CLINICAL

Evidence-based care of a patient with a myocardial infarction

Jacinta Kelly
Abstract
Quality nursing care of the patient with a myocardial infarction is realized in accordance with evidence-based practice and by the willingness of nurses to adjust nursing practice as new evidence emerges. The framework for the holistic care of the patient following a myocardial infarction encompasses a comprehensive assessment, planning, intervention and evaluation process. The intention of this case study is to illustrate the rationale and evidence base underpinning the holistic approach to the care of this patient group. However, constant in the care of the patient following a myocardial infarction (MI) is the nursing commitment to an evidence-based holistic approach. Applying a case study method, this article explores the current evidence base that informs the process of assessment, clinical decision making and selection of nursing interventions in the first 12 hours of holistic care of a patient with a MI. A pseudonym is used to maintain the patients anonymity.
CASE PRESENTATION

I
Jacinta Kelly is Postgraduate Nursing Student, Waterford Regional Hospital, Ardkeen, Co. Waterford, Ireland Accepted for publication: December 2003

t is essential to optimize services for patients presenting with cardiac problems to enhance the continuing downturn in death rates from cardiovascular disease (Department of Health and Children, 1999). Consequently, changes in the delivery of health care and the increasing awareness of the need urgently to treat patients with acute coronary syndromes have led to the provision of thrombolysis in the emergency department as opposed to the coronary care unit.

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Joseph Ryan, a 60-year-old man, was admitted to the emergency room of a regional healthcare facility complaining of central chest pain, radiating down his arms and into his jaw. Joseph reported the pain as the worst pain ever; he was short of breath, clammy and nauseous. The pain began approximately 2 hours before admission to the emergency department while he was cutting the hedge and was unrelieved by rest. However, the pain returned and persisted, despite rest. An immediate electrocardiograph (ECG) (Figure 1), together with a brief targeted history and physical examination, confirmed a diagnosis of an inferior MI. An additional right-sided ECG was performed that excluded concurrent right ventricular involvement.
IMMEDIATE NURSING MANAGEMENT IN THE EMERGENCY DEPARTMENT

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Figure 1. Electrocardiogram indicating Josephs inferior myocardial infarction with ST segment elevation in leads 11, 111, aVF and reciprocal ST segment depression in leads V1V4, 1 and aVL.

In the emergency department, the immediate nursing management was as follows: Joseph and his family were reassured Blood pressure, pulse and respiratory rate were ascertained Oxygen therapy was delivered via nasal cannulae at 4 litres per minute Continuous monitoring of oxygen saturation was commenced Continuous cardiac monitoring was applied

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Soluble aspirin 300 mg was administered in an effervescent drink Intravenous accesses were placed in the antecubital fossae of both arms Blood specimens were reserved for biochemical profile, full blood count, coagulation studies and troponin I. Observing the indications and contraindications to thrombolysis and in accordance with evidence-based hospital guidelines for the treatment of MI (Table 1), Josephs intravenous thrombolytic and adjunctive therapy were administered with his consent within 20 minutes of arrival at the emergency department. This is referred to as the door-to-needle time, so a time of 20 minutes was duly audited.
PREPARATION FOR TRANSFER

Table 1. Hospital guidelines for the evidence-based treatment of coronary thrombosis

Two puffs of sublingual nitroglycerine were administered at 5-minute intervals to a maximum of 3 x 2 puffs Clopidogrel 300 mg orally Indications and contraindications to thrombolytic therapy were observed Consent to administer thrombolytic therapy was obtained Weight-adjusted dose of intravenous tenecteplase 8000 units (thrombolytic agent) was administered over 10 seconds Subcutaneous low weight molecular heparin at 1 mg/kg Intravenous metoprolol 5 mg over 5 minutes, repeated x 2 to 15 mg total Intravenous Cyclimorph was administered at 2.5 mg that care was taken to maintain his dignity and privacy (Vickers, 2003).

Woodrow (2000) advised that patients with uncomplicated MIs are best cared for in specialist coronary care units. Therefore, attention was directed towards preparing for Josephs safe transfer from the emergency department to the coronary care unit. Specific emphasis was placed on the provision and functionality of vital transfer equipment, such as: Oxygen supply Cardiac monitor Defibrillator Pulse oximetry Emergency drugs. Before Josephs transfer from the emergency room, a precursory history and summary of treatments received was communicated to the coronary care staff by the chest pain nurse specialist. A comprehensive verbal and written report was obtained once Joseph was safely transferred to his monitored coronary care bed.
HOLISTIC ASSESSMENT STRATEGY

Haemodynamic assessment
An assessment of vital signs, including blood pressure, heart rate and 12-lead ECG, was immediately undertaken. To assess blood pressure, the left arm was used because of its proximity to the main aorta (Docherty, 2002). The absence of relative coolness of Josephs distal limbs served as a rapid and useful guide to peripheral perfusion (Hillman and Bishop, 1996). ECG monitoring for assessment of dysrhythmias and ST segment elevation was implemented as an assessment tool because it is noninvasive, well tolerated by patients and provides continuous information about the heart (Docherty and Douglas, 2003). However, it should be remembered that the patient is always more important than the monitor (Wark, 1997). ECGs are adjuncts to, and not a substitute for, patient care (Woodrow, 2000). Therefore, it was imperative to observe Joseph as well as the monitor. Furthermore, Darovic and Franklin (1999) advise that assessment of haemodynamic stability should also take into account the pathophysiology and compensatory changes for the patients underlying problem. Subsequently, a working comprehension of the pathophysiology of inferior MI underpinned Josephs haemodynamic assessment process.

In the coronary care unit, a holistic approach to Josephs assessment was carried out which evaluated his total state of being (Dossey et al, 1995). Maintaining accurate clinical records was also essential for an accurate assessment of Josephs physical, psychological and social wellbeing and, whenever necessary, the views and observations of family members were obtained in relation to that assessment (An Bord Altranais, 2002). Throughout his assessment, Joseph was reassured and interventions were explained, which signified

Respiratory assessment
Initial assessment of the patient involved the nurse observing problems, such as visible cyanosis of the lips or being cold to touch (Jevon and Ewens, 2001). Rate, rhythm and

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regularity of breathing as well as chest expansion were all noted and documented (Docherty, 2002). Chest symmetry, skin condition and accessory muscle use were assessed and documented (Cox and McGrath, 1999). Wilson and Channer (1997) demonstrated that hypoxaemia in the first 24 hours after an MI is a frequent and predictable occurrence that remains undetected unless a pulse oximeter is used. While pulse oximetry was used continuously to assess Josephs oxygenation status, it was acknowledged that there are factors that can interfere with pulse oximeter accuracy (Table 2). However, pulse oximetry is only one component of the complex system of oxygen metabolism (Darovic and Franklin, 1999). Therefore, respiratory assessment was also carried out for signs and symptoms of fatigue, weakness, exertional dyspnoea or dizziness, which may have been indicative of tissue hypoxia (Sole et al, 2001).

Pain assessment
Pain assessment was a priority because continued pain is a symptom of ongoing MI, which places additional risk on non-infarcted myocardial tissue (Urden et al, 2002). Teanby (2003) commented that pain and pain assessment are vital to good medical and nursing care for judging a patients progress, the impact of treatment and occasionally for arriving at a proper diagnosis. The P, Q, R, S, T approach (Table 3) to Josephs chest pain assessment was implemented. To minimize bias and obtain reliable and valid data, the Manchester triage (Figure 2) assessment ruler was also used to assess accurately and consistently the severity of Josephs pain. The Manchester Triage Group (1997) cautioned that the environment and patients perceptions and beliefs can be barriers to effective pain assessment. Therefore, Josephs pain assessment also included noting subjective manifestations such as grimacing, increased muscle tone or restlessness (Kitt et al, 1995).

Table 2. Factors interfering with oximeter accuracy

False-high oxygen saturation levels Hypothermia Ambient light False-low oxygen saturation levels Skin pigment Elevated serum lipids Ambient light Poor signal detection Motion Poor peripheral perfusion Hypothermia
Adapted from Hillman and Bishop (1996)

Anxiety assessment
Josephs level of anxiety was assessed because increased anxiety levels result in raised neuroendocrine activity, which may worsen myocardial ischaemia (Evans, 1998). Verbalization of anxiety, tense facial expression and body movements are indicative of patient anxiety (Sole et al, 2001). Alternatively, autonomic responses to anxiety (rapid pulse rate, increased blood pressure, increased respirations, dilated pupils, dry mouth and peripheral vasoconstriction), are frequently the most reliable index of the degree of anxiety when behavioural and verbal responses are not congruent with the circumstances (Hudak et al, 1998).
OBJECTIVE FINDINGS

Table 3. P, Q, R, S, T approach to chest pain assessment

P Precipitating and palliative factors: patients are asked to describe what brought on the pain and what measures have helped relieve the pain Q Quality: patients are asked to describe in their own words what the pain feels like R Region and radiation: patients are asked to point to the location of the pain and if the pain goes anywhere S Severity: patients are asked to rate the pain on a scale of 110 with 10 being the worst pain ever experienced T Time: patients are asked how long the pain lasts and any temporal associations
Adapted from Urden et al (2002)

Josephs blood pressure was 140/90, oxygen saturation 99% on 4 litres of oxygen/minute, temperature 36.4C and heart rate 92 beats per minute with normal sinus rhythm and resolution of ST segment elevation. Neck vein distension and peripheral oedema were not present. On chest auscultation, there was no evidence of adventitious sounds. Joseph reported his central chest pain as 2 on the Manchester triage scale and described the pain as mild. The results of the biochemistry profile, coagulation studies, full blood count and chest radiograph were unremarkable. However, the specific test

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for detection of myocardial damage, troponin I, was decidedly positive at 4.8 ng/dl.
PSYCHOSOCIALSPIRITUAL FINDINGS

Joseph, a widowed farmer with four teenage children, although anxious, was fully alert and oriented on presentation to the coronary care unit (Glasgow Coma Scale 15/15). He lives an active life, smokes 1015 cigarettes daily and consumes alcohol occasionally (around 4 units/week). Joseph enjoyed excellent health until his admission. His hobbies include fishing and supporting Gaelic football. He is a practising Roman Catholic.
NURSING PLAN

glyceryl trinitrate (GTN) 20 mg/20 ml via syringe driver at 0.6 ml/hr was increased to 0.9 ml/hr as per hospital guidelines, to dilate coronary arteries and reduce ischaemic pain (Vickers, 2003). Repeated narcotic drug therapy (morphine sulphate 24 mg intravenous bolus) aimed to relieve pain and anxiety, as this may lead to a lowered threshold for cardiac arrhythmias, increased myocardial workload and provocation of coronary artery

Excruciating Worst ever Very bad Severe

Nursing goals were to relieve Josephs symptoms, limit the extent of myocardial damage, reduce cardiac workload and manage complications (Sole et al, 2001). Josephs nursing care plan incorporated a human perspective (Figure 3), which considered his physical needs in association with his psychological and sociocultural needs (Kinney et al, 1998).

Quite bad Moderate Mild stinging

Interventions for myocardial tissue perfusion

Oxygen therapy was continued at 4 litres per minute via nasal cannulae because it was important to assist the myocardial tissue to continue its pumping activity and to repair the damaged tissue around the site of the infarct (Sole et al, 2001). An upright position was preferable to foster better lung expansion, decreasing venous return, lowering preload and decreasing cardiac workload (Urden et al, 2002). However, if Joseph had been offered a choice of position, it may have helped him retain a sense of control and prevented feelings of powerlessness (Kinney et al, 1998). Oxygen therapy was humidified to prevent damage to ciliary function and to moisten the upper airway, thereby enhancing gas exchange (Adam and Osborne, 1997). Further humidification was offered in the form of mouth care as a comfort measure. Bed rest was also promoted, as it is effective in improving oxygenation, thereby promoting healing and relieving pain (Thompson, 1997).

No pain at all

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Figure 2. Manchester triage pain scale. Adapted from: Manchester Triage Group (1997).

Survival Recovery Minimal suffering

Seen as an individual Provided with information Respected Involved in decision making Receive emotional comfort and support

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Family relationships Connection to the real world

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Religious or spiritual beliefs Cultural values

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Interventions for pain relief

Having established that Josephs three peripheral vascular lines were patent and intact,
Figure 3. Human needs of the critically ill (adapted from Kinney et al, 1998).

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Ongoing explanations, reassurance and support were necessary to allay fear and anxiety for Joseph and his family. Indicated by Josephs behavioural, verbal and autonomic responses, the nurses therapeutic use of touch contributed to anxiety reduction and illustrated touch as a powerful tool for preserving patient individuality, coping mechanisms and self-identity...

Table 4. Complications of myocardial infarction

Cardiogenic shock Cardiac rupture Heart failure Sudden death Thromboembolism Ventricular septal defect Ventricular aneurysm Ruptured papillary muscles Extension of myocardial infarction Atrioventricular heart block which frequently follows an inferior wall myocardial infarction with the right coronary artery perfusing the atrioventricular node in 90% of the population
Adapted from Hubbard (2003)

Ensuring that staff conversation did not disturb patients (Kinney et al, 1998) Acknowledging his fears and anxieties (Whiteley et al, 2000) Addressing and treating him respectfully (Kinney et al, 1998) Facilitating his family to be present to touch and comfort their loved one (Whiteley et al, 2000) Active listening (Hudak et al, 1998) Staff identifying themselves by name (Kinney et al, 1998) Consistent use of curtains to maintain his dignity and privacy (Kinney et al, 1998) Pain control (Docherty and Douglas, 2003) Presencing (Kinney et al, 1998) Implementing care in a calm, supportive and confident manner (Sole et al, 2001) Spiritual care (Hudak et al, 1998; Kinney et al, 1998; Sole et al, 2001; Urden et al, 2002) Providing him with a call bell (Urden et al, 2002).

spasm (Thompson, 1997). While morphines vasodilatory properties may have the potential to reduce blood pressure, Woodrow (2000) argues that adequate pain relief is important both for humanitarian reasons and to prevent further stress responses. Further to providing comfort during pain, a relationship of trust, respect and support enabling empowerment of the patient was actively promoted by means of presencing simply being there for the patient and partnership (Taylor, 1992).

Interventions for complications of myocardial infarction

Dysrhythmias are experienced more frequently than any other MI complications, with the incidence at virtually 100% (Hubbard, 2003). Vigilance for ventricular fibrillation with cardiac monitoring was maintained as this represents a life-threatening arrhythmia (Docherty and Roe, 2001). Bed rest was strongly advocated to reduce cardiac workload. To ensure Josephs dignity and comfort and to facilitate monitoring of urinary output, the use of a bedside commode was permitted (Sole et al, 2001). Subsequent to Josephs arrival in the coronary care unit, 510 second runs of an accelerated idioventricular rhythm and frequent premature ventricular contractions were noted. Maj et al (2001) advise that these reperfusion arrhythmias are often self-limiting and may not require treatment. While Joseph did not require intervention, emergency cardiac drugs had nonetheless been made readily available. Nursing interventions also included being alert to any further complications (Table 4). Manifestly, Joseph did not develop complications as significant deviations in his baseline subjective and objective observations were not observed.

Interventions for anxiety and stress relief

Ongoing explanations, reassurance and support were necessary to allay fear and anxiety for Joseph and his family. Indicated by Josephs behavioural, verbal and autonomic responses, the nurses therapeutic use of touch contributed to anxiety reduction and illustrated touch as a powerful tool for preserving patient individuality, coping mechanisms and self-identity (Kinney et al, 1998). However, it was also important to establish and maintain professional boundaries by ensuring that the nurse/patient relationship does not become personal and avoiding over involvement with the patient (Sheets, 2001). Additional measures to prevent Joseph experiencing stress included: Noise control (Urden et al, 2002) Orienting him to the sounds of alarms (Woodrow, 2000)

Interventions for complications of therapy

Bleeding is the most significant potential complication associated with thrombolytic

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therapy, particularly intracranial bleeding (Brown et al, 2000). Therefore, ongoing neurological assessment with the Glasgow Coma Scale was implemented as a nursing intervention. Fortunately, Joseph did not exhibit any signs of bleeding, such as neurological changes, hypotension, tachycardia or narrowed pulse pressure (Whiteley et al, 2000). Nonetheless, continuous monitoring of heart rate and rhythm, oxygen saturation and intermittent blood pressure were undertaken. Furthermore, all three vascular access sites were covered with clear, occlusive dressings to facilitate assessment of these sites for bleeding and infection (Casey et al, 1998). Intramuscular injections and further insertion of access devices into non-compressible arterial or venous sites were avoided as thrombolytic therapy disrupts normal blood clotting and could precipitate bleeding via these routes (Maj et al, 2001). Additionally, frequent assessment was carried out for overt bleeding in urine, sputum, gums and stool (Urden et al, 2002). Maj et al (2001) advised that the patient be encouraged to report suspicious signs of bleeding or anaphylaxis, such as headache, lower back pain, nausea, abdominal pain, rash, vomiting, fever or extensive bruising.
CARE OF THE FAMILY

EVALUATION

As a result of timely evidence-based interventions, Josephs vital signs remained stable and resolution of ST segment elevation was sustained. In the first 12 hours of his admission to hospital, Joseph did not display any untoward effects of the thrombolytic therapy or complications of MI, and his chest pain and anxiety resolved completely. Lockhart et al (2000) affirmed that patients who have been admitted to hospital and survive a MI are usually highly motivated to reduce their risk of a further infarction. Therefore, referral forms for the cardiac rehabilitation nurse, dietitian and smoking cessation nurse were prepared. Joseph and his family expressed satisfaction with their overall care.
CONCLUSION

Offering open-ended visiting times as an intervention to reduce the familys crisis response has shown demonstrable benefits (Carr and Clarke, 1997). Hartshorn et al (1997) argued, however, that prolonged visits can deplete the patient of valuable energy required for vital healing and recovery. Therefore, a compromise was found between the familys need for proximity and Josephs need for rest by the nurses ability to reassure the family and provide information without excessive distrubance to Joseph. Research on the needs of families of patients in coronary care units has suggested that the family place utmost importance on having hope and receiving assurances about the treatment and prognosis of the patient (Appleyard et al, 2000). Leske (1998) suggested that the family need to have environmental comforts and supportive interventions available. Table 5 lists practical interventions that were extended to Josephs family.

The rapid expansion in knowledge of the treatment for patients with MI has led to an awareness of the need to adjust practice on an ongoing basis (Brown et al, 2000). In Josephs case, judicious and expeditious initiation of thrombolytic therapy in the emergency department provided an undeniably successful outcome. A safe and well-coordinated transfer of the patient to the appropriate setting of the coronary care unit ensured that further evidence-based assessments and interventions could be provided. A humanistic assessment and intervention strategy encompassing psychological, social, biological and spiritual elements of the person

Table 5. Supportive interventions for Josephs family

Personal needs, such as bathroom facilities, cafeteria and telephone Facilities where they could be alone or privately consult with physicians, counsellors or religious leaders Orientation to coronary care unit Explanation of procedures and treatments Education Supplementary information in pamphlet form Frequent and honest verbal information Involvement in care and decision making Encouragement and support Telephone number of coronary care unit Overnight accommodation in the hospital family room

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was found to be the most appropriate method by which to care for a patient in the coronary care unit. Interventions were directed at establishing a secure environment, provided by monitoring equipment and experienced coronary care nurses, to observe for complications of MI and of therapy. Consideration for the family was recognized as integral to providing holistic care for the patient in the coronary care unit. Evaluation of the patient identified the need to provide further supportive measures in the form of secondary prevention, rehabilitation and education. This article has demonstrated that the optimal care of the patient presenting with an acute MI relies on the commitment of critical care nurses to the application of current evidence-based holistic practices and their enthusiasm to embrace new roles as new evidence emerges. BJN

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KEY POINTS
A holistic approach to the nursing care of the patient with a myocardial infarction is well supported by evidence and literature. Effective communication and safe transfer of the coronary care patient to a monitored environment is paramount. Application of a holistic assessment, planning, intervention and evaluation strategy is conducive to quality care in this client group. Research-based evidence provides information on how to adjust nursing practice to optimize patient care.

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