Care Plan

ON
Mayocardial
Infarction

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 INTRODUCTION
As part of our clinical experience I was posted in for two week from
to . Here I have taken history of patient and done physical examination. I have
prepared case presentation on Mayocardial Infarction which is the life
threatening condition. I have assessed about its causes, symptoms and treatment
modalities.

My patient, Mrs. Manguben Nakum suffering from MI admitted on

with the symptoms of sudden chest pain restlessness. Here the patient treated
with emergency treatment. After the reports finalized for MI patient taken on
Thrombolytic therapy with vasodilators. I have provided comprehensive care to
the patient with administration of medication, Dietary management, Prevention
of complications, Psychological support to patient and family members. After the
discharge of patient I have explained about continuing care at home with
explanation of drugs. Also encouraged about follow up, diet, yoga and exercises.

PRESENT COMPLAINTS:

c/o Sudden Chest pain with tightness

Faintingsince 1 day

Restlessness since 1 day

Shortness of breathsince 2 days

Sweating since 2 days

Decreased urinary output since 3 days

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PRESENT MEDICAL HISTORY:

 My patient came with the sudden chest pain and restlessness with fainting
on She has symptoms of shortness of breath since 2 days and decreased
urine output since 3 days. Emergency treatment given after diagnosis of
condition. The diagnosis done with Electrocardiogram, Echocardiogram,
Angiography, Cardiac enzyme test.

PAST MEDICAL HISTORY:

 Patient has history of High Blood Pressure and 20% coronary blockage
before 5 years and admitted at Civil hospital Rajkot for one week

PAST SURGICAL HISTORY:

 Patient has history of hysterectomy before 3 years

FAMILY HISTORY:

Family tree:

Ramanbhai Manguben

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 Ratiben Samjibhai Mukeshbhai Sarojben

Hitesh Disha Madhav

- Patient

- Male

- Female

FAMILY INFORMATION:

Sr.no Name of family Relationship Age Education occupation Marital

member with patient status

1 Ramanbhai J. Nakum Husband 65 10th pass Farmer Married

2 Manguben R. Nakum Self 60 7th pass Housewife Married

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3 Samjibhai R. Nakum Son 40 10th pass Farmer Married

4 Ratiben S. Nakum Daughter in 36 10th pass Housewife Married

law
5 Mukeshbhai R. Nakum Son 32 B.Com Job Married

6 Sarojben M. Nakum Daughter in 28 12th pass Housewife Married

law
7 Hitesh S. Nakum Grand son 12 6th pass ------ Unmarried

8 Disha S. Nakum Grand 5 ------ ------ Unmarried

daughter
9 Madhav M. Nakum Grand son 6 ------ ------ Unmarried

Family income per year: 30,000

Family history of illness: No any

ALLERGIES AND MEDICATION:

Patient have no any allergies

Patient taking antihypertensives since 5 years

HABITS:

Patient has no any habits currently

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FUNCTIONAL HEALTH PATTERN:

 INTERPERSONAL RELATIONSHIP:
The patient has good relationship among family members and members are
caring and very supportive to Manguben

 HYGIENE:
The patient has good health practices but due to illness can’t do own daily
activities

 REST/SLEEP:
The patient has complain of impaired sleeping pattern

 ELIMINATION PATTERN:
The patient has decreased urinary output with normal bowel moments.

 DIETIC HISTORY:
 General appearance: Anxious
 Appetite: good
 Diet: oily and spicy
 Meal pattern: Normal
 Need assistance : needed

PHYSICAL ASSESSMENT

GENERAL APPERANCE
 Level of consciousness - semiconscious
 Orientation - Confused
 Activity - Lethargy

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 Body built - moderate

ANTHROPOMETRIC MEASUREMENT

1. Height: 5.2’

2. Weight: 67kg

3. Mid upper arm circumference: 16cm

VITAL SIGN

1. Temperature: 101 F

2. Pulse: 96bpm

3. Respiration: 24/min

4. Blood pressure: 140/90mmhg

5. SPO2: 90%

6. Pupil: Normal

7. Pain: Present

HEAD

 Hair: equally distributed

 Colour of hair: Black and white
 Scalp: clean
 Pediculosis: absent

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FACE

 Face: Anxious
 Facial puffiness: Absent

EYES

 eye brows: symmetrical

 eye lid/lashes: normal
 eye ball : normal
 conjunctiva: Pale
 sclera: white
 puncta: Normal
 cornea: regular
 iris: normal
 eye discharge: absent
 use of glasses: no
 Pupil:
 Equally reacting to light: yes
 Dilated and fixed, unequal: fixed
 Visual acuity: blurred vision

NOSE

 Nasal septum: central

 Nasal polyps: absent
 Nasal discharge absent

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MOUTH

 Number of teeth: 32
 Denture: present
 Dental carries: absent
 Odour of mouth: no
 Gums: healthy

LIPS

 healthy
 Cleft lips : absent
 Stomatitis: absent

SINUS

 Maxillary sinus infection : no

 Frontal sinus infection: no

EARS

 Size: normal
 Shape: symmtrical
 Position and alignment: normal
 Redness: absent
 Discharge: absent
 Cerumen: absent
 Lesions : absent
 Foregin body: absent
 Hearing acquity: normal
 Use of hearing Aid: no
 Tuning fork test:

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 Weber test: normal
 Rinner test: normal

BREAST

 Male:
- Lump: -----
- Swelling: -----
- Gynacomastia: -----

 Female:
- Symmetry : normal
- Pain: absent
- Lump; absent
- Discharge: absent
- Trauma: no
- History of present breast disease/surgery: no

RESPIRATORY SYSTEM
 Respiratory rate; Normal

Inspect the chest

 Thoracic cage-shape- normal

 Configuration- normal
 Skin colour and condition – pallor
 Chest expansion- asymmetric

Percussion

 Lung filed: clear

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  Resonance: hyper resonance
 Diaphragmatic excursion: normal

Auscultation

 Breathing sound- vesicular

 Adventitious sound- Absent
 Respiratory pattern- tachypnea

CARDIOVASCULAR SYSTEM

 Pulse: 94bpm
 Heart sound: S1. S2 heard
 Abnormal heart sound: S3 present
 Murmurs: present
 Carotid pulse rate: 94bpm
 Blood pressure: 140/90mmhg

DIGESTIVE SYSTEM

 Abdominal girth: 60cm

 Diarrhea/constipation no

Inspection

 Size- rounded
 Symmetry – normal
 Scar- no
 Lesions- no
 Redness- no

Palpitation

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  Tenderness- absent
 Fluid collection- absent

Percussion

 Ascites/peritonitis: no
 gas/fluid collection; no

Auscultation

 bowel sounds normal

GENITO URINARY SYSTEM

 frequency of urination: Decreased

 urine last voided: Today in early morning
 colour: pale yellow
 Oliguria
 catheter present: No
 urethral discharge: absent

INTIGUMENTORY SYSTEM

 skin colour Brownish to black

 dermatitis: absent
 allergies if any: no
 lesion/abrasions: absent
 tenderness/redness: absent
 surgical scar: no
 abnormal growth: no
 secretion: no

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MUSCULOSKELETAL SYSTEM

 range of motion possible

 weakness
 extremity strength- equal

SPINE

 lordosis/kyphosis/scoliosis: Absent

MENTAL STATUS

 Memory: Normal
 Knowledge: poor
 Thinking: normal
 Judgment: Impaired
 Insight: Present

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 LABORATORY INVESTIGATION

Sr. Name of investigation Normal Patient’s findings Remarks

no Findings

1 WBC 4000-10000 12000 per cumm Increased

2 RBC 3.9 – 5.8 6.9mill/cumm Increased

3 Hemoglobin 12 -16 9 gm/dl Decreased

4 Platelets 150 – 490 500 Normal

thous/cumm
5 M.C.H.C 32 – 36 33.4 gm/dl Normal

6 M.C.H 24 – 32 30.4 pg Normal

7 M.C.V 75 – 92 90 fl Normal

8 R.D.W SD 35 – 47 40.6 fl Normal

9 ESR 0 – 20 23mm/hr Increased

10 Blood CK-MB 0 .0 – 10.4 11 ng ml Increased

11 Blood Troponin T ≤ 0.04 0.041 ng/ml Increased

12 Serum Cholesterol < 200 239 mg/dl Increased

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 ANY OTHER INVESTIGATIONS

1. ELECTROCARDIOGRAM
 ST segment elevation

2. CORONARY ANGIOGRAPHY

CATH NO : 26345

APPROACH : Radial

ANAESTHESIA : Local

DYE : Omnipaque

CATHETER : 5F Tiger

HAEMODYNAMIC DATA : HR-90/Min, ABP 110/70, SPO2 -99%

LEFT MAIN CORONARY ARTERY :Normal.

LEFT ANTERIOR DESCENDING

ARTERY :Moderate size, type III vessel, shows

60% plaque at the level of D1. Fair

size D1 has 45% osteal and proximal lesion.

LEFT CIRCUMFLEX ARTERY :Non-dominant, normal

RIGHT CORONARY ARTERY :Dominant,

CONCLUSION : MODARTE TO SEVERE CORONARY ARTERY DISEASE AND

DISURRUPTED LV FUNCTION

3. ECHOCARDIOGRAPHY

 Moderate MR and Left ventricular dysfunction.

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 DETAILS OF MEDICATION
Drug name Dose& route Action Indications Side-effects Nursingresponsibilities

Injection 1.5 million IU Thrombolytic Mayocardial Low blood * Assess therapeutic

Streptokinase IV agent Infarction,Pulmonary pressure, response
embolism, Arterial allergic reaction, * Assess vitals regularly
thromboembolisam flushing, * Regular assessment
Nausea, of side effect of
Headache, streptokinase
dizziness, rash * Assess complications
related to disease
condition
Headache,
Tablet Nitroglycerin 5 mg Coronary Acute MI, Heart Flushing, * Evaluate therapeutic
sublingualy vasodilator failure, Chronic Dizziness, response
It Decreases stable angina Tachycardia, * The tablet should be
preload and pectoris, Pulmonary Postural placed between lips
afterload and hypertension, hypertension, and gum
improves blood Hemorrhoids, Palpitation, * It should be comply
flow through retained placenta Nausea, with complete medical
coronary Vomiting, Pallor, regimen
vasculacture Sweating and * Assess vitals regularly
rash * Regular assessment
of side effect of

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 DETAILS OF MEDICATION
Drug name Dose& route Action Indications Side-effects Nursing
responsibilities

Injection Morphine 4-8 mg IV Opiet analgesic Moderate to Drowsiness, * Evaluate therapeutic

Decreases pain severe pain, Headache, response in patient.
impulse dyspnea in end Bradycardia, * Assess vitals regularly
transmission at stage disease, edema, change in *Maintain I/O chart and
spinal cord level Pulmonary BP, Blurred vision, check for constipation
by interacting disease Nausea, Vomiting, * Check for CNS
with opioid Cramps, changes
receptor Constipation, * Check for allergic
Thrombocytopenia, reaction
Apnea, rash
* Check the
Antipletlate temperature, pulse and
Aspirin Tablet 50 – 325mg/ agent, It Acute MI, Confusion, BP after administration
day orally decreases Prophylaxis of Seizures, * Evaluate therapeutic
platelet MI, Ischemic Intracranial response in patient.
aggregation stroke, Angina, hemmordage, * Check for allergic
Thromboembolic Tachycardia, reaction and side
disorder, Mild to Hypotension, effects
moderate pain Hearing loss,
Hpokalemia,
Edema, Nausea

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 and Vomiting

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 Disease condition

Myocardial Infarction (abbreviated as "MI") refers to the process by which

myocardial tissues are permanently destroyed in the region of the heart that are
deprived of an adequate supply of blood (myocardial ischemia) because of a
reduced coronary blood flow: subsequently, necrosis or death to the myocardial
tissues occurs.

Prolonged episodes of ischemia kill many cells in the portion of myocardium

supplied by the occluded vessel. An area of cell death secondary to ischemia is
termed an infarct. The dead tissue should not be labeled ischemic because
ischemia carries a connotation of continued albeit diminished, function as well as
potential viability.

Clinical classification of different types of myocardial infarction :

Type 1-Spontaneous myocardial infarction related to ischemia caused by a

primary coronary event, such as plaque fissuring or ruptures

Type 2- Myocardial infarction secondary to ischemia resulting from an imbalance

between oxygen demand and supply, such as coronary spasm

Type 3 - Sudden death from cardiac disease with symptoms of myocardial

ischemia, accompanied by new ST elevation or left bundle branch block, or
verified coronary thrombus by angiography. In this type of MI death occurs before
blood samples can be obtained

Type 4-Myocardial infarction associated with primary percutaneous coronary

intervention

Type 5- Myocardial infarction associated with coronary artery bypass graft

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DEGREE OF DAMAGE:

1. Zone of Necrosis: Death of the heart muscle caused by extensive & complete
oxygen deprivation, irreversible damage.

2. Zone of Injury Region of the muscle surrounding the area of necrosis; inflamed
& injured, but still visible if adequate oxygenation can be restored.

3. Zone of Ischemia: Region of the heart muscle surrounding the area of injury,
which is ischemic & viable; not endangered unless extension of the infarction
occurs.

CLASSIFICATION:

A. According to the layers of the heart muscle involved, MI can be classified as:

1. Transmural (Q - wave) infarction

2. Non transmural (Subendocardial) infarction

B. Location of MI is identified as the location of the damaged heart muscle

within the left ventricle or right ventricle:

1. Left ventricular infarction

2. Right ventricular infarction

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 ETIOLOGY

Picture of book Picture of patient

 Coronary artery disease  Present

 Atheroslrosis  Present
 Complete occlusion of artery
by thrombus or embolus.
 Vasospasm  Present
 Anemia  Moderately present
 Decreased oxygen supply to  Present
heart

RISK FACTOR

Picture of book Picture of patient

 Emotional stress  Present

 Surgical procedure associated
with acute blood loss
 Increased levels of high
sensitivity C – reactive
protein
 Increased thickness of the  Present
inner layer of carotid arteries
 Cocaine use
 Thyrotoxicosis
 Family history
 Age  Present

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 CLINIAL MNIFSTATION

Picture of book Picture of patient

 Sudden Substernal chest pain  Present

 Restlessness  Present
 Cool and clammy skin  Present
 Rapid heart rate  Present
 Tachephnea  Prsent
 Decreased cardiac output  Present
 Shortness of breath  Present
 Profuse sweating
 Jugular vein distension  Present
 Vasoconstriction  Present
 Oliguria  Present
 Disorientation and confusion

DIAGNSTIC EVALUTION

Picture of book Picture of patient

 History and physical  Done

examination
 Electrocardiogram  Done
 Angiography  Done
 Cardiac enzyme test: CK-MB  Done
& LDH1
 PET
 Radionuclei Imagening 22
 CBC & Trponin test
 MEDICAL MANAGEMENT


Picture of book Picture of patient

 Oxygen therapy  Oxygen therapy

 Thrombolytic therapy  Tab Nitroglycerine 5 mg
- Streptokinase IV sublingualy stat
- Plasminogen activators IV  Tab Aspirin 300mg orally
 Analgesics  Tab clopidogrel 300mg orally
- Morphine  Tab Pantocid 40 mg BD
 Vasodilators  Injection Streptokinase 1.5
- Nitroglycerine (sublingual or milliunit + 100 ml NS over 45
IV) to 30 min
 ACE Inhibitors  Injection Morphine 4-8 mg
 Calsium Channel Blockers IV
 Anticogulants – Heparin

SURGIAL MANAGEMENT

Picture of book Picture of patient

 Coronary Artery Bypass  No any surgery done

Surgery
 Percutaneous Transluminal
Coronary Angioplasty
 Coronary Stent
 Atherectomy
 Transmyocardial Laser
Revascularization 23
 NURSING DIAGNOSIS

1. Acute pain related to mayocardial ischemia & decreased mayocardial oxygen

supply and demand seconadary to reduced coronary blood flow as evidenced by
chest pain and restlessness

2. Ineffective cardiopulmonary and peripheral tissue perfusion related to reduced

coronary blood flow from coronary thrombus and atherosclerosis as manifested
by dyspnea and oliguria

3. Decreased cardiac output related to decreased cardiac contractility due to

cardiac rupture

4. Ineffective gas exchange related to interruption of blood flow to the

pulmonary alveoli as evidenced by dyspnea and cyanosis and hypoxemia.

5. Activity intolerance related to fatigue secondary to insufficient oxygenation as

evidenced by weakness and exertional discomfort.

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6. Anxiety related to threat of death, pain & changes in health status as
manifested by restlessness, agitation.

7. Knowledge deficit related to disease process, medication, home activities and

rehabilitation as manifested by frequent questioning about illness and
management.

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 NURSING CARE PLAN
24Assessment Nursing Expected Planning Intervention Evaluation
diagnosis outcomes
Subjective Data: Acute pain To reduce * Assess pain * Assessed substernal The sudden
Patient came with related to pain at chest pain with chest pain is
sudden chest pain mayocardial maximum restlessness reduced
and restlessness ischemia and level
decreased * Assess vitals * Vitals are:
mayocardial Pulse : 96BPM
oxygen supply Respiration:24/min
and demand Temperature:101 F
Objective Data:
secondary to
*I have assessed * Obtained 12 lead ECG
reduced coronary * Provide emergency
vitals of patient during pain
blood flow as management
Pulse : 96BPM - Provided semi fowlers
evidenced by
Respiration:24/min position and
chest pain
Temperature:101 F administered oxygen
therapy
* Checked the level - Administered Morphine
of pain by pain IV according to doctors
scale prescription

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 NURSING CARE PLAN
Assessment Nursing Expected Planning Intervention Evaluation
diagnosis outcomes
Subjective Data: Ineffective Promoting * Assessment of vital * Assessed tachycardia The family
Patients family pulmonary and adequate function (90/min) with increased members
members peripheral tissue tissue Blood pressure (140/90) The dyspnea
complained about perfusion related perfusion And Informed to and
dyspnea and to reduced and cardiac physician restlessness is
restlessness coronary blood output reduced with
flow from * Administer treatment * administered oxygen normal Blood
coronary therapy pressure
thrombus and - Administered heparin
atherosclerosis as according to doctor’s
Objective Data: evidenced by prescription
Assessed dyspnea - Administered Injction
tachycardia streptokinase IV
(90/min) with according to doctor’s
increased order
Blood pressure
(140/90) * Provide comprehensive * Provided semi fowler’s
care to patient position
- Encouraged bed rest

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 NURSING CARE PLAN
Assessment Nursing Expected Planning Intervention Evaluation
diagnosis outcomes
Subjective Data: Ineffective gas Improve * Assessment *Assessed tachyphnea Patient
Patient came with exchange related respiratory (24 resp./min) with 90 % verbalized that
complain of to irruption of function oxygen saturation difficulty in
difficulty in blood flow to the breathing
breathing pulmonary * Administer medication *Administer oxygen reduced
alveoli as therapy according to
evidence by doctors order
dyspnea and - Administered Tab
cyanosis clopidogrel according to
doctors prescription
Objective Data:
* Maintain fluid balance *Maintained intake and
Patient have output chart regularly
decreased oxygen and administered Iv fluids
saturation at 90% as ordered
and have cental
cyanosis * Provide comprehensive * Provided comfortable
care bad with clean linen and
given fowler’s position
- Given supportive care as
needed

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 NURSING CARE PLAN
Assessment Nursing Expected Planning Intervention Evaluation
diagnosis outcomes
Subjective Data: Anxiety related To reduce * Assessment * Patient is restless and The anxiety of
Relatives said that to threat of death anxiety sleepy patient is
patient is restless and changes in reduced
an anxious the health status
* Provide needed * Informed patient about
information and Disease condition its
communication prognosis and treatment

Objective Data: * Provide psychological *Ensure patient to share

Prognosis of support her problems and
patient thinking related to
becomes poor disease condition

* Encourage Patient for *Encouraged for deep

stress relieving exercise breathing exercise

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 HEALTH EDUCATION
I given health education on various aspects of health, disease condition its causes,
sign and symptoms, diagnostic investigation, treatment and follow-up during his
stay in the hospital and at the time of discharge.

1. Disease condition
Informed about basic details of Mayocardial Infarction, what is it, causes of
MI, sign and symptoms, treatment modalities, complications and prognosis.
I explained about needed procedures required for treatment.

2. Medication
I have explained all the drugs which patient has prescribed. The effect of
this drugs on disease, main side effects. The patient informed about time,
route and frequency of drugs.

3. Nutrition
I explained about salt restriction with high protein diet. Advised not to take
high cholesterol especially LDL. It requires restriction of oily food and junk
food. Encouraged patient to take green leafy vegetables and iron rich foods.

4. Home care
I have explained about the drugs required after discharge; its time,
frequency, route. Encourage about regular inatake of medicines and dietary
requirements. Encouraged for regular exercise and yoga.

5. Follow-up
Encouraged about the importance of regular follow up. Informed about the
signs of complications, bluish discoloration, chest pain with palpitation etc.
Informed patient that he must came to hospital if any symptoms of
complication occur.

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 CONCLUSION
After the completion of this case presentation as a clinical assignment, I have
learned about following:

 Mayocardial Infarction:
 Causes and risk factors of MI
 Pathophysiology of MI
 Clinical manifestation of MI
 Diagnostic evaluation required for MI
 Medical and surgical management for MI
 Nursing management for MI

Through this case presentation, I have compared these points from

book to reality.

Finally, I have learnt about the communication skill, knowledge, Advance

Nursing care and improved my leakings.

BIBLIOGRAPHY
1. Waugh Anne & Allison Grant (2014), “Ross and Wilson : Anatomy and
Physiology in Health and Illness”, Elsevier publication, printed in China.
2. Smeltzer Suzanne, Bare Brenda and at.al, “ Brunner & Suddarth’s Textbook
of Medical Surgical Nursing”, Wolters Kluwer (India) Pvt Ltd, India; Sanat
Printers.
3. Shanbhag Tara, Smita Shenoy and at.al (2016), “Pharmacology for Nurses”,
Elsevier publication, India; Thomson press, India.
4. Kaur Navdeep (2015) “Textbook of Advance Nursing Practice”, Jaypee
Brothers Medical Publishers; Rajkamal Electric press, Hariyana.

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