ACP Case Study (2) - 1
ACP Case Study (2) - 1
ACP Case Study (2) - 1
NUR339
7th Semester
Bachelor of Nursing
School of Nursing
Introduction................................................................................................................................3
Diagnosis....................................................................................................................................4
Electrocardiogram......................................................................................................................5
Cardiac Biomarkers....................................................................................................................5
Pharmacological Treatment........................................................................................................7
Conclusion................................................................................................................................14
Reference..................................................................................................................................15
Case Study - Acute Myocardial Infarction
Introduction
It was narrated in Sahih Buhari that the Prophet (peace be upon him) said, "There are
two blessings which many people do not appreciate: Health and free time" (Bukhari, n.d.,
Book 81, Hadith 1). Health is an important virtue in a person’s life that must be always cared
for. However, the fact that publications by the Ministry of Health (2020) reported most deaths
how health has been neglected today. The document detailed the finding stating that a total of
59% of cardiovascular disease caused deaths composed of males when compared to the
remaining 41% of females. Given the importance of health and statistics of institutions
hinting on the deteriorating level of health in communities, the present case study is going to
unravel the case of a patient with ST segment elevation myocardial infarction. According to
the World Health Organization (2016) ST segment elevated myocardial infarction (STEMI)
is a type of cardiac arrest which occurs when the blood supply to the heart by the artery is
partially or completed occluded and as a result the heart muscles become ischemic, or
necrosis occur.
This is a case study about a 32-year-old male Rajkumari Santhosh (name changed for
confidentiality) who came to ADK ER with symptoms of myocardial infraction. After seeing
elevations in ECG and positive cardiac biomarkers patient was sent to Cath lab to perform a
coronary angiography and percutaneous coronary intervention. Patient was shifted to CCU
for further monitoring Moreover, as per any case study, the outline of this assignment has
been formulated to address clinical topics of the specific case such as. nursing assessment of
the patient, the diagnosis of his primary illness, myocardial infraction by using diagnostic
criteria, along with the causes/ risk factors contributing to myocardial infarction.
treatment, a nursing care plan related to the main complaints of the patient, and a concept
map in relation to the pateint. To sum up the analysis, the case study will summarise the most
prominent takeaways from the whole case study to provide a brief and concise conclusion
along with recommendations to fill the gaps identified in practice on the study which was
Nursing Assessment
History
Azaan is a married man with no children, he was a smoker but quitted 2 years ago he
also mentioned that in July 2022 he was prescribed cholesterol medicine (Crestat 10mg HS
(only at night)) but after some time he stopped taking it. He had no past surgical history, but
both of his parents have hypertension. On top of that he mentioned that his grandfather
passed away after suffering from a heart attack. Azaan presented to the Emergency room of
ADK with a history of chest pain since last night (8/5/24) and was radiating to his shoulder
and left arm. He took some medication (paracetamol 650mg) for pain relief hence it subsided.
According to him pain started to increase at 1am and he finds difficulty in breathing.
Physical Assessment
The main goal of performing the physical assessment was determining the overall
health and signs that may complicate the patient’s diagnosis and treatment. By focusing on
cardiovascular changes a physical examination was done Vitals were recorded Blood
pressure: 100/80 mmhg, pulse rate: 125 bpm, respiratory rate 30, temperature 37.2 and Spo2
at 87%. A cardiovascular physical examination begins with inspection this can be achieved
by assessing skin colour and perfusion for both central and peripheral cyanosis and pallor
especially on the palms, conjunctiva, or inner lower lip in darker-skinned patients. It is also
important to check for Jugular Vein Distension (JVD), jugular vein distension indicates right
side heart failure and sometimes pulmonary edema (Claire et al., 2021). Inspect the
precordium for deformities, scars, or abnormal pulsations. Note the presence and type of
edema, assessing the depth and rebound time. Look for signs of Deep Vein Thrombosis
(DVT) such as unilateral warmth, redness, swelling, and pain in the calves. During palpation,
compare the rate, rhythm, and quality of peripheral pulses bilaterally (carotid, radial, brachial,
posterior tibialis, dorsalis pedis), and assess capillary refilling time. Detect any heaves or
thrills on the anterior chest wall, indicative of severe right ventricular hypertrophy. for
auscultation, listen to heart sounds at the Aortic, Pulmonic, Tricuspid, and Mitral areas (,
identifying S1 and S2 sounds, heart rate rhythm, and any extra sounds like murmurs, S3, S4,
and pleural friction rubs. Additionally, auscultate the carotid artery for bruits, which indicate
system. In relation to the patient no abnormal observation was seen in the patient.
Disease Condition
contains fatty acid and cholesterol causing the coronary arteries to narrow, because of this
there is reduced blood flow to the cardiac muscles causing ischemia followed by reduced
oxygen supply symptoms such as dizziness, shortness of breath and chest pain occurs. Over
the time this plaque ruptures and blood clot forms occluding the artery completely. Due to
this occlusion the blood flow to the heart is completely stopped from the coronary arteries to
the cardiac muscles. As a result of inadequate oxygen and nutrients the affected tissue or
myocardial cells occur affecting the heart’s oxygen demand and supply irreversible damage
can occur to the cardiac muscles can if blood flow is not restored (Hinkle & Cheever2018).
out the risk factors associated with the disease. According to Benjamin et al. (2019) the
disease (STEMI) has several identified risk factors associated with it. These include the main
risk factor being atherosclerosis, followed by hypertension and dyslipidaemia (Libby et al.,
2011; Sarwar et al., 2010). With such broad risk factors, it emphasises how easily one can be
liable to the dangers of STEMI without proper awareness on preventing the risk factors. For
instance, there are many causes to hypertension such as stress, and other biological factors
including genetics. Furthermore, it is worth noting that the reason for atherosclerosis being
the main risk factor for STEMI is because of the nature of the occurrence. Atherosclerosis
occurs due to the accumulation and build-up of plaque in the coronary artery, which is the
main artery to the heart (Ference et al., 2021). Therefore, mitigating the risk factors of
STEMI requires the individual to adopt a healthy lifestyle that elevates all areas of health in
life. Going in depth with the present case, the patient was a previous smoker, with a family
member also being diagnosed with hypertension. These markers make the patient, Azaan, a
liable target for STEMI. It also reinforces the authenticity of the stated risk factors.
Moreover, it helps to rule out what could have been the causes for the diagnosis of Azzan
Diagnosis
The global prevalence of MI in individuals < 60 years was found 3.8%. (Salari et al.,
2023), Studies done by Michaud et al. (2019) revealed the diagnosis criteria for acute
myocardial infarction divides into 4 major components which are elevated cardiac troponin
thrombus in coronary angiography. Some of the signs and symptoms present in Azaan
include chest pain radiating to the neck and shoulders followed by shortness of breath and
dizziness. Chest pain is the most common symptom in myocardial infarction which can be
radiating to neck jaw or shoulder sometimes other times it can be only central to the heart the
pain is often described as squeezing or tightness in the chest other symptoms include
shortness of breath, light-headedness, nausea and vomiting (Kumar Singh & Kumar Jat,
2022). Regarding these four components, STEMI can be diagnosed by several ways including
angiography of the coronary artery and heart to identify any clots, by ischemic symptoms as
shortness of breath, by specific changes revealed in ECG reports, and elevated troponin I
from blood tests (Salari et al., 2023). In the case of Azaan, he reported to the hospital with
pain in the chest and shortness of breath. Furthermore, it is highly probable that the history of
smoking and presence of several risk factors along with blood tests led to the discovery of
STEMI.
Electrocardiogram
Technology has boosted the medical industry to another level, helping doctors and
nurses more efficient care to patients. Regarding the current case study, one of the most
significant pieces of equipment throughout the study is the repeated mentioning of the
intervening the diagnosis of STEMI and other related diseases. It is important to take an 12-
lead ECG within 10 minutes of a patient reporting substantial pain on the chest area (Hinkle
& Cheever, 2018). ECG can show several types of changes, such as T-wave inversion, ST-
segment elevation, and abnormal Q waves In a case of STEMI, the ST segment is elevated 1
mm above the isoelectric line, measured 0.06 to 0.08 seconds after the QRS complex at the J
point, hence, leading to the diagnosis of STEMI (Hinkle & Cheever, 2018). In relation to the
patient the ECG revealed elevation in lead III and AVF suspecting an inferior myocardial
Cardiac Biomarkers
One of the most useful tests to determine any cardiac damage or to confirm the
diagnosis for myocardial infarction is checking troponin level of the patient. Blood tests
reveal that Troponin I increase in 4 to 6 hours, peaks at 12 hours, and returns to base level in
3 to 10 days, where troponin-T stays elevated for 12 to 48 hours and falls to base in 10 days
unlike Troponin I. Another test to determine cardiac damage is CK-MB even though it
usually elevates 6 to 12 hours, troponins show elevation in most AMI cases within 2 to 3
hours of arrival. (Morton & Fontaine, 2018). In relation to the patient Azaan’s cardiac
biomarkers are elevated which confirmed the diagnosis of acute myocardial infarction.
patient. On Angiogram it was revealed that there is blockage in the right coronary artery just
as suspected from ECG and was 95% blocked hence PCI was performed to RCA via the right
femoral artery. The angiogram, as explained previously in the case study, refers to the
observation of blood clots in the coronary artery to the heart. Such an observation can help to
intervention is an intervention strategy where surgeons use a stent to keep open a narrowed
blood vessel to increase blood flow using a catheter insertion (Knuuti et al., 2020).
Echocardiography
Echocardiography is a crucial tool used in medical field while diagnosing and
assessing patients with myocardial infarction, it can detect regional wall motion abnormalities
caused by ischemia almost immediately after onset, at the same time it can also assesses right
ventricle infarction and provides valuable findings (Thygesen et al., 2018). Additionally, it
pericardial effusion, and cardiac tamponade (Tsega et al., 2023). In relation to the patient an
urgent echocardiography was done since elevation was seen in the inferior side of the heart as
right coronary also supplies blood to both right atrium and right ventricle, hence the
echocardiography was done to rule out any wall abnormalities due to reduced blood flow to
Medical Management
As people say, prevention is better than cure. It is important for patients recovering
from myocardial infarction to adopt a healthy lifestyle, including smoking cessation, regular
physical activity, and following a healthy diet rich in vegetables, fruits, fish, and whole grains
while reducing the intake of red meat, butter, and full-fat dairy products. (Qian et al., 2024).
exercise-based cardiac rehabilitation, initiated early and tailored to the individual, has been
shown to positively impact disability, quality of life, and reduce morbidity and mortality in
both post-MI and other cardiovascular condition patients (Gomes et al., 2019). Additionally,
diabetes, and hyperlipidaemia, is essential in the treatment and ongoing care of these patients
recovering from myocardial infarction can improve their prognosis, enhance their quality of
Below are medications given to the patient during the hospital stay
Injection Pantoprazole 40 mg twice a day
Side effects Rash, headache and diarrhoea. Patient had no side effects
Health Advise the patient to report signs such as rash, diarrhoea or headache.
education Educate the patient regarding the indication and side effects of the
medicine.
Group Analgesics
Side effects Abdominal pain, flatulence, belching and vomiting Patient had no side
effects.
Health Educate the patient regarding the indication and side effects of the
education
medications.
Advise the patient not to skip any doses and to take it regularly as
Indication Panic attacks, anxiety disorders and seizure disorders. In related to Azaan
given for anxiety and restless behaviour.
Side effects confusion, blurred vision, weakness, and irritation. Patient had no side
effects.
Health Educate the patient regarding the indication and side effects of the
education medications, advise the patient not to skip any doses and to take it regularly
as prescribed by the doctor (Basit, 2023).
Group Lactulose
Mechanism used to relieve constipation and reduce straining during bowel movements.
of action In the colon, lactulose is metabolized by bacteria into acids, increasing
osmotic pressure and drawing water into the bowel, which softens stools
and makes them easier to pass. This action reduces the need for straining,
helping alleviate discomfort associated with hard stools and constipation.
Indication To avoid constipation so that he can avoid straining while passing stool,
straining can increase myocardial workload.
Side effects rash, anaemia and jaundice. Patient had no side effects
Health Teach the patient the use and how the medicine works, educate the patient
education
regarding the side effects and advise to report them (Skidmore-Roth, 2024).
Group Antiplatelet
Mechanism irreversibly inhibits COX-1 in platelets, leading to decreased synthesis
of action of thromboxane A2, a potent promoter of platelet aggregation. This
antiplatelet effect reduces the risk of clot formation, which is particularly
beneficial in preventing myocardial infarctions.
Indication chest pain, strokes and prevent formation of blood clots in blood vessels.
Side effects gastric irritation, bleeding nausea and heartburn Patient had no side
effects.
Health Educate the patient regarding the indication and side effects of the
education
medications, Advise the patient not to skip any doses and to take it
Side effects Atrial fibrillation, bleeding, fatigue, and hypertension. Patient had no
side effects.
Health Educate the patient regarding the indication and side effects of the
education
medications, Advise the patient not to skip any doses and to take it
Side effects Dyspnea, nausea, dizziness and constipation Patient had no side effects
Health Educate the patient regarding the indication and side effects of the
education
medications, Advise the patient not to skip any doses and to take it regularly
Infarction as evidenced by a report of chest pain radiating to left arm including shoulders and
Goal: With Proper nursing interventions and care, the patient's cardiac output will be normal
with normal Blood pressure and absence of shortness of breath within 24 hours.
Assess and monitor To form baseline data and to Patient BP 100/70 mmhg, pulse
patient vital signs hourly. prevent further complications. 100 bpm, RR 24 bpm SP02 87%.
Patient is tachypnoeic.
Auscultate heart and Helps to identify S3/S4 heart Auscultated both heart and lung
lung sounds 4th hourly. sounds with muffled tones, sounds. No abnormal lung
Palpate peripheral Decreased cardiac output may Peripheral pulse is regular and
al., 2010).
Keep the patient in Helps to expand the lungs and Patient on Fowler's position and
et al., 2023).
Administer stool Helps to reduce straining during Patient receiving syrup EVA-Q
by the doctor.
Evaluation: With proper nursing interventions and care, patient BP was normal along with a
normal pulse, respiratory rate and was maintaining oxygen at Room Air within 24 hours.
Goal: Proper nursing interventions and instilling care for 8 hours, patient will feel reduced
Assess patient pain level Helps to identify key symptoms Assessed patient pain level,
severity, location, onset, regarding the condition which pain radiating to shoulders,
duration if the pain is may deteriorate patient’s health pain level is at 7/10.
Put the patient on complete Reduces myocardial oxygen Patient on complete bed rest
bed rest until doctor’s order. demand to minimise the allowed to mobilise after 10
Monitor ECG elevations. Ischemia during angina attack Monitored ECG changes no
et al., 2010).
order.
Nursing Diagnosis 3: Anxiety related to deficient knowledge regarding the disease condition,
Goal: Adequate information regarding the disease condition, medications and treatment will
Assess the patient's Helps to identify areas of lack of Assessed the level of
Educate the patient Helps the patient to have a better Educated the patient about the
regarding disease understanding about the disease disease condition such as risk
condition. and reduce anxiety making the factors, causes and types.
Provide authentic and Reduces fear and instils assurance Provided accurate information
correct information in treatment making the patient about the care and treatment of
about the care, relax and more comfortable while the patient.
Treat the patient in a Reduces fear and anxiety and Treated the patient in a
supportive and calm provides patients with a more supportive and a calm manner.
calm.
Evaluation: with proper nursing interventions and care of 24 hours patient anxiety was
decreased.
Nursing Diagnosis 4: Risk for bleeding related to surgery such as PCI and CAG along with
anticoagulation medications.
Goal: with proper nursing interventions and care, patient’s will be free from any kind of
bleeding.
Assess vital signs Helps to identify potential Vitals are closely monitored.
bleeding.
Assess for Signs and Frequent assessment for signs of No signs of bleeding present
symptoms of Bleeding. bleeding (e.g. hematomas at the in the patient observed.
Monitor both haemoglobin Helps to detect early signs of Patient haemoglobin and
and haematocrit levels of bleeding (Gulanick & Myers, haematocrit level is normal.
as Prescribed and Monitor maintained, minimising the risk of and monitoring patient
Apply Pressure to catheter Applying manual pressure on the Applied pressure while
site after removal. catheter insertion sites prevents removing the catheter for 15
Educate the Patient on the Educating the patient such as Educated the patient
warning signs of bleeding feeling dizziness or pain or dark regarding warning signs of
symptoms go unnoticed.
Evaluation: patient is free from any risk of bleeding with proper nursing interventions and
care.
Recommendation
monitoring program for ST Elevation Myocardial Infarction (STEMI) patients, utilizes digital
tools like mobile apps and websites to deliver cardiac rehabilitation services remotely. It
positively impact prognosis in MI management within the Maldives healthcare system also.
infarction is a severe acute heart attack that often can be fatal. Given the statistics of the high
intervention strategies are required to reduce the high number of fatalities. Furthermore, the
case study has thoroughly analysed and provided nursing care plans developed for Azaan
along with the medications that are prescribed for treatment of STEMI. As strongly
elaborated in the assignment, the prevention and early detection of such life-threatening
diseases can mean life and death at times. Therefore, providing clear and concise information
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