Case Study: Nursing Care for a Patient with Myocardial Infarction

While in clinical PEP, I had to deliver care to a patient suffering from myocardial infarction (MI) as per the required standards of nursing practice. Mr J was a 49-year-old male of Hispanic origin who was admitted to the Coronary Care Unit at 9 am. The patient presented to the Emergency Department at around 7 am as he was having left sided chest pain since the past two hours before presenting to the healthcare setting. The patient had described the pain to be crushing in nature, and he was suffering from shortness of breath, sweating and sense of impending doom. An Electrocardiograph (ECG) was carried out that showed significant changes as ST elevations in leads I, aVL, V2, V3, V4, V5 and V6. These changes denote Anterolateral Myocardial Infarction. Laboratory investigations done reported a normal full blood count, and normal levels of sodium, potassium, creatinine, chloride, urea, liver enzymes and urates. Further, the triglyceride and cholesterol levels of the patient were significantly elevated. The cardiac enzyme level was elevated minimally at the initial level; however, it rose after five hours.

The patient was a slim built and tall individual with 77 kg weight and 180cm height. He had suffered a stroke one and a half years ago and thus was a known case of hypertension. He was reported to have an attending medical clinic for care support. His parents were known to be hypertensive. An assessment was carried out to understand the social history of the patient; the revealed that he is a professor at the city university, teaching sociology. Although the patient was a non-alcoholic, he was a regular smoker. He smokes 5-6 rolls of cigarette per day. He is married with two children and has a peaceful social life.

At this juncture, it was thought appropriate to carry out a thorough nursing assessment of the patient that would help in collecting information about the patient’s psychological, physiological, spiritual and sociological status. According to Butcher et al. (2018, p. 352), nursing assessment is considered to be the first step in the comprehensive nursing process, aimed at laying the path for patient-centred care. Objective data for the patient was first collected that revealed the vital signs of the patient to be as follows- BP: 138/92 of Hg, the temperature of 36 degrees Celsius, pulse rate of 62 per minute and respiratory rate of 23 per minute. The patient’s skin was warm and there was the absence of cyanosis. The patient was oriented to people and place, and alert when he was brought into the unit. A respiratory system assessment indicated that air entry was normal bilaterally and the lung fields were clear. Assessment of the cardiovascular system revealed that there were no visible heaves, thrills or pulsation. S1 and S2 could be heard. Assessment of the GI tract indicated that the patient has no difficulties in swallowing and no mass was felt in the abdomen that was non-tender and soft when palpated. the musculoskeletal system assessment identified that the patient had normal muscle tone and gait. The power on the left side was 5/5, and that on the right side was 3/5. This was the residual effect of the stroke suffered earlier (Giger 2016, pp. 35-36).

Background and Assessment of the Patient

A nurse is required to understand the pathophysiology of acute conditions so that the care plan can be outlined ideally. It the present case, it was ensured that a knowledge of myocardial infarction was brought into focus. Acute Myocardial Infarction (MI) results due to thrombotic occlusion of the coronary artery, thereby leading to irreversible necrosis and cell injury. The condition is commonly known as a heart attack (Reed, Rossi & Cannon 2017, p. 197). The important risk factors for such condition include smoking, diabetes and high blood pressure (Ibrahim, Riddell & Devireddy 2014, p. 342). Anterolateral MI is a result of thrombotic occlusion occurring in the left anterior descending artery and occlusion occurring in the coronary branches. According to the World Health Organization standards for detection of MI, the three factors that are to be considered are a patient history of prolonged and severe chest pain, serial enzymes levels and electrocardiography (Chava & Dauerman 2018, p. 213). Most cases of heart attacks take place between 4 am, and 10 am due to higher level of blood adrenaline that is released from the adrenal glands at the morning hours. The augmented adrenaline is a contributing factor for rupture of the cholesterol plaques (Nakashima et al. 2017, p. 362).

The patient, in the present case, experienced shortness of breath, sense of impending doom and profuse sweating and chest pain at the initial phase of myocardial infarction. According to Ibrahim, Riddell and Devireddy (2014, p. 343) chest pain is the hallmark of acute MI. The pain that the patient suffered at the initial stage was due to the blockage of coronary artery that supplies blood to the heart. Injury to heart muscle is due to the heart muscle’s deprivation of oxygen and blood, which leads to the sensation of chest pressure and chest pain (Ibanez et al. 2017, p. 120). Shortness of breath is due to the reduction of cardiac output, while the profuse sweating is due to sympathetic activation. Further, the sense of impending doom is a result of adrenaline release together with other catecholamines.

Critical care nursing is a specialized nursing field that has the focus on the care of unstable and critically ill patients following surgery, extensive injury or life-threatening diseases. Critical care nurses are to work in diverse environments where they are entailed to deliver patient-centred appropriate care (Blais 2015, pp. 157-158). According to Morton et al. (2017, p. 1056), critical care nurses are to engage in therapeutic and professional relationships that encompass collegial generosity in relation to mutual trust and respect if relationships with the care context. A nurse is supposed to maintain the boundaries between personal and professional relationships. In the present case, an attempt was made to establish a successful therapeutic relationship with the patient. In introduction was given to the patient and the patient’s name was used while talking to him. Since a handshake was not feasible due to the patient’s condition, it seemed appropriate to hold his hand as a warm gesture. The patient’s privacy was maintained when he was brought into the critical care unit that ensured a safe environment. While carrying out the assessments, active listening was an appropriate approach as the patient felt the importance of the nurse’s attempt to understand his concerns. Eye contact was maintained with the patient and smiling at intervals made the patient comfortable. Eye contact and smiles are crucial to engage the patient in a conversation (Urden, Stacy & Lough 2015, p. 34). Speaking calmly and slowly was also imperative, as the communication was two-way (Adam 2017, p.89). Maintaining professional boundaries is crucial while incorporating caring behaviours. The patient’s preference for handholding was assessed prior to engaging in such acts.

Pathophysiology of Myocardial Infarction

As opined by Blais (2015, p.163) nurses are to communicate effectively with patients in a respectful manner. The dignity, values, culture, rights and beliefs of the patients are to be considered while delivering care that is culturally sensitive. The patient in the present case was of Hispanic background for whom culturally sensitive care was to be given. Evidence points out that people of the Hispanic origin face major issues while obtaining care. A significant barrier from the nurse’s end is unfamiliarity with linguistic and cultural subtleties. To address this concern for the patient under care, an interpreter was appointed who has professional in working with Hispanic patients. Professional interpreters ensure that the communication between patient and care provider is culturally appropriate (Adam 2017, p. 65). In addition, challenges emerge from cultural mistrust together with the inclination to receive alternative care. Individuals of Hispanic origin might have the inclination towards seeking alternatives to care at the initial stage, thereby delaying the conventional treatment (Giger 2016, pp. 45-46). In the present case, an assessment was done to understand whether the patient had such a predisposition. It was found that the patient did not have any such predisposition, making the process of nursing care easier.                       

Respecting the autonomy of the patient is an integral element of patient advocacy as demonstrated by a critical care nurse (Shafipour, Mohammad & Ahmad 2014, p. 234). Personal autonomy is valued in the healthcare system, and the principle of considering autonomy has an association with enabling the patient to make their own choices regarding healthcare interventions. Respecting patient’s autonomy is invoked in ideas about fidelity, confidentiality, truth-telling and privacy (Kourkouta & Papathanasiou 2014, p. 65). In the present case, the patient was assured that his confidentiality would be maintained while delivering care by a multi-professional team. The patient was also supported by health education about the health condition he was suffering from so that he could come to terms with the changes associated with MI. Further, the patient’s privacy was maintained as no individual was allowed into the room where the patient was admitted at inappropriate timings. A curtain guard was put in place to maintain privacy while diagnostic assessments were carried out.

A culture of safety can be ensured in care unit when a nurse engages with other healthcare professionals to share knowledge and practice, with the aim of supporting patient-centered care (Nelson 2017, p. 5). The initial care process for the patient involved the contribution of the other healthcare professionals in addition to that of the nurse. The emphasis of inter-professional-team in due course of patient care is on the promotion of a safety culture. High quality relationships of nurses with other professionals lead to increased satisfaction and autonomy (Wiechula et al. 2016, p. 723). While carrying out the assessment procedure for the patient, efforts were given to communicate effectively with the technicians in charge. Communication was done clearly, and sufficient information was exchanged with the concerned person. Information was provided in a concise and logical manner so that assessment process was organized.

Nursing Care and Communication with the Patient

The immediate nursing care provided to the patient included 600 600 µg Glyceryl trinitrate (GTN) given sublingually. The aim was to relieve the pain suffered by the patient. GTN is a well-known vasoactive agent that is given to patients for reducing myocardial oxygen consumption. As a result, there is a decrease in ischemia condition and successive pain. The patient was also administered Aspirin 300 mg orally. Aspirin is an antiplatelet medicine reduces the platelet aggregation, thereby preventing the formation of thrombus. The patient is therefore at reduced risk of suffering MI (Karch & Karch 2016, p. 342).

Mr J was placed in a semi-fowlers position and was given oxygen at the rate of five litres per minute with the help of Hudson’s mask for assisting in breathing. As he was suffering from anxiety, he was educated on the significance of taking bed rest and complying with the ongoing treatment. Once the diagnosis for the patient was confirmed, the main objective was to address the blocked artery and ensure restoration of blood flow. This process is known as reperfusion (Urden, Stacy & Lough 2015, p. 64). Upon carrying out an assessment of the patient’s clinical manifestation and presentation, it was concluded that though he could be considered for Streptokinase infusion the same must not be given to him as he had a history of stroke and was having residual effects. Research indicates that streptokinase leads to symptomatic intracranial haemorrhage in individuals who have a history of stroke (Ibanez et al. 2015, p. 119). Once a patient undergoes treatment for opening the artery, the individual becomes relieved of pain as the damage to the heart muscle is ceased. Early reperfusion is known to preserve the heart’s normal pumping action. For achieving early reperfusion for Mr J, he was placed in a comfortable and restful environment after which treatment was initiated. The patient was motivated to verbalize fear and anxiety so that the same can be resolved timely.

The nursing care plan for Mr J included administration of morphine injection 2.5 mg through the intravenous route for relieving pain as GTN was not effective in relieving pain. The patient was further guided to report the nature of chest pain he was suffering from. It was thought appropriate to attach a cardiac monitor for monitoring the heart rhythm and rate (Chava & Dauerman 2018, p. 213). Assessment of the vital signs was carried out every two hours for the first six hours and then at every three hours. In addition, monitoring was done for signs of reperfusion. This is indicated by the return of the ST segment to baseline and dysarrhythmia (Morton et al. 2017, p. 1056).

Culturally Sensitive Care and Patient Autonomy

Mr J was advised complete bed rest for the first four days of admission and visitors were restricted from visitors. The rationale was to allow the patient to have optimal rest that fosters healing process of the heart. Complete stage of rest is effective in the reduction of the workload of the heart (Kaplow 2015, p. 176). A patient-centred diet was outlined for the patient. This was specifically low cholesterol and low sodium and fat diet. An excess amount of sodium in the body leads to increased blood pressure and augmented workload of the heart. Blood cholesterol is increased due to excess amount of saturated fat in the body (Adam 2017, pp. 451-452). The patient thus required a low sodium diet since he was hypertensive. A fat-free diet ensured that the elevated cholesterol level, as indicated from the blood tests, was in control.

The daily medication regime for the patient included Tab Glyceryl trinitrite 600 µg p.r.n, Tablet Aspirin 150mg once daily, Tablet Isorsobide dinitrite 10mg three times a day; tablet Enalpril 5mg daily; and tablet Simvastatin 20mg nocte.  Isorsobide dinitrite is a coronary and peripheral vasodilator that is effective to increase blood flow and improve collateral circulation. This results in a reduction of preload and after-load, thereby causing a decrease in myocardial oxygen consumption and increase in cardiac output. Simvastatin belongs to the drug category of HMG CoA reductase inhibitors, also known as ‘statins’. These are known to reduce the level of cholesterol that is bad for health, namely the low-density lipoprotein or LDL, and increase the level of cholesterol that is good for health, namely high-density lipoprotein or HDL (Lehne & Rosenthal 2014, p. 196).

Evaluation of patient condition after delivery of care interventions is crucial to ensure that the desired outcomes of the patient are achieved. A thorough review of the patient is crucial in this respect that has to encompass different nursing considerations. Patient progress is to be evaluated to understand the observable outcomes aligned with patient goals (Blais 2015, p. 436). In the present case, nursing evaluation of the patient’s condition was done to monitor his progress and bring significant changes in interventions provided. On the second day of Mr J’s admission, an assessment was carried out that indicated that he was suffering from slight chest pain. When enquired, it was reported that the patient perceived the pain to be vague and did not require intervention. He also reported relief from profuse sweating. Accordingly, the nursing intervention provided for the day encompassed reduction of oxygen administration level to four litres per minute with the help of Hudson’s mask. Monitoring of the cardiac output of the patient continued while the vital signs were checked at an interval of three hours. The patient could well tolerate the meals given to him and had a normal appetite. Further, no medication seemed to lead to major side effects for the patient.

Interprofessional Collaboration and Culture of Safety

On the third day, a similar rigorous assessment was carried out to understand the progress of the patient after the provided intervention. The patient was reported to be pain-free and was not requiring oxygen administration. This implied that the patient was no longer in critical condition. An examination of the cardiac enzymes was carried out that reflected that improvement was achieved as the reports where better as compared to that obtained after patient admission. On the fourth day of the admission, the patient was given the permission to move out of his bed. A physiotherapist was referred to, who gave the advice of regular exercise. On the consecutive day, the patient was transferred to the Medical Ward where the aim was to provide him with collaborative care. The chief nursing goal was patient rehabilitation after MI. According to Clark et al. (2015, p. 36), cardiac rehabilitation has the ability to bring significant improvements in the heart’s functioning through better heart rate and reduction of the risk to develop complications due to heart disease. Mr. J was known to be a regular smoker, and it was imperative to ensure that he quits smoking. It was a challenging task to motivate the patient to quit smoking. Research has repeatedly indicated that smoking increases the risk of developing coronary heart disease by two-fold. Smoking cessation enables reduction of this mention risk in a rapid manner (Gaalema et al. 2015, p. 67).

The patient was after that discharged from the hospital on the next day. As per protocol, the patient was advised to visit the medical clinic as a follow-up after six weeks. Since the patient was a smoker, he was also educated on the importance of quitting smoking. Further, he was advised to commence on a balanced diet considering his need of lifestyle modification and dietary requirements. A physiotherapist was consulted who took a session on the importance of regular physical exercises. The medication regimen outlined for the patient was explained to him, and he was encouraged to comply with the same. His discharge medications included Tablet Asprin 150mg daily; tablet Simvastatin 20mg nocte; tablet Enalpril 5mg daily; Tablet Glyceryl trinitrite 600µg p.r.n and Tablet Isorsobide dinitrite 10mg three times a day. The medications prescribed to the patient are known to be highly effective in treating the conditions presented by the patient. However, the full benefits of the medications are not realized if the patient does not adhere to the regimen outlined. Factors leading to low level of medication adherence are myriad, and these are to be realized for eliminating the same for each patient (Butcher et al. 2018, p. 47). It is known that angina is accompanied by discomfort and chest pain though the severity of symptoms might vary (Blais 2015, 68). The patient was therefore advised to get medical help in case he felt any such symptoms.

Immediate Nursing Care Provided to the Patient

In conclusion, the nursing care provided to the patient was an effective one since the comprehensive and patient-centred approach was taken. Exceptional care delivery is required for treating patients in a safe and best manner.

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