CASE PRESENTATION ON MYOCARDIAL INFARCTION

INTRODUCTION

Acute Myocardial Infarction

Acute coronary event which causes interruption of blood flow from the coronary vessels to the myocardium. If prolonged it will lead to injury and irreversible death of myocardial tissue.

OBJECTIVES
 To describe the pathophysiology, clinical manifestations and treatment of myocardial infarction.  Use the nursing process as a framework for care of patients with MI.  Describe the nursing care of the patient with myocardial infarction.

GENERAL INFORMATION
Name: Mr. JT Sex: male Age:66 y/o Wt.: 75 kg Occupation: Businessman Citizenship: Filipino Arrived on unit by: STRETCHER Admission date: August 30,2006 Admitting v/s: BP: 230/110 mmHg PR:110bpm RR:26cpm TEMP: 36.8C Reason for admission: chest pain Medical diagnosis: Acute Myocardial Infarction

Chief Complaint:  chest pain radiating to the left arm

HEALTH HISTORY
HISTORY OF PRESENT ILLNESS  3 days PTA (+) dyspnea on exertion (+) bipedal edema grade I (+) 2 pillow orthopnea  3 hrs PTA (+) worsening dyspnea (+) chest pain radiating to the left arm (+) restlessness (+) easy fatigability

FAMILY HISTORY
FATHER HPN (+) (-) DM ASTHMA (+) CANCER (-) MOTHER (-) (+) (-) (-)

Past Medical History

 S/P: coronary artery bypass graft 4 vessel 1988(Phil. Heart Center) Personal/social history:  (+) heavy smoker 35 pack years  (+) alcoholic beverage drinker  Separated from wife for 20 yrs with 4 children working abroad.

Gordons Health Pattern Assessment

Health Perception and Mgt.

 Pt. is uncooperative and does not follow specific instructions for him, otherwise he keeps on moving.

Nutritional and Metabolic

 The pt. has poor appetite and consumes 1 of rice every meal. With the onset of disease he lost his appetite decreasing his rice consumption from 1cup to a cup. He is a heavy smoker and alcohol drinker.

Elimination Pattern
 He claimed that before his illness he is experiencing constipation and usually defecate within 2 3 days interval. Sometimes he used supplemental fiber which is readily available in the market, urinates frequently usually 6 8 times a day.

Sleep and Rest Pattern

 He has poor sleeping pattern, usually sleeps between 11/past midnight and wokes up from time to time. He does not take a nap in the afternoon. With his stay at the hospital, even though the environment is conducive to sleeping still he cannot sleep well because he feels anxious.

Mobility
 In motor and physical aspect there were slight changes, he felt weak and dizzy. Sometimes thus limiting his activities.

Cognitive/Perceptual
 Mentally the pt. is well oriented and coherent the pt. did not experience any disorientation as to time, space and personality. He worried , though, about his condition and things like outcome of his illness.

ADLs
 At present, slight movement causes him fatigue and was advised CBR without BRP. But the pt. was hesitant to follow.

Beliefs/ Values
 Pt. is Roman Catholic, however he seldom hears mass because he is living alone.

Health Maintenance
 When he gets sick, he does not seek medical assistance and tries to self medicate with Isordil. He does not submit himself to regular check up and continues to smoke against doctors advise.

Coping Stress
 When faced with any undertakings or obstacles he claims that he does not want to let a day pass without doing anything to counter it. He goes out and attends anything that could divert his attention while thinking of a good solution to his problem, he never wants to bother anyone in the family except when the problem is way to much for him to bear.

Role Relationship
 He is married with four children, unfortunately due to undisclosed reason pt. got separated. At present his caregiver is his sister in law. All of his children are presently working abroad with constant communication with his caregiver.

REVIEW OF SYSTEMS

Review of Systems
 Constitutional : Wt. loss of 5 kgs. In 1 month
(+) restlessness (+) weakness (+) easy fatigability

 Skin: (+) rashes (+) ithcing  HEENT: (+) dizziness (+) lightheadedness (+) hoarseness (+) nasal flaring (+) headache (-) nasal discharge  Chest: (+) mild chest tightness  Respiratory: (+) SOB (+) tachypneic RR:37 cpm (+) non productive cough (+) wheezes (+) chest x-ray result suggested mild to mod. lung hyperinflation

 Cardiovascular: S/P Coronary Artery Bypass Graft 4 vessel 1988 (+) tachycardic PR:110bpm (+) hypertension BP: 230/110 (+) palpitation (-) murmurs  Peripheral Vascular: (+) intermittent claudication  Musculoskeletal: (-) muscle pain  Extremities: (+) bipedal edema grade I (+) necrotic wound Left big toe  Neurologic: (-) fainting (-) seizure  Hematologic: (-) bleeding (-) anemia  Endocrine: (-) heat / cold intolerance  Gastrointestinal: (+) constipation (-) nausea/vomiting

PHYSICAL EXAMINATION

V/S:  BP: 230/110 mmHg  RR:26 cpm  PR:110 bpm  TEMP: 36.8oC

PHYSICAL EXAMINATION
 Conscious  Coherent, in moderate cardiorespiratory distress  Pale palpebral conjuctiva  Anicteric sclera  Moist buccal mucosa  (-) tonsillopharyngeal congestion  (-) lymphadenopathy  (-) Anterior neck mass  Equal chest expansion  (-) retraction(-)wheezes

 (+) coarse crackles, both lung fields  (+) harsh breath sounds  (-) murmur  Flat abdomen  (-) cyanosis  (+) bipedal edema grade I  Extremity  (+) necrotic wound on L big toe  (-) neurologic deficit on PE

EFFECTS OF ILLNESS TO GROWTH AND DEVELOPMENT

OLDER ADULTS (OVER 65 YEARS)

Categorizing the aging population Young Old: 65 75 y/o Old: 75 85 y/o Old old: 85 100 y/o Elite old: over 100 y/o

Theories of Aging
 Wear and tear theory Proposes that human, like automobiles have vital parts that run down with time, leading to aging and death.  The faster the organism lives, the quicker it dies  The cells wear out through exposure to internal and external stressors, including trauma, chemicals and buildup of natural wastes.

 Genetic theory Proposes the organism genetically programmed for a predetermined number of cell divisions after which the cells/ organism dies.  Immune theories The immune system becomes less effective with age, and viruses that has incubated in the body become able to damage body organs

Psychosocial theories
 Disengagement theory Aging involves mutual withdrawal between the older person and others in the elderly persons environment.  Activity theory The best way to age is to stay physically and mentally active.  Continuity theory People maintain their values, habits and behavior in olds age.

Eriksons developmental task

 Ego integrity vs. despair Integrity View life with a sense of wholeness and derive satisfaction from past accomplishment View death as an acceptable completion of life Accept ones one and only life cycle

Despair Believe they have made poor choices during life and wish they could live life over.

Cognitive
 Piagets phases of cognitive development end with the formal operations phase  Memory Short term memory Recent memory Log term memory

Moral development
 Kohlberg moral development is completed in the early adult years.
HEALTH PROBLEMS Chronic disabling illness

THEORY OF NURSING AS A FRAMEWORK OF THE CASE STUDY

OREMS GENERAL THEORY OF NURSING

Dorothea Orems theory includes these related concepts: self care, self - care deficit and nursing systems. Self care theory based on four concepts: self care, self care agency, self care requisites and therapeutic self care demand.

 Self care - Refers to those activities and individuals performs independently throughout life to promote and maintain personal well being.  Self care agency - is the individuals ability to perform self care activities. It consists of two agents: a.) a self care agent (an individual who performs self care independently) b.) a dependent care agent ( a person other than the individual who provides care)

 Self care requisites/self care needs > are measures/actions taken to provide self care.

There are 3 categories:

 Universal requisites are common to all people. They include maintaining intake and elimination of air, water and food, and balancing rest, solitude, and social interaction, preventing hazard to life and well being and promoting normal human function.

 Developmental requisites result from maturation or are associated with condition or events such as adjusting to a change in body image or to a loss of a spouse.  Health Deviation Requisites. Results from illness, injury, or disease or its treatment, they include actions such as seeking heath care assistance, carrying out prescribed therapies , and learning to live with the effects of treatment.

 Therapeutic self care Demand. Refers to all self care existing self care requisites or in other words, action to maintain health and well being.

SELF CARE DEFICIT THEORY

SELF CARE

SELF CARE AGENCY

<
DEFICIT

SELF CARE DEMANDS

NURSING AGENCY

Self care deficit results when self care agency is not adequate to meet the known self care demand

SELF CARE DEFICIT THEORY

SELF CARE

SELF CARE AGENCY

<
DEFICIT

SELF CARE DEMANDS

NURSING AGENCY

5 methods of helping:
 Acting or doing for  Guiding  Teaching  Supporting  Providing an environment that promotes the individuals abilities to meet current and future demands.

DISCUSSION

Acute Myocardial Infarction

Acute coronary event which causes interruption of blood flow from the coronary vessels to the myocardium. If prolonged it will lead to injury and irreversible death of myocardial tissue.

Differentiate ischemia from infarction

Myocardial Infarction:  Myocardial ischemia:  Occurs when there is an  A lack of oxygen to the abrupt decrease in myocardium due to coronary blood flow inadequate perfusion, following a thrombotic/ embolic occlusion of a causing an imbalance coronary artery, leading to between oxygen supply necrosis of myocardial and demand. tissue due to prolonged ischemia.  Relieved w/ SL nitrates  Occlusion with collateral  Not totally relieved with SL nitrates vessels.

The Blood supply of the heart comes from the 2 Coronary arteries 1. Right coronary artery supplies the RIGHT atrium and RIGHT ventricle, inferior portion of the LEFT ventricle, the POSTERIOR septal wall and the two nodes- AV (90%) and SA node (55%)

2. Left coronary artery- branches into the LAD and the circumflex branch  The LAD supplies blood to the anterior wall of the LEFT ventricle, the anterior septum and the Apex of the left ventricle  The CIRCUMFLEX branch supplies the left atrium and the posterior LEFT ventricle

Statistics
 Annually 1 million patients sustain an AMI in U.S.  33% of AMI patients diehalf of these within the 1st hour of infarction  46% of AMI have ST segment elevation or new onset of LBBB (STEMI)  The rest are diagnosed w/ NSTEMI

PATHOPHYSIOLOGY

Atherosclerotic Vascular Disease:

Generalized and Progressive
Atherosclerotic plaque Plaque rupture/ fissure & thrombosis Unstable angina MI

Normal

Fatty streak

Fibrous plaque

}ACS

Ischemic stroke/TIA

Critical leg ischemia Clinically silent Stable angina Intermittent claudication Cardiovascular death

Increasing age ACS, acute coronary syndrome; TIA, transient ischemic attack

Causes: Coronary atherosclerotic heart disease Coronary thrombosis/embolism Myocardial ischemia

Decreased cardiac output Decreased myocardial O2 supply Decreased myocardial contractility

Cellular hypoxia

Altered cell membrane Int.

Decreased arterial pressure

Stimulation of baroroeceptors

Stimulation of sympathetic receptors

Increased peripheral vasoconstriction Increased myocardial contractility

Increased afterload Decreased myocardial tissue perfusion

Increased myocardial O2 demand

Increased HR

Decreased diastolic filling

Modifiable Risk Factors

 Diabetes  Hypertension  Dyslipidemia  Obesity  Smoking history  Sedentary/stressful lifestyle

Non Modifiable Risk Factors

 Age  Male gender  Family history of CAD/genetics  Race

Signs and Symptoms of AMI

Signs and Symptoms of AMI

 Chest pain with and without radiation  Diaphoresis  Nausea / vomiting  Restlessness, sense of feeling unwell  Fear of impending doom

Classic Angina of Infarction

 Quality - squeezing, gripping, pressure like,
suffocating, heavy, burning, oppressive discomfort. *Angina is almost never sharp or stabbing, and usually does not change with position or respiration

 Duration - anginal episode is typically minutes to

hours, and often builds in intensity. *Fleeting discomfort or a localized stabbing ache even lasting hours is rarely angina.

Anginal Equivalents (atypical symptoms)

 Dyspnea or sudden shortness of breath  Fainting  Fatigue which is out of the ordinary  Vague sudden abdominal pain associated with diarrhea and diaphoresis usually with vomiting  Sudden severe palpitations with breathlessness (sudden onset atrial fibrillation) A sudden loss of consciousness with or without pulselessness, is definitely vascular in origin either a massive CVA or AMI

DIAGNOSIS OF MYOCARDIAL INFARCTION

Diagnosis of MI
W.H.O. and A.H.A. criteria: (2 out of 3)  Classic anginal or characteristic anginal equivalent type of symptoms  Typical ECG changes  Typical rise and fall of cardiac enzymes

Diagnostic Confirmation Tools

 12 Lead Electrocardiograph (EKG)  Cardiac biomarkers
Total CPK CPK MM CK-MB Troponin T/I

AMI Recognition
 Know what to look for  ST elevation
> 1mm in the limb leads  2mm in the chest leads Two contiguous leads

 ST depression  Symmetrically peaked T waves  Know where you are looking

ST Segment Elevation
 Presumptive evidence of AMI  Indication for immediate reperfusion therapy

AMI Localization

I II III

aVR aVL aVF

V1 V2 V3

V4 V5 V6
Anterior: Septal: Inferior: Lateral: V3, V4 V1, V2 II, III, AVF I, AVL, V5, V6

1st ECG Result:

 NSR normal sinus rhythm  LVH Left Ventricular Hypertrophy  Anterolateral wall ischemia  T/C Subendocardial Infarct

ECG Results
8/20/2006 Interpretation: Sinus Tachycardia LVH ST elevation Anterior chest leads of injury pattern Lateral wall ischemia

ECG
8/22/2006 Interpretation: NSR LVH Myocardial infarct Subendocardial anterolateral wall

Antero-septal Infarction

Creatine Phosphokinase (CPK)

 CK MB, - BB, - MM  CK-MB is the myocardial band
Rise in 3-12 hours, peaks in 12-24 and resolve in 1 1/2 to 2 days sensitive for myocardial injury

CPK-MB RESULT
 61 HI U/L
nv 0-16 U/L

Troponins T and I
 Rises in 3-12 hours, peaks in 12 to 24 hours and only resolves in 5 to 14 (5 to 10) days.

 Have nearly absolute myocardial tissue specificity.  Is now the preferred biomarker for the diagnosis of AMI  Cardiac troponins may also be elevated in CHF, myocarditis, pericarditis, sepsis, chronic kidney disease

TROPONIN T RESULT
 POSITIVE (QUALITATIVE)

Hematology
Leukocyte : H 16.2 Hemoglobin : L 138.0 Hematocrit : 0.41 Lymphocyte: 0.12 Monocyte : 0.05 Granulocyte : H 0.83 M/F 4.0-11.0 Male 140-160 Male 0.40-0.54 0.20-0.40 0.020-0.070 0.50-0.70

Blood Chemistry
 Urea : HI 11.5 mmol/L  Creatinine : HI 344 umol/L  Sodium : LO 131  Potassium : 7 U/L  CK- MB : HI 61 U/L
3.2 7.1 71 - 133 137 - 145 3.5 5.1 0 - 16

Lipid Profile
 Total cholesterol  HDL
LDL VLDL Triglycerides

Hi 350 mg/dl < 200 mg/dl Lo 20 mg/dl > 40 mg/dl

Hi 250 mg/dl 28 mg/dl 100 60 80 mg/dl 25 50 mg/dl 40 - 160 mg/dl

X - Ray
 Findings:  Pneumonitis right base  Heart size normal  Atheromatous aorta

MEDICAL MANAGEMENT

MEDICAL MANAGEMENT
 Goal  To minimize myocardial damage.  To preserve myocardial function.  To prevent complications.

THROMBOLYTIC THERAPY
Action: to dissolve and lyse the thrombus in a coronary artery, allowing blood to flow into the coronary artery again, minimizing the size of the infarction and preserving ventricular function. Reduce the patients ability to form a stabilizing clot, so the patient is at risk for bleeding should be used if the patient is bleeding or has a bleeding disorder. Must be administered as early as possible after the onset of symptoms that indicate acute myocardial infarction.

STREPTOKINASE
 Classification: Thrombolytic enzyme  Action: acts with plasminogen to produce an activator complex which enhances the conversion of plasminogen to plasmin. Plasmin then breaks down fibrinogen, fibrin clots and other plasma proteins, promoting the dissolution (lysis) of the soluble fibrin trapped in intravascular emboli and thrombi.  Indication: Acute myocardial infarction for reopening of coronary vessels

NURSING CONSIDERATIONS
Minimize the number of times the patients skin is punctured. Avoid intramuscular injections. Draw blood for laboratory tests when starting the IV line. Start IV lines before thrombolytic therapy; designate one line to use for blood draws. Check for signs and symptoms of bleeding.

NURSING CONSIDERATION
Do not add other medications to streptokinase. Assess for bleeding tendency, heart disease, and/or allergic reactions.

ASPIRIN/ACETYLSALICYLIC ACID
 Classification: Antithrombotic, analgesic/antipyretic  Indication: As antithrombotic for the prophylaxis of thromboembolic disorders in preventing myocardial infarction and transient ischemic attack.

LOW MOLECULAR WT. HEPARIN

 Clexane 0.4 ml SQ BID  Generic Name : Enoxaparin Sodium  Classification: Anticoagulant, Low molecular weight heparin  Action: Decreases the incidence of recurrent angina, MI and death  Indication: Treatment of unstable angina and non Q-wave myocardial infarction, administered with aspirin

NURSING CONSIDERATIONS
 Monitor vital signs; observe for early signs and symptoms of bleeding.  May experience mild discomfort, irritation and hematoma at injection site. Report any unusual bruising, bleeding or weakness..

ANTITHROMBOTIC
 Plavix 75 mg/cap OD  Classification: Antiplatelet drug  Action: Inhibits platelet aggregation by inhibiting binding adenosine diphosphate (ADP) to its platelet receptor.  Indication: prevention of atherothrombotic events in patients suffering from myocardial infarction.

NURSING CONSIDERATIONS
 Watch out for signs of bleeding including occult blood, especially during the first weeks of treatment.

NITRATES
 Isoket drip 20cc + 90cc D5W to run at 20ugtts/min.  Generic Name: Isosorbide dinitrate  Classification: Coronary vasodilator  Action: Smooth muscle relaxant, ventricular end-diastolic pressure and volume are diminished, thus reducing cardiac work and implicitly myocardial oxygen requirements; the arterial vessels are dilated as well, which leads in a slight drop in aortic and systemic blood pressure relieving the myocardium from a part of its afterload.

NURSING CONSIDERATIONS
 Side effects include headache, hypotension, dizziness and weakness which can be managed by slowly increasing the dose until the required daily dose has been attained.

ANALGESIC
 Morphine 4mg IV every 6 hours  Generic Name: Morphine sulfate  Classification: Narcotic analgesic  Action: principal actions of therapeutic value of morphine are analgesia and sedation; reduces anxiety; reduces preload, which in turn decreases the workload of the heart and relaxes the bronchioles to enhance oxygenation.  Indication: severe pain of infarction

NURSING CONSIDERATION
Check blood pressure, pulse, respirations before and after giving morphine sulfate DO NOT GIVE morphine if respiratory rate is less than 12 cpm. Always put bedside rails up following injection of narcotics. Encourage deep breathing techniques to prevent pneumonia and atelectasis.

ANTIHYPERTENSIVE
 Captopril 25 mg/tab BID  Classification: Angiotensin Converting Enzyme Inhibitors  Action: ACE converts angiotensin I to angiotensin II, a potent endogenous vasoconstrictor substance.

NURSING CONSIDERATION
 Observe for precipitous drop in blood pressure within 3 hours after initial dose if on diuretic therapy and low salt diet.  If blood pressure falls rapidly, place on supine; have saline solution infusion available.

ANTIHYPERTENSIVE
 Betaloc 50 mg/tablet OD  Classification: Beta-blockers  Action: Block the sympathetic nervous system (beta-adrenergic receptors) especially the sympathetics to the heart, producing a slower heart rate and lowered blood pressure.

NURSING CONSIDERATIONS
 Avoid activities that require mental alertness until drug effects realized.

ANTIHYPERTENSIVE
 Dilatrend 6.25 mg 1 tablet BID  Classification: Alpha-beta adrenergic blockers  Action: blocks alpha- and beta-adrenergic receptors causing peripheral dilation and decreases peripheral vascular resistance; decreases cardiac output, reduces reflex orthostatic hypotension.  Indication: reduce cardiovascular mortality in clinically stable clients who have survived an acute myocardial infarction

NURSING CONSIDERATIONS
 Reduce the dose if bradycardia (HR less than 55 bpm) occurs.

ANTI-ISCHEMIC AGENT
 Vastarel 35 mg/tablet BID  Generic Name : Trimetazidine diHCL  Classification: Metabolic anti-ischemic agent  Action: Increases coronary flow reserve, thereby delaying the onset of exercise- induced ischemia.  Indication: prophylactic treatment of episodes of angina pectoris

Causes: Vastarel Coronary atherosclerotic heart disease Coronary thrombosis/embolism Myocardial ischemia
Decreased cardiac output Decreased myocardial O2 supply Decreased myocardial contractility

Streptokinase ASA Clexane Plavix Cellular hypoxia Oxygen

Altered cell membrane Int.

Decreased arterial pressure

Stimulation of baroroeceptors

Stimulation of sympathetic receptors Increased myocardial O2 demand

Increased peripheral vasoconstriction

Increased afterload

Nitrates / Morphine
Increased myocardial contractility

Captopril Increased HR Betaloc / Dilatrend

Decreased myocardial tissue perfusion

Decreased diastolic filling

NURSING CARE PLAN

ASSESSMENT NURSING DIAGNOSIS Acute pain related to ischemia of myocardial tissue GOAL OF CARE NURSING INTERVENTION 1. Monitor and document characteristics of pain, noting verbal reports, nonverbal cues and autonomic responses. RATIONALE EVALUATION

S> Makulog ang daghan ko, as verbalized by the patient. > crushing, squeezing chest pain radiating to the left arm O > P/S: 8/10 Levines sign With facial grimace Groaning Diaphoretic Dyspneic Changes in body posture noted Changes in autonomic response: *BP230/110mmHg *PR-110bpm *RR-26cpm

Within the 8 hours shift the patient will: SHORT TERM GOALS: 1. Report pain is relieved and or controlled with appropriate time frame for administered medications. 2. Verbalize methods that provide relief. 3. Demonstrate use of relaxation techniques and diversional activities. LONG TERM GOAL: 1. Follow prescribed pharmacological regimen.

Variation of appearance & behavior of patients in pain may present a challenge in assessment. Verbal history & deeper investigation of precipitating factor should be postponed until pain is relieved. Respiration may be increased as a result of pain & anxiety; release of stress induced catecholamines increase heart rate & blood pressure. Pain is subjective and must be described by the patient. Provides baseline for comparison to aid in determining effectiveness of therapy, resolution or progression.

The patient reported that pain is relieved, verbalized and demonstrated relaxation techniques that provided relief.

2. Obtain full description of pain from patient including location, intensity, duration, characteristics & radiation. Assist patient to quantify pain by comparing it to other experiences.

ASSESSMENT

NURSING DIAGNOSIS

GOAL OF CARE

NURSING INTERVENTION 3. Instruct patient to report pain, stat.

RATIONALE Delay in reporting pain hinders pain relief/ may require increased dosage of medication to achieve relief. Severe pain may induce shock by stimulating the SNS, thereby creating further damage & interfering with diagnostics & relief of pain. Decreased external stimuli, which may aggravate anxiety & cardiac strain, limit coping abilities & adjustment to current situation. Helpful in decreasing perception or responses to pain. Provides a sense of having some control over the situation, increase in positive attitude. Hypotension/ respiratory depression can occur as a result of narcotic administration. These problems may increase myocardial damage in presence of ventricular insufficiency.

EVALUATION

4. Provide quiet environment, calm activities & comfort measures.

5. Assist/instruct in relaxation technique.

6. Check v/s before & after narcotic or medication.

ASSESSMENT

NURSING DIAGNOSIS

GOAL OF CARE

NURSING INTERVENTION 7.Position the client on HBR

RATIONALE

EVALUATION

To decrease chest discomfort. Reduce pressure from abdominal contents on the diaphragm & better lung expansion & gas exchange, venous return to the heart decreases, which reduces the work of the heart.  Increases amount of oxygen available for myocardial uptake & thereby may relieve discomfort associated with tissue ischemia.

8. Administer supplemental Oxygen by means of nasal cannula, 3-5 LPM. 9. Administer medications as indicated. a) ASA, (antithrombotic) b) Streptokinase (Thrombolytics) c) Isoket (Antianginal) d)Betaloc (Betablockers) e)Analgesics

ASSESSMENT S> garo magagadan na ako,as verbalized by the pt. O> restless > diaphoresis > pale palpebral conjunctiva > easy fatigability > RR = 26 cpm

NURSING DIAGNOSIS Ineffective tissue perfusion related to reduced coronary bloodflow from coronary thrombus and atherosclero tic plaque

GOAL OF CARE Within the 8 hour shift the patient will: SHORT TERM GOALS: 1.Verbalize understanding of condition, therapy & effects of medications. 2.Demonstrate behaviors/lifesty le changes to improve circulation. 3.Demonstrate increased perfusion as individually appropriate. LONG TERM GOAL: 1. Lifestyle modification

NURSING INTERVENTION 1. Investigate sudden changes or continued alterations in mentation.

RATIONALE Cerebral perfusion is directly related to cardiac output and is also influenced by electrolyte acid base variations, hypoxia 7 systemic emboli. Systemic vasoconstriction resulting from diminished cardiac output may be evidenced by decreased skin perfusion & diminish pulses. Cardiac pump failure and/or ischemic pain may precipitate respiratory distress; however sudden/continued dyspnea may indicate thrombolembolic pulmonary complications. Decreased intake/persistent nausea may result in reduced circulating volume, which negatively affects perfusion & organ function. Specific gravity measurements reflect hydration status & renal function.

EVALUATION The patient verbalized understanding of condition and demonstrated lifestyle changes.

2. Inspect pallor, cyanosis, mottling, cool clammy skin. Note strength of peripheral pulse. 3.Monitor respirations, note work of breathing.

4.Monitor intake, note changes I urine output. Record urine specific gravity, as indicated.

ASSESSMENT

NURSING DIAGNOSIS

GOAL OF CARE

NURSING INTERVENTION 3.Asses GI function, noting anorexia, decreased/absen t bowel sounds, N&V, abdominal distension, constipation. 4.Encourage active/passive leg exercises, avoidance of isometric exercises.

RATIONALE Reduced blood flow to mesentery can produce GI dysfunction, e.g. loss of peristalsis. Problems may be potentiated/aggravated by use of analgesics, decreased activity, and dietary changes. Enhances venous return, reduces venous stasis, and decreases ris of thrombophlebitis; however, isometric exercises can adversely affect cardiac output by increasing myocardial work & oxygen consumption. Indicators of DVT, although DVT can be present without positive Homans sign.

EVALUATION

5.Assess for Homans sign, erythema, edema.

ASSESSMENT S: Madalion akong mapagal, as verbalized by the patient.

NURSING DIAGNOSIS Activity intolerance r/t: a)Imbalance between myocardial oxygen supply & demand b) Presence of ischemia

GOAL OF CARE Within the 8 hours shift the patient will: SHORT TERM GOALS: 1.Identify negative factors affecting activity tolerance & eliminate/reduc e their effects when possible. 2.Use identified techniques to enhance to activity tolerance 3.Participate willingly in desired activities 4.Report measurable increase in activity tolerance.

NURSING INTERVENTION 1.record/docume nt HR & rhythm & BP changes before, during & after activity, as indicated. Correlate with reports of chest pain/SOB.

RATIONALE Trends determine patients response to activity & may indicate myocardial oxygen deprivation that may require decrease in activity level/return to bed rest, changes in medication regimen or use of the supplemental oxygen. Reduces myocardial workload/oxygen consumption, reducing risk of complication.

EVALUATION The patient identified negative factors affecting activity tolerance, used identified techniques, participated willingly and reported measurable increase in activity.

O:> with cardiopulmonar y distress  with Dyspnea on exertion  2 pillow orthopnea  restless  easy fatigability Abnormal ECG result Vital signs: BP 230/110mmHg PR 110bpm RR 26cpm

2.Encourage rest (bed/chair) initially. Thereafter, limit activity on basis of pain/ adverse cardiac response. Provide nonstress diversional activities. 3.Instruct patient to avoid increasing abdominal pressure.

Activities that require holding the breath & bearing down (Valsalva maneuver) can result to bradycardia & rebound tachycardia with elevated BP.

ASSESSMENT

NURSING DIAGNOSIS

GOAL OF CARE 5. Demonstrate a decrease in activity tolerance. LONG TERM GOAL: 1. Perform ADLs, independently.

NURSING INTERVENTION 4.Explain pattern of graded increase of activity level, e.g. getting up to commode/sitting in chair, progressive ambulation, and resting after meals. 5.Review s/s reflecting intolerance of present activity level/requiring notification of NOD/MD. 6.Emphasized CBR with NBP, as ordered.

RATIONALE Progressive activity provides a controlled demand on the heart, increasing strength & preventing overexertion.

EVALUATION

Palpitations, pulse irregularities, development of chest pain, or dyspnea may indicate need for changes in exercise regimen/medication.

Reduces myocardial workload/oxygen consumption, reducing risk of complications.

Discharge plan
Outcome Evaluation - Decreased DOB as felt by the pt. RR: 19cpm  Decreased severity of chest pain as verbalized by the pt.  Reduced orthopnea to 1 pillow  Increased appetite  Stable v/s: BP: 130/90 PR:82 RR:19 TEMP: 36.9C

Health teaching
1. 2. 3. 4. 5. 6. 7. 8. 9. Diet low fat/ low salt; (DASH) diet Medications instructed Exercise PROM/AROM/ deep breathing exercise; avoid valsalva maneuver, running, brisk walking Avoid stressful activities/ stop smoking, alcohol Minimize stair climbing to 1 flight stair then rest periods of 5 mins Sleep with 1 pillow Avoid lifting more than 5 kls Meditations and biofeedback exercises instructed Follow up check up after a week then as instructed.