Bethlehem University

Faculty of Nursing and Health

Sciences
Nurs336/337

Case Study

"STEMI"

Student name: Ali Hawamde

Supervised by: Mr. Muhammad Thawabtah

spring 2020

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 Index:

Subject Page

Demographic data 3

Introduction 4

Patient's History 5

Physical Examination 6-7

Diagnostic tests 7-8

Lab tests 9-10

Pathophysiology 11-12

Medication 13-15

Nursing care plan 17-19

Discharge plan 20

Reflection 21

References 22

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  Demographic data

Student’s Name: Ali Hawamde Date:11/8/2020

Patient initials: M.G

Date of Admission:9/11/2020

Age: 65 years

Sex: male

Room/bed number: Room1 / bed4

Ward: ACVC.

Medical DX.: STEMI.

Informants: Pt., Pt file, Health care providers.

Diet: low fat low salt diet.

IV Fluids type and amount/24 hours):50cc/ hr – NS 0.9 – 500CC .

.Output: Pt is not on I/O Chart

Vital Signs: T= 36.8° P=70bpm BP=140/86 R=24bpm Sat. 97%

.Pain Score: On admission 10/10 but now 0/10

.Pain: Assessment Tool: Numeric

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 Introduction

We are required for our medical surgical course to take a case that we

see at hospital, and work on it in depth. I choose this case because the

diagnose and the patient’s history were really interesting for me and

grabbed my attention immediately, which made me think I want to

learn more about this case.

At the beginning it was difficult but after reading a lot about her case,

I gained a lot of information and understood it more. This patient has

a lot of complications which will help me relate what I learn in theory

to practice, not to forget the skills that I will learn from working with

a critical case like this one.

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Chief complaint:

Severe Retrosternal Chest Pain, burning stabbing in nature, squeezing chest

feeling, nausea and vomiting twice with sweating.

History of present illness:

The patient complained of chest pain and tightness synchronized with

nausea and vomiting. he went to Alia Hospital and then referred to Al -Ahli

hospital as a case of primary PCI for an urgent Cardiac Cath.

Past Medical & Surgical History

Free

Nutritional History

He has good Appetit, his weight is around 100 and his tall 179cm, his BMI

is 31 which mean that he is Obese. he hasn’t any allergy for any type of

food

Allergies: Unknown

Family History: IHD

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 Physical Examination:

 General appearance: looks good .

 Body mass index: is 31.2, he is obese.

Reason: due to lack of movement and bad diet.

 Eyes: BERRLA.

 Neck: Normal findings.

 Muscoskeletal system: Normal findings

 Skin: he has scar on his leg due to previous injury

 Abdomen: abdomen is distended .

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 Reason: he didn’t defecate for 2 days, glycerin Suppositories

given .

- Gastro-Urinary System: Voiding normally without pain, without

foleys or condom catheter.

Diagnostic Procedures

1- Cardiac Cath:

Cardiac Cath through the RT Distal Radial Artery on 9/8/2020, as a primary

PCI, and the result was as follow: -LM: distal atheroma.
-LAD: MID 90%.
-D1: Proximal Atheroma.
-CX: Proximal and Mid 90%.
-OM1:No stenosis.
-M2: Origin Atheroma
-OM3:Normal
- RCA:Mid Total TIMI Flow=0.

Tow PTCA Applied inflated 3.7mm.

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Result: TIMI Flow III / Integrilin, the patient recommended to follow up and
to do another PCI for LAD and CX after one month

2- cardiac echo: on 11/8/2020, and showed that:

- EF 42%.
- Inferior, posterior and lateral hypokinesia.
- Mild diastolic Dysfunction.
- Mild to Moderate MR and TR.
-No pericardial effusion.
-Both Aorta mildly dilated.

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  Lab Tests

10-8-2020
Chemistry
Test Result Normal Rational Interruption
range
Sodium 139 mmol/L 133-146 ------- -------
Potassium 4.1 mmol/L 3.5-5.5 ------- -------
Chloride 107 mmol/L 95-110 ------- -------
Creatinine 0.83 0.5-0.9
BUN 25 6-20 BUN slightly Pt started on
elevated 50cc/hr 0.9
because of low N/S
fluid intake.
Troponin I 30 0-0.4 ------- -------

Coagulation
Test Result Normal Rational Interruption
range
PT 12.8 sec 11-14 ---------
APTT 27 25-36 --------
INR 1.028 0.95-1.29 ------- -------

Complete Blood Count

Test Result Normal Rational Interruption
range
WBC 7.3 4.60-10.2
NEU 10.9 2-6.9
NEU% 64.4 % 37-80
LYM% 29 10-50
MONO% 7.7% 0-12
EOS% 1.3 0-7
BASO% 0.973 % 0.2-5
RBC 4.3 4.04-6.13 / /
HGB 13.2 12.2-18.1
HCT 36.5 37.7-53.7
MCV 84.3 80-97

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 MCH 30.2 27-31.2
MCHC 35 31.8-35.4
RDW 12 11.6-14.8
PLT 154 142-424

Serology
Test Result Normal Rational Interruption
range
HBsAg Nigative (-) ------- -------

Lipid profile
Test Result Normal Rational Interruption
range
Cholesterol 221 Less than Bad diet and Pt started on
200 high fat antihyperlipidemic
intake. medication.
HDL 41 Desirable
above 60 / /
And high
risk above
35
LDL 148 130-159 is
borderline High fat Teach the pt. to
intake adjust his diet
TRIGLYCIRID 155 150-200
E borderline. High fat Teach the pt. to
intake adjust his diet

 Pathophysiology

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myocardial ischemia happens if blood supply to the myocardium does not
meet the demand. If this imbalance persists, it triggers a cascade of cellular,
inflammatory and biochemical events, leading eventually to the irreversible
death of heart muscle cells, resulting in MI.

STEMI (ST elevation myocardial infarction): A STEMI is the combination

of symptoms related to poor oxygen supply for the heart with elevation of
the ST segments on the electrocardiogram followed by an increase in
proteins in the blood related to heart muscle's death. STEMI usually
develops by formation of an occlusive thrombus (blood clot) in a major
coronary artery previously affected by atherosclerosis. Plaque may rupture
or erode, and can trigger platelet aggregation and fibrin deposition, which
lead to formation of an occlusive thrombus in a coronary artery. This
occlusive thrombus completely blocks a coronary artery and interrupts blood
supply to part of the myocardium (heart muscle), profound changes take
place in the myocardium that lead to irreversible changes and death of
myocardial cells, and ultimately ST-segment elevation myocardial infarction
develops.

ST-segment elevation myocardial infarction (STEMI) is myocardial necrosis

with ECG changes showing ST-segment elevation that is not quickly
reversed by nitroglycerin. Troponin I or troponin T and CK are elevated.

In those who survive STEMI, the infarcted muscle is gradually 41 replaced

by scar tissue (fibrosis), and the extent of damage will determine the overall
pumping ability of the heart, and is a determinant of ‘heart failure’ and
longer-term survival.

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STEMI ECG

POST CATH ECG

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  Medications

Name Dose Route Rationale M.O.A Side effects Contraindication Nursing

s Considerations
Trade 100m P.O aspirin and Inhibition of gastrointestinal -Allergy to Assess patient for
Name: g clopidogrel platelet ulcerations, NSAIDS, nasal signs of bleeding
Aspirin 1X1 prove effective aggregation abdominal pain, polyps, asthma, (petechiae,
at reduction of through upset stomach, hemophilia, ecchymosis,
Generic thromboemboli inhibition of heartburn…. bleeding ulcers bloody or black
Name: c complications. platelet -Cautiously with stools, bleeding
Acetyl synthesis of impaired renal gums).
salicylic thromboxane function,
acid A2, a potent influenza,
vasoconstricto chickenpox,
r and inducer surgery scheduled
of platelet within 1wk
aggregation - Cautiously with
pregnancy or
lactation

Trade 75mg P.O. aspirin and Clopidogrel is - Upper -Hypersensitivity. Search Results
Name: 1X2 clopidogrel a respiratory tract -Active pathologic Featured snippet
Plavix prove effective thienopyridine infection ,Chest bleeding (eg, from the web
at reduction of compound that pain ,Headache peptic ulcer, Monitor patient for

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Generic thromboemboli inhibits ,Flulike syndrome intracranial signs of
Name: c complications. platelet ,Arthralgia , hemorrhage). thrombotic
Clopidogre aggregation by Dizziness thrombocytopenic
l selectively ,Diarrhea . purpura, Monitor
binding to for signs and
adenylate symptoms of
cyclase- bleeding
coupled
adenosine
diphosphate
receptors.
Trade 2.5mg P.O. To eases the selectively and -Dizziness,, - Sinus -Caution patients
Name: 1X1 workload on the competitively Insomnia bradycardia, 2°/3° to avoid driving or
Hypocor heart and binds to and ,Bradyarrhythmia heart block, other activities that
improves blood blocks beta-1 , Upper cardiogenic shock, require alertness.
Generic flow. adrenergic respiratory overt cardiac --Advise patients
Name: receptors in infection failure, to change
Bisoprolol the heart, ,Diarrhea, hypersensitivity, positions slowly to
decreasing Rhinitis . sick sinus minimize
cardiac syndrome without orthostatic
contractility permanent hypotension
and rate, pacemaker disease
reducing or angina
cardiac output,
and lowering

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 blood
pressure.
Trade 40mg S.C. Reduces the Enoxaparin - Bleeding, Pain Active major -administer in
Name: 1 X1 risk of recurrent binds to and and irritation at bleeding, subcutaneous
clexane MI. potentiates the injection site, thrombocytopenia tissue.
antithrombin Skin reactions with antiplatelet -DO NOT aspirate
Generic (a circulating such as itching, antibody in or massage site.
Name: anticoagulant) hives and redness. presence of
Enoxaparin to form a Blood clots which enoxaparin or
complex that form a solid heparin History of
irreversibly swelling at the heparin-induced
inactivates injection site thrombocytopenia
clotting factor (haematoma). (HIT) .
Xa.
Trade 20mg po prevention of preventing the Gastrointestinal Hypersensitivity to Check Liver
Name: 1*2 recurrent MI. conversion of symptoms such as atorvastatin Active enzymes
Lapitor HMG-CoA to diarrhea. liver disease or (ALT/SGPT)
mevalonate, Cold symptoms unexplained
Generic statin such as a runny or transaminase
Name: medications stuffy nose. elevation
atorvastatin decrease Joint pain, Pregnancy,
cholesterol Insomnia, lactation.
production in Urinary tract
the liver. infection, Nausea.

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  Nursing Care Plan

Nursing Dx (1): Activity Intolerance R/T cardiac dysfunction.

goal: patient will be able to tolerate activity without dyspnea and chest discomfort.
Intervention Rational Evaluation
1. monitor heart rate ,rhythm, 1-for early detection of the abnormalities and do the Ongoing
respirations and blood pressure intervention.
for abnormalities.
2. assist with active or passive 2-to maintain good muscle tone.
ROM exercises at least QID.
3. instruct patient in isometric and 3-to improve and increase activity level.
breathing exercises.

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Nursing Dx (2): Deficient Knowledge r/t new diagnosis.
goal: The client will able to correctly perform all tasks before to discharge.
Intervention Rational Evaluation
1. monitor patient’s readiness to 1) to promote optimal learning environment ongoing
learn and determine best when patient show willingness to learn.
methods
2. instruct in dietary needs and 2) To avoid high blood pressure and maintain
restrictions, such as limiting normal cardiac function.
sodium or increasing potassium. 3) these are helpful in improving cardiac
3. instruct exercises to be function.
performed, and to avoid
overtaxing activities.

Nursing Dx (3): Decreased Cardiac Output related to altered contractility.

goal: patient demonstrate adequate cardiac output .
Intervention Rational Evaluation
1) Note skin color, temperature, 1) For an early detection for hypoxia and low ongoing
and moisture. BP.
2) Check for any alterations in 2) Decreased cerebral perfusion and hypoxia are
level of consciousness. cause irritability.
3) Assess heart rate and blood 3) tachycardia and significantly low blood
pressure. pressure in response to reduced cardiac
output.

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Nursing Dx (4): Risk for Fluid Volume Excess.
Goal: Patient has balanced intake and output and stable weight.

Intervention Rational Evaluation

1. Monitor input and output 1) 1st action to maintain normal volume. Ongoing
closely.
2. Monitor and note BP and HR. 2) tachycardia and increased BP are indication
for dehydration and excessive blood volume.
3. Review chest x-ray
3) X-Ray studies show pulmonary edema if
exists.
4. Review serum electrolytes. 4) Electrolytes indicators of fluid status and
guide therapy.

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Nursing Dx (5): Imbalanced Nutrition: More Than Body Requirements.
Goal: Client will show weight loss with optimal maintenance of health R/T excessive intake in relation to metabolic need
as manifested by 32BMI.

Intervention Rational Evaluation

1. Document weight. 1. Patients may be unaware of their actual Ongoing
weight.
2. Perform nutritional assessment. 2. To know the pattern and types of intake.

3. Assess the level of activity. 3. To establish program exercise that will help
in weight loss.

4. Encourage water intake. 4. Water assists in the excretion of byproducts

and accelerate fat breakdown.

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 Discharge Plan

 (M)Medication: : when the patient is discharged he will get a list

of medications he needs to take. My role as a nurse is to explain to
the patient each medication, its name, dose, route, frequency and
any side effects. I should write this information on a paper and give
it to the patient family; I also should ask questions to make sure
that the patient family understand what has been taught.

 (E) Environment: the environment should be quiet with cool temp

and humidity.
 (T) Treatment: Any further treatment that the patient needs other
than medication and diet modification, when the patient
understands what is going on, he cooperates in his treatment and it
should run smoothly and easier. The patient needs to understand
the importance of taking his medications on time.
 (H) Health education: Health education is an important aspect in
maintaining a healthy life,
 (O) Outpatient clinic: Patient needs a follow up date to see the
progress of his status and to decide either to continue with this
treatment or modify it. My role as a nurse is to set an appointment
and make sure the patient knows the date, time and place.

 (D) Diet: Consume a diet high in vegetables, fruits, whole grains,

low-fat dairy products, and foods that are rich in beta-carotene,
potassium, magnesium and fiber.

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  Reflection

I choose this case because the diagnose was really interesting for me and
filled with a lot of things, and grabbed my attention immediately, which
made me think I want to learn more about this case. At the beginning it
was difficult but after reading a lot about him, I gained a lot of
information and understood it more

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  References:

Books:

 Smeltzer, Suzanne. Textbook of medical surgical nursing. 12th

edition. Philadelphia: Lippincott Williams &Wilkins, 2010.

Websites:

* Nurse Labs.

*Medscape.

*WebMD.

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