walls consist of just a thin tunica intima, making them ideally suited for their role: the exchange of materials between the blood and the interstitial fluid. Veins are farthest from the heart so they experience the least pressure. Their walls are thinner than arterial walls and their lumens are larger, allowing them to accommodate a large volume of blood. The tunica adventitia is the heaviest wall layer in veins. It is classified as venules, small veins and medium sized veins.

PHYSIOLOGY OF THE HEART

ELECTRICAL ACTIVITY OF THE HEART Depolarization phase - Sodium channels are open. - Potassium channels are close - Calcium channels begin to open. Early repolarization phase - Sdium channels are close. - Some potassium channels are open causing early repolarization - Calcium channels are open, producing the plateau by slowing further repolarization. Final repolarization phase - Calcium channels are close - Many potassium channels are open.

CARDIAC CYCLE - refers to the repetitive pumping process that begins with the onset of cardiac muscle contraction and ends with the beginning of the next contraction. It consists of process of systole and diastole.

REGULATION OF HEART FUNCTION

Cardiac output- is the volume of blood pumped by either ventricle of the heart each minute. Stroke volume- the volume of blood pumped per ventricle each time the heart contracts. Heart rate- the number of times the heart contracts each minute. CO = SV x HR INTRINSIC REGULATION OF THE HEART refers to the mechanism contained within the heart itself.

Venous return- the amount of blood that returns to the heart and to which the ventricular walls are stretched at the end of diastole is called preload.
Starling's law of the heart Stroke volume is directly proportional to the preload. Afterload- refers to the pressure against which the ventricles must pump blood.

EXTRINSIC REGULATION
refers to mechanism external to the heart such as either hormonal or nervous regulation. Baroreceptor reflex- stretch receptors that monitor blood pressure in the aorta and in the wall of internal carotid arteries, which carry blood to the brain. Cardioregulatory center- located in the medulla oblongata of the brain which receives and integrates action potentials form the baroreceptors. It controls the action potentials in the SNS

Pathophysiology

Predisposing factors

SMOKING
Metaplasia of the epithelial lining of trachea

Lifestyle: Increase fat uptake

Fatty streaks in the left coronary artery

Hyperglycemia
Hardening of artery Impaired circulation

Decrease ciliary action

Inflammatory response

CBG is always higher than normal.

Bacterial colonization (Infection)

Formation of atheroma Narrowed artery CHEST RADIOGRAPH shows aorta is atheromatous

Inflammatory process PNEUMONIA

Decrease blood supply

Presence of opacities in both lower lobes of the lung.

Accumulation of exudates and debris in the alveoli

Ischemia
Necrosis of heart tissue- infarction Weak performance of the damage area Backward failure Cardiomegaly is the result of compensatory mechanism of the heart of increasing the HR; CHEST PAIN is felt because of increase workload of the damaged heart.

Impaired gas exchange

Nursing Care Plan

Assessment Subjective cue: Masakit ang dibdib ko as verbalized by the patient. Objective cues: >w/ facial grimace >Pain scale (8) >weak in appearance >pallor (as exhibited by pale nail beds) >V/S: BP:100/80 HR: 98 RR: 26 O2 sat: 98%

Diagnosis Acute pain related to tissue ischemia

Planning After a series of nursing intervention the patients report of pain will diminish from 8/10 to 5/10.

Intervention >Obtain full description of pain from client. Assist client to quantify pain by comparing it to other experiences

Rationale >Provides baseline for comparison to aid in determining effectiveness of therapy, resolution, progression of problem. >Decrease external stimuli w/c might aggravate anxiety and cardiac strain.

Evaluation Goal met. -Patient experienced relief from pain and his pain scale decreased from 8/10 to 5/10

>Provide quiet environment and comfort measures. Approach client calmly and confidently.
>Assist/instruct in relaxation technique

>Helpful in decreasing perception/respon se to pain. >Increase amount of available for myocardial uptake and thereby may relieve discomfort associated w/ tissue ischemia.

>Administer O2 via nasal canula or face mask as indicated. >Administer medications as indicated.

Assessment Subjective Cue: Nahihirapan akong huminga as verbalized by the patient. Objective cues: >V/S: BP:100/80 RR:26 HR:98 O2 sat: 93% >Restless >w/ Dry Cough >w/ crackles >w/ chest heaviness >Pallor >Dry skin and poor skin turgor >Cold clammy skin

Diagnosis Impaired gas exchange in relation to inflammation as manifested by decreased O2 saturation (93%)

Planning After a series of nursing intervention the client will demonstrate improved ventilation and oxygenation. Absence of symptoms of respiratory distress.

Intervention >Assess respiratory rate, depth, and ease

Rationale Manifestation of respiratory distress are dependent on/indicative of the degree of lung involvement and underlying general health status.

Evaluation >Goal partially met. >Demonstrates improved airway patency, as evidenced by adequate oxygenation by pulse oximetry (current O2 sat: 98%)

>Monitor heart rate/rhythm Tachycardia is usually present as a result of fever/dehydration but may represent a response to hypoxemia. Prevents overexhaustion and reduces oxygen consumption/dem ands to facilitate resolution of infection. Promote maximal inspiration,

Maintain bed rest. Encourage use of relaxation technique and diversional activities

Elevate head and encourage frequent position changes, deep breathing and effective

Assessment

Diagnosis

Planning

Intervention >Observe for deterioration in condition, noting hypotention, copious amounts of pink/bloody sputum, pallor, cyanosis, change in level of consciousness, severe dyspnea, restlessness >Monitor ABGs, pulse oximetry

Rationale >may indicate underlying condition such as pulmonary edema or shock.

Evaluation

>administer O2 therapy by appropriate means >Prepare for insertion of Endotracheal tube as indicated >Administer medications as

Identifies problem, follows progress of dse process/improve ment; facilitate alterations in pulmonary therapy.

The purpose of oxygen therapy is to maintain PaO2 above 60 mmHg. Promote ventilation and provide patent airway