Case Study 01.

A patient with Myocardial Infarction

Introduction

In the midst of a complex network of global health challenges, there is one adversary that stands out as
particularly daunting: cardiovascular diseases. These conditions can occur to anyone at any time, anywhere.

According to the World Health Organization (WHO), these are the current leading cause of death, globally.
Alarmingly, in 2019, 17.9 million people died from CVDs, accounting for 32% of global deaths. Of these, 85% were
caused by strokes and myocardial infarction or heart attack.

Myocardial infarction, commonly known as heart attack, is a condition that occurs when a segment of the heart
muscle is deprived of oxygen-rich blood. This case study will be delving into the intricate landscape of this medical
condition, providing a comprehensive exploration of its causes, clinical manifestations, diagnostic pathways and
findings, as well as management strategies.

Through a real-life case, we will navigate through the medical nuances that surround this condition. We will be
discussing subtle warning signs that may precede an attack and the urgency of medical intervention in the journey of
a patient with heart attack. Additionally, this will not only provide us with a deeper understanding of myocardial
infarction but also highlight the importance of awareness and prevention.

Join us as we analyze the journey of a patient through the lens of medical expertise, shedding light on the
significance of early recognition, effective healthcare response, and the pivotal role that a nurse plays in managing a
patient with a myocardial infarction.

References:

1. World Health Organization: WHO. (2021). Cardiovascular diseases (CVDs). www.who.int.

https://www.who.int/news-room/fact-sheets/detail/cardiovascular-diseases-(cvds)
2. Heart attack. (n.d.). Johns Hopkins Medicine.
https://www.hopkinsmedicine.org/health/conditions-and-diseases/heart-attack#:~:text=A%20heart%20attac
k%20(myocardial%20infarction,the%20heart%20muscle%20is%20blocked.

Definition

Myocardial Infarction, also known as coronary occlusion and heart attack, is a sudden occurrence of
myocardial ischemia that results in myocardial death. An initial thrombus in conjunction with coronary
atherosclerotic stenosis frequently results in the region of myocardial necrosis, which may thereafter experience
angina pectoris. Three yet distinct clinical features establish the spectrum of ACS; unstable angina, Non-ST
segment elevation myocardial infarction (NSTEMI), and ST-segment elevation myocardial infarction
(STEMI)

Etiology
Coronary Artery Disease is one of the common causes of Heart Attack or Myocardial Infarction. This
occurs due to the build-up of the cholesterol-containing deposits that cause occlusion of the coronary artery,
commonly called plaques. When these plaques tear, blood clots form around them causing blockage thus decreasing
oxygen supply to the myocardium. It will then slowly necrotize leading to a heart attack.

Other causes of MI are as follows:

1. Coronary Spasm/ Vasospasm of the coronary artery
2. Embolism from the Left Atrium
3. Coronary Artery Vasculitis
4. Hematologic abnormalities, such as sickle cell disease

Certain predisposing factors increase the susceptibility of certain individuals to experiencing a myocardial
infarction.

Non-Modifiable Risk Factors: Modifiable Risk Factors:

1. Age 1. Smoking
2. Gender 2. Illegal Drug use
3. Family History 3. Obesity
4. Hypertension
5. High blood cholesterol
6. Physical Inactivity or Sedentary Lifestyle
7. Stress
8. Alcohol abuse

Reference:

1. American Heart Association (2021). Understanding your risk to prevent Heart Attack.
https://www.heart.org/en/health-topics/heart-attack/understand-your-risks-to-prevent-a-heart-attack
2. https://www.nhlbi.nih.gov/health/heart-attack/causes

Pathophysiology
Clinical Manifestations
Although some individuals do not show any obvious sign of an MI (a silent heart attack), significant
clinical manifestation usually occur:

● Abrupt (usually) onset of pain, often described as severe and crushing in nature. The pain may radiate
anywhere on the upper body, but most often radiates to the left arm, neck, or jaw.

● Nausea and vomiting

● Feelings of weakness

● The skin becomes cool, clammy and pale

● Urine output decreases

● Tachycardia develops

● A mental state of great anxiety and a feeling of doom often develop

Diagnostic Findings

● Patient History

○ PQRST Assessment

○ History of previous illnesses

○ Family history of heart disease

● Electrocardiogram (ECG)

○ Provides information that assists in diagnosing acute MI

○ It should be obtained within 10 minutes from the time a pt reports angina or arrives in the ER

○ It usually identifies the: type and location of MI

○ Classic ECG Changes: T-wave inversion, ST-segment elevation, and abnormal Q wave

● Echocardiogram

○ Evaluate ventricular function

○ Used when ECG in nondiagnostic

○ Detects hypokinetic and akinetic wall motion

○ Determine the ejection fraction

● Laboratory Tests (Cardiac Biomarkers)

○ Creatine Kinase and its Isoenzymes (Increase with damage to cardiac cells)

■ CK-MB – increase within few hours and peaks within 24 hours of an MI

○ Myoglobin (Heme protein transports O2)

 ■ Increase within 1 to 3 hours and peaks within 12 hours after the onset of symptoms

■ Not very specific in indicating an acute cardiac event

○ Troponin (Protein in myocardium)

■ Isomers I & T – detected in serum within few hours during acute MI and remains
elevated for long period, often as long as 3 weeks.

REFERENCES
1. Corwin E. (2008). Handbook of Pathophysiology (3rd ed.). Lippincott Williams & Wilkins, a Wolters
Kluwer business.
2. Smektzer, S., Bare, B., Hinkle, J., & Cheever, K. (2008). Brunner & Suddarth’s Textbook of
Medical-Surgical Nursing (11th ed.). Lippincott Williams & Wilkins, a Wolters Kluwer business.

Surgical Management

Surgical interventions are performed to reperfuse and revascularize ischemic myocardial tissue when
patients are refractory to conservative management methods such as PCIs which are performed through a skin
puncture rather than a surgical incision. These surgeries include:

● Percutaneous Transluminal Coronary Angioplasty (PTCA) - A balloon-tipped catheter is used to open

blocked coronary vessels and resolve ischemia to improve blood flow within a coronary artery by
compressing the atheroma.
● Coronary Artery Stent - A metal stent is placed to overcome the risk of restenosis leading to
vasoconstriction, clotting, and scar tissue formation. The stent is initially positioned over the angioplasty
balloon to provide structural support to a vessel at risk of acute closure.
● Coronary Artery Bypass Graft (CABG) or Bypass Graft - A blood vessel is grafted to an occluded
coronary artery so that blood can flow beyond the occlusion. Major indications for CABG are:
○ alleviation of angina that cannot be controlled with medications or PCI
○ treatment for left main coronary artery stenosis or multivessel CAD
○ prevention of and treatment for MI, arrhythmias, or heart failure
○ treatment for complications from an unsuccessful PCI

References:
1. Diagnosis | NHLBI, NIH. NHLBI, NIH. Published March 24, 2022.
https://www.nhlbi.nih.gov/health/atherosclerosis/diagnosis#:~:text=To%20diagnose%20atherosclerosis%2
C%20your%20doctor,physical%20exam%20helps%20detect%20symptoms
2. Hinkle J, Cheever K, Overbaugh K. Brunner & Suddarth’s Textbook of Medical-Surgical Nursing. 15th ed.;
2021.

Medical Management

The goals of medical management are to minimize myocardial damage, preserve myocardial function, and
prevent complications. Even before reaching the hospital, emergency personnel may begin treatment of a suspected
heart attack with:

● Morphine - This analgesic drug reduces pain and anxiety, also has other beneficial effects as a vasodilator
and decreases the workload of the heart by reducing preload and afterload.
 ● Anticoagulants - Given to prevent clots from becoming larger and block coronary arteries. They are
usually given with other anti clotting medicines to help prevent or reduce heart muscle damage.

● Aspirin, clopidogrel, heparin, or other anti clotting agents - to prevent new clots

● Thrombolytic drugs - to dissolve existing clots ("clot-busting" drugs such as tPA) or thrombus in the
coronary artery, allowing blood to flow through again, minimizing the sizeof the infarction preserving
ventricular function.

● Oxygen - To protect heart tissue.To provide and improve oxygenation of ischemic myocardial tissue;
enforced together with bed rest to help reduce myocardial oxygenation consumption. Given via nasal
cannula at 2 to 4 L/min.

● Nitroglycerin - to widen coronary vessels. First-line of treatment of angina pectoris and acute MI; causes
vasodilation and increases blood flow to the myocardium.

● Drugs to decrease the heart's workload and pain, relieve anxiety, or regulate heart rhythm.

● Stool Softeners - Given to avoid straining that may trigger arrhythmias or another cardiac arrest.

● Sedatives - In order to limit the size of infarction and give rest to the patient. Valium or an equivalent is
usually given.

References:

1. https://www.templehealth.org/services/conditions/heart-attack-myocardial-infarction/treatment-options
2. https://nurseslabs.com/myocardial-infarction/

Nursing Management:

NURSING ASSESSMENT:

Signs and Symptoms:

Subjective:
1. Reports of chest pain radiating to the left arm

Objective:
1. Facial grimace
2. Restlessness characterized by changes in level of consciousness
3. Dizziness and Disorientation
4. Labored breathing
5. Tachycardia - 140 bpm
6. Hypotension - 90/50
7. Pallor

Review of Systems:
1. CNS: dizziness and disorientation (changes in mentation)
2. Cardiovascular: chest pain and changes in BP (hypotension)
3. Circulatory: palpitations, tachycardia 140 bpm
4. Respiratory: labored breathing and dyspnea
 5. Musculoskeletal: Chest pain radiating to the left arm
6. Integumentary: pallor and slightly cyanotic

Patient’s Risk Factors:

Non-modifiable:

1. Gender and Age - Client is male and 45 years old. Myocardial infarction is prevalent in males in this age
group.

Modifiable:

No information pertaining to modifiable risk factors was stated for this case.

PRIORITIZATION OF NURSING DIAGNOSES:

1. Ineffective Tissue Perfusion secondary to Myocardial Infarction related to inadequate blood supply to the
heart as evidenced by chest pain, dizziness, disorientation, tachycardia, hypotension and dyspnea
2. Decreased Cardiac Output secondary to Myocardial Infarction related to occluded artery as evidenced by
chest pain, dyspnea, tachycardia, dizziness, disorientation, and hypotension
3. Acute Pain secondary to Myocardial Infarction related to blocked coronary arteries and low oxygen-rich
blood flow as evidenced by chest pain, clutching the chest, restlessness, labored breathing, and dyspnea
4. Risk for Cardiogenic Shock

NURSING CARE PLAN:

ASSESSMENT DIAGNOSIS OUTCOMES INTERVENTIONS RATIONALE EVALUATION

SUBJECTIVE DATA: Ineffective Tissue Short-term INDEPENDENT: INDEPENDENT: Short-term Goals:

Perfusion Goals: 1. Obtain ECG 1. An ECG will
● Chest pain secondary to 2. Assess the reveal signs Goals met. After 24
radiating to the Myocardial Within 24 hours patient’s of a present hours of nursing
left arm Infarction related to of nursing capillary refill, or past heart intervention, the
● Dizziness inadequate blood intervention, color, and pulses attack while patient achieved
supply to the heart the patient will 3. Monitor vital also vital signs within
OBJECTIVE DATA: as evidenced by achieve vital signs especially identifying normal range and
chest pain, signs within BP anINEd pulse the severity exhibited warm and
Vital Signs: dizziness, normal limits 4. Monitor of damages normal skin.
● Heart rate: 140 disorientation, and have warm alterations in to the heart.
bpm tachycardia, skin with Level of 2. A blockage
● BP: 90/50 hypotension and neither pallor or Consciousness that causes Long-term goals:
dyspnea cyanosis. 5. Refer to cardiac diminished
Other data: rehabilitation blood and O2 Goals met. Within 3
● Disorientation Long-term supply the days of nursing
● Labored goals: DEPENDENT: heart will intervention, the
breathing manifest a patient presented as
● Pallor Within 3 days 1. Start CPR reduced alert and responsive
of nursing 2. Administer capillary with a good level of
intervention, reperfusion refill, pallor consciousness.
the patient will treatment and/or
be alert and 3. Administer cyanosis, and
present with a fibrinolytics weak
coherent level 4. Administer peripheral
of aspirin pulses
consciousness 3. One of the
priorities for
this diagnosis
is to achieve
a BP and
pulse rate
within
normal
range.
4. Altered LOC
such as
disorientation
and mental
confusion
may be an
indicator of
poor
peripheral
tissue
perfusion
developing
into
cardiogenic
shock
5. To lessen the
chance of
recurrence of
sudden
cardiac death.
DEPENDENT:
1. Start CPR if
there is no
pulse detected
2. All patients
with prolonged
ST-segment
elevation and
symptoms of
ischemia
lasting less than
12 hours should
receive
reperfusion
treatment in
order to restore
blood flow after
the attack
3. To bust blood
clots and
salvage the
cardiac tissues
4. Aspirin will
maintain blood
 flow through a
constricted
artery

SUBJECTIVE DATA: Decreased Cardiac Short-term INDEPENDENT: INDEPENDENT: Short-term Goals:

Output secondary Goals: 1. Assess the 1. Assess the
● Chest pain to Myocardial patient’s patient’s
radiating to the Infarction related to Within 24 hours medical medical history Goals met. Within
left arm occluded artery as of nursing history that and evaluate 24 hours of nursing
● Dizziness evidenced by chest intervention, may cause what conditions intervention, the
pain, dyspnea, the patient will decreased can be a risk patient achieved
OBJECTIVE DATA: tachycardia, have a blood cardiac output factor for vital signs that are
dizziness, pressure that is or MI decreased within normal
Vital Signs: disorientation, and within normal 2. Assess cardiac output range and exhibited
● Heart rate: 140 hypotension range and whether the and myocardial absent dyspnea.
bpm demonstrate pain’s infarction
● BP: 90/50 decreased or etiology is MI 2. To rule out Long-term goals:
absent dyspnea. or angina angina, the
Other data: 3. Monitor vital nurse must Goals met. Within a
● Disorientation Long-term signs assess that the week of nursing
● Labored goals: especially BP chest pain intervention, the
breathing and pulse occurs without patient is aware of
● Clutching of Within a week (evaluate the regard to how to manage
chest of nursing quality of activity, lasts myocardial
intervention, pulses on for longer, and infarction and
the patient will both points) is not relieved regularly
verbalize an 4. Assess by rest or participates in
understanding cardiac medication. activities that
of how to enzymes 3. The HCP must decrease the
manage 5. Encourage be informed workload of the
myocardial bed rest and when the BP heart.
infarction and activity drops as it can
be able to restrictions lead to
participate in 6. Start CPR cardiogenic
activities that shock
decrease the DEPENDENT: 4. Myoglobin,
workload of the 1. Administer troponin, and
heart. thrombolytic creatine kinase
therapy are cardiac
2. Administer enzymes, also
beta blockers known as
3. Administer cardiac
oxygen biomarkers.
Cardiac
troponin I or
cardiac
troponin T are
both extremely
sensitive and
specific for MI.
5. Bed rest will
lessen the
workload
which will
prevent
 inadequate
perfusion and
harm to the
heart.
6. If no pulse is
detected, CPR
must be done.

DEPENDENT:
1. To dissolve
intravascular
clots to
prevent
ischemic
damage and
improve blood
flow
2. To lower
myocardial
contraction
and promote
myocardial
perfusion
3. To increase
perfusion to
the heart and
other tissues

SUBJECTIVE DATA: Acute Pain Short-term INDEPENDENT: INDEPENDENT: Short-term Goals:

secondary to Goals: 1. Evaluate the 1. Evaluate
● Chest pain Myocardial Within 24 effectiveness effectiveness Goals met. Within
radiating to the Infarction related to hours, patient of pain in order to 24 hours, patient
left arm lasting blocked coronary will verbalize control assess whether verbalized pain
for about than 30 arteries and low pain relief and interventions the patient relief and was able
minutes oxygen-rich blood be able to rest requires other to sleep
flow as evidenced and/or sleep DEPENDENT: pain control comfortably.
OBJECTIVE DATA: by chest pain, comfortably 1. Administer options
clutching the chest, nitroglycerin Long-term goals:
Vital Signs: restlessness, Long-term 2. Administer DEPENDENT:
● Heart rate: 140 labored breathing, goals: oxygen 1. Nitroglycerin Goals met. After 3
bpm and dyspnea 3. Administer will dilate days of nursing
● BP: 90/50 After 3 days of morphine blood vessels intervention, the
nursing and therefore patient is now able
Other data: intervention, reduce pain to perform daily
● Disorientation the patient will 2. Chest pain tasks without
● Restlessness be able to increases discomfort and
● Labored perform daily with the lack assistance
breathing tasks without of oxygen
discomfort and 3. Morphine
assistance. can decrease
the oxygen
demand of
the heart and
relax the
patient.
SUBJECTIVE DATA: Risk for Short-term 1. Assess the 1. Assess the Short-term Goals:
Cardiogenic Shock Goals: patient’s patient’s
● Chest pain medical history medical Goals met. After
radiating to the After 24 hours that may history and 24 hours of
left arm lasting of intervention, indicate history evaluate what intervention, the
for about than 30 the patient will of conditions can patient displayed
minutes display stable cardiovascular cause their stable vital signs.
vital signs diseases signs and
OBJECTIVE DATA: especially the 2. Monitor vital symptoms to Long-term goals:
BP and pulse signs especially worsen
Vital Signs: BP and pulse 2. The vital Goals met. After 1
● Heart rate: 140 Long-term 3. Monitor level of signs, week of nursing
bpm goals: consciousness especially BP intervention, the
(Tachycardia) and changes in and pulse, patient displayed
● BP: 90/50 After 1 week of mental status should be alertness and
(Hypotension) nursing 4. Monitor monitored in responsiveness with
intervention, patient’s oxygen order to ensure a normal LOC.
Other data: the patient will saturation and that the patient
● Disorientation not be at risk gas exchange will not go
● Restlessness for cardiogenic into
● Labored shock and cardiogenic
breathing display shock
alertness as 3. Changes in
well as a mental status
normal level of are an
consciousness indicator of
shock,
especially
lowered LOC
4. Oxygen
saturation and
tissue
perfusion is an
influential part
of ensuring
that the patient
will not go
into
cardiogenic
shock.

References:
1. https://www.nursetogether.com/myocardial-infarction-nursing-diagnosis-care-plan/
2. https://nurseslabs.com/myocardial-infarction-heart-attack-nursing-care-plans/#h-what-is-myocardial-infarct
ion
3. https://www.healthline.com/health/paleness#:~:text=Paleness%2C%20also%20known%20as%20pallor,nu
mber%20of%20red%20blood%20cells.
4. https://en.wikipedia.org/wiki/Reperfusion_therapy
5. https://www.youtube.com/watch?v=H_VsHmoRQKk
6. https://www.ncbi.nlm.nih.gov/books/NBK557411/
7. https://www.ncbi.nlm.nih.gov/books/NBK537076/#:~:text=Myocardial%20infarction%20(MI)%2C%20col
loquially,hemodynamic%20deterioration%20and%20sudden%20death.
8. https://my.clevelandclinic.org/health/diseases/16818-heart-attack-myocardial-infarction