Myocardial Infarction Care Plan Essay

This assignment will present a nursing care study of a patient on a cardiac ward. The patient will be referred to as

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Ann had taken ill at home previously that day and her husband had called for an ambulance. Ann presented with chest pain radiating down her left arm, shortness of breath, nauseated, fatigue and weakness. Investigations later showed that Ann had experienced an Acute Myocardial Infarction. Acute Myocardial Infarction, also known as heart attack, is characterised by the ischemic death of myocardial tissue (Porth, 2005). Diagnosis of an Acute Myocardial Infarction is based on the presenting signs and symptoms, Electrocardiogram changes and serum cardiac markers (Porth, 2005).Myocardial Infarction Care Plan Essay

Whilst Ann is on the ward she will be monitored continuously via Electrocardiogram. I chose Ann for my care because I was on duty when she was admitted to the ward and I assisted with her admission. As this was my first week I knew I would have a six week opportunity to follow Ann’s journey of care. As Ann was very anxious and nervous when she arrived on the ward I spent a lot of time talking to her to make her feel at ease. I built up a good rapport with this patient.

Mehrabian (1981) states that developing a rapport with the patient involves being professionally friendly, showing interest and actively using non verbal and verbal communication skills. I also chose Ann because from doing her assessment I could see she had other underlying problems aside from her cardiac condition. Ann was hypertensive, high cholesterol, type two diabetes and was overweight. After being told Ann was going to be awaiting for inpatient cardiac surgery I agreed along with my mentor that Ann would be a good case for my care study as she is at high risk of developing pressure sores whilst in theatre and recovery.Myocardial Infarction Care Plan Essay

Taking a patient history is arguably the most important aspect of patient assessment (Crumbie, 2006). Ann is married forty years to her husband Jim who is a bricklayer. Ann recently retired as an office worker. They have two daughters and one son together and three young grandchildren whom she occasionally looks after. Ann smokes 20 cigarettes a day and drinks 2-3 units at the weekends. Ann was diagnosed with diabetes type 2 seven years ago and is medication and diet controlled. Ann also suffers from hypertension and high cholesterol. At five foot four inches and thirteen stone Ann is overweight.

Ann has a history of three Acute Myocardial Infarctions and has had PCI stenting three times. There is a history of myocardial infarctions in her family as her father died at the age of seventy following an acute Myocardial Infarction. This is a brief history of Ann from what I have taken from her assessment; a full assessment can be seen in the appendix. According to Barret D (2009), in order to care for patients individual needs there must be a nursing process by which nurses can deliver patient centred care supported my nursing models or philosophies.Myocardial Infarction Care Plan Essay

In order to deliver this care, a five stage approach must be taken (Hogston, 1999). These five stages are assessment, diagnosis; care planning, implementation and evaluation, all together equal ADPIE (Kozier B, 2004). The cardiac ward used Roper, Logan and Tierney model to assess the patients being admitted to the ward as a way of comparing how a patient’s life has changed due to illness or admission to the hospital (Roper N, 1980). This model was the first to be developed in the United Kingdom.

Tierney (1998) claims the contribution that the model has made to nursing is that it has encouraged nurses to refocus on health rather than ill health. The model also shows the complexity of nursing. The model covers the patient’s whole lifespan. In the model patients are seen as engaging in twelve basic activities of living (Pearson et al 2005). The twelve activities of living are maintain a safe environment, communicating, breathing, eating and drinking, eliminating, personal cleansing and dressing, controlling body temperature, mobilising, working and playing, expressing sexuality, sleeping and dying.

Each activity is seen to have five influencing factors, those being, biological. Psychological, socio-cultural, environmental and politico-economic. A copy of my own assessment of Ann using this model is included in the appendix. Minardi (2007) maintains that assessment is an evolving, incremental gathering and processing of information relevant to the clients situation or needs. Assessment must take place firstly to get a picture of the patient before setting out any goals or care planning.Myocardial Infarction Care Plan Essay

At this stage I established what Ann could and couldn’t do of the activities of daily living. The twelve activities of daily living provide the framework for assessment. Assessment is a systematic, deliberate and interactive process that underpins every aspect of nursing care (Heaven and Maguire, 1996). The nurse must involve the patient in the process and make the assessment patient centred. Ford and McCormack (2000) state that assessment is best approached through biography because people come with a past, present and a future.

The nursing assessment should have physical, psychosocial, emotional, spiritual, social and cultural dimension, a holistic approach. To be effective the process must be structured and clearly documented. Ann was assessed using the Braden scale (Appendix ) and her score was 18. This showed Ann was at risk of developing pressure sores. A pressure sore results when healthy tissues become devitalized so causing localized tissue death (Bale, 1997). The skin has been broken down when direct, unrelieved pressure occurs over bony areas. According to Waterlow (1988) most pressure sores are preventable.Myocardial Infarction Care Plan Essay

The Braden identifies patients at risk of pressure sores and the severity of risk, therefore lower score means higher risk. Ann was given her date for surgery which was whilst I was in my final week of this placement. I done the pre operative checklist (see appendix) on the ward and followed Ann to theatre with the staff nurse for the patient handover and also to see how my goal would be maintained in the theatre setting. Patient problems relating to the activities of daily living are identified during assessment and transferred to the plan of care (Pearson, 2003).

Problem identified Following Ann’s assessment (appendix) there were a number of problems identified, for the purpose of this assignment I will focus on one problem, set goals and discuss the nursing intervention I feel is most appropriate to the problem. Ann’s problem has been identified as at high risk of developing a pressure sore during surgery. Goals set Ann’s goals of care will be based on the SMART criteria; subjective, measurable, achievable, realistic and have an appropriate timeframe.

Short term Ensure Ann’s skin is clean and intact before commencement of the operation Medium term Ensure Ann is protected during surgery from developing pressure sores Long term Continue to protect Ann’s skin post-surgery in the recovery ward Discussion of nursing interventions In the theatre Ann self transferred to the operating table with minimal assistance, the anaesthetic nurse done a pre operative check to ensure Ann’s skin was intact on all areas prone to developing pressure sores.Myocardial Infarction Care Plan Essay

Scott (1999) states that metabolic and circulatory changes resulting from anaesthesia can assist to the development of pressure sores, therefore it is vital skin is checked prior to any interventions. Anaesthesia can lead to periods of low blood pressure (Bliss and Simini 1999) which may affect the pressure areas of the skin because of reduced blood flow and reduced tissue oxygenation. The operating table is hard and solid but is essential for the surgeon to complete the operation without the patient moving.

A pressure relieving overlay mattress is laid on top of the operating table and is made of gel, this aids in reducing the risk of pressure sore development whilst keeping a hard, solid surface for the surgeon to work upon. (Armstrong and Bortz 2001). NICE (2003) guidance is that patients should be placed on ‘either a high-specification foam theatre mattress or other pressure-redistributing surface as a minimum provision’. As Ann had a cannula inserted in her left wrist an arm board was in situ so that Ann’s arm was not in danger of hanging off the table or getting pulled or caught.Myocardial Infarction Care Plan Essay


These were covered with gel pads to act as a pressure relieving device to prevent pressure sores on the elbows Anaesthetics cause the patient to lose muscle tone and it is important to take care. when positioning the arm board as irreparable damage to brachial plexus could result (McEwan 1996). It was important Ann kept norothermia during surgery as intra-operative hypothermia reduces the blood flow to the skin which can result in hypoxia, reduced skin oxygen tension (Kurz et al 1996) and therefore tissue damage (Scott et al 2001). This was ensured by the use of air pressured heating blankets.

Once Ann’s surgery was finished and the Anaesthetist and surgeon were happy for her to be transferred to the hospital bed and sent to Cardiac Intensive Care Unit for recovery a sliding sheet was used to transfer Ann. (NMC 2008) states it is paramount that nurses know how to use this equipment appropriately. A sliding sheet slides the patient safely and without harm to the nurses or the patient and reduces risk of causing friction burns to the patient’s skin. A further post operative skin check took place before Ann left the theatre.Myocardial Infarction Care Plan Essay

This was to ensure the skin was still intact and that there were no red areas. Ann’s skin pressure areas had no visible areas. If Ann had developed any pressure sores she would be at a high chance of developing anxiety caused by the pain of the pressure sore and her discharge from hospital may be delayed and she may also require community care after for wound dressings. This would be very inconvenient to Ann who does not drive and would have no transport to the local health centre. She would have to pay for public transport.

Also if Ann had developed pressure sores she would be less trusting of the NHS and would have little faith to return to the hospital again of fear that she may develop another pressure sore. Now that the care has been implemented the next process is evaluation. This should be an ongoing process in patient care. It’s at this evaluative stage that the nurse can look at the effectiveness of the care plan. According to Hogston (1999) the two purposes of evaluation are to see if the initial assessment was correct and if the goal was realistic and achieved.Myocardial Infarction Care Plan Essay

I went to see Ann on my final day of placement on the post operative ward; Ann had not developed any pressure sores whilst recovering. From looking through her charts I could see this was correct and documented. Therefore I feel my goal for Ann conformed to the SMART criteria and was successful in the best interests for the patient’s health. In conclusion this care study has enabled me to gain a better understanding of the nursing process and the need for a model such as the activities of daily living. The nursing interventions set out for Ann enabled her to stay free from pressure sores whilst in theatre and post theatre.

Myocardial Infarction is a disease of the heart that is caused by occlusions in the coronary arteries. The circulation of blood through the ventricles is reduced and the capacity of the heart to absorb oxygen is diminished. Artherosclerosis is mainly implicated with myocardial infarction.

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MI is primarily evaluated using the ECG readings in which the ST-segment is usually elevated. By, analyzing the morphology of the ECG inconjuction with other tests, the condition can be correctly evaluated. The coronary occlusions can be dissolved using thrombolytic therapy.Myocardial Infarction Care Plan Essay

In this case study, the close collaboration between nursing and other interventions illustrates the clinical procedure for handling patients with myocardial infarction in a hospital setting. It also gives insight into the complications of MI that may occur in a patient together with the necessary interventions from the nursing staff. The study questions are answered sequentially as follows;Myocardial Infarction Care Plan Essay

Mr. Jones gradually developed symptoms of myocardial infarction. He started by experiencing excruciating chest pain that radiated to his jaw and left arm, shortness of breath (dyspnea) and diaphoresis (sweating), which culminated in sudden unconsciousness (syncope). These are the typical signs and symptoms of myocardial infarction.

They do not present immediately but gradually. The classic symptom of myocardial infaction is usually chest pains, which radiate to other parts of the body such as the left and right arms, lower jaw, neck, back, and the epigastrium, which resemble the heartburn.

Often, MIs are caused by accumulation of atherosclerotic plaque, which stimulates the forming of intracoronary thrombus. Intracoronary thrombus results in the occlusion of the coronary artery. This gives rise to insufficient circulation of blood through the ventricles hence myocardial infarction. The level of occlusion determines the severity of MI (Cotran, Kumar & Robbins, 1994).

Many other conditions that are uncommon can cause the coronary artery to block and thereby cause a myocardial infarction. They include rare inflammation of coronary arteries, a blood clot in another place of the body other than the ventricle e.g., in the heart chamber, a wound near the heart through a stab, the spasmal effects of taking cocaine on the coronary artery, and complications arising from heart surgery and/ or another rare heart conditions.Myocardial Infarction Care Plan Essay

An ECG is performed to compare cardiac activities in the ventricular areas. The ST segment elevation is used to indicate on the ECG. Mr. Jones’ ECG signal indicated that there was an ST-segment elevation in leads II, III, and aVf on the ECG, which is indicative of MI. however, the ECG alone cannot be used to reliably diagnose myocardial infarction. It should be noted that the ECG also evaluates other heart conditions.

Consequently, the morphology and the principal components of the signal may give contradictory diagnosis. For instance, myocardial infarction is evaluated by observing the characteristics of the ST segmement. An elevation of the segment is indicative of possible myocardial infarction. However, the ST segment elevation is also indicative of the inherited type of cardiac arrhythmia called Brugada Syndrome. Consequently, other tests are necessary including laboratory tests, urine and blood sample analysis etc..Myocardial Infarction Care Plan Essay

Cardiac enzymes are used as biomarkers that are evaluated to determine the heart function. There are particularly useful in evaluation of myocardial infaction although they are essential in assessment of other conditions that may lead to increment in cardiac biomarker level (Rao, Miller, Rosenbaum, & Lakier, 1999).

Cardiac enzymes such as creatine kinase-MB are ordered when the severity of myocardial infarction needs to be determined. The level of cardiac proteins in the blood corresponds to the severity of the myocardial infarction in the patient. Therefore, by determining these enzymes it makes the work of risk stratification of patients with myocardial infarction easier.

Once admitted to the CCU, It is the prerogative of the nurses to measure the blood pressure, changes in the heart and respiratory rates related to the physical examination of the patient. The most common examination performed on patients with suspected myocardial infarction is an ECG, which often indicates the presence of abnormalities in the left ventricle. In addition, laboratory tests of blood proteins related to the heart is performed to indicate if degeneration of myocardial cells is present.Myocardial Infarction Care Plan Essay

MI results in diminished supply of oxygen to the heart due to the degeneration of cardiac cells. Consequently, the capacity of the heart to extract oxygen from blood may be compromised. The significance of using oxygen to make sure that the red blood cells are saturated maximally to compensate for the heart’s diminished ability to extract the oxygen.

Mr. Jones’ oxygen demands clearly outstripped supply oxygen dosage ameliorated the situation before comprehensive diagnosis and treatment ensued (Cotran, Kumar & Robbins, 1994). Administration of oxygen supplements treatment of patients with MI. Mr. Jones had shortness of breath and an episode of syncope. As treatment ensued, his oxygen supply had to be stabilized through administration of supplemental oxygen.
Myocardial infarction may give rise to other cardiac conditions that may need proper medical attention. Such conditions include the Wenckebach (Type 1) and Type 2 disarrhythmias. Wenckebach or Type I block is an intermittent cardiac conduction failure. In Wenckeback, conduction reduces as conduction velocity progressively reduces until failure of cardiac electrical conduction occurs. The ECG pattern of the condition shows the PR interval getting progressively longer until the non-conducted wave occurs.Myocardial Infarction Care Plan Essay

Thrombolytic therapy initiates cardiac hemorrhage in patients with myocardial infaction. It is initiated to dissolve the coronary clots thereby easing the flow of blood and supply of oxygen to the heart. However, this therapy is not suitable in certain conditions such as recent surgery, stroke in the recent past, high blood pressure e.t.c.

The thrombolytic drugs are known to cause hemorrhage elsewhere in the body that can be life threatening in scenarios where a patient underwent surgery recently or is hypertension is present. In the case of Mr. Jones, he became unconscious as soon as he arrived at the reception. In addition, he had very high pressure at 130/92, which made it inappropriate to initiate thrombolytic therapy (Marcus, et al, 2007).

Myocardial infarction is associated with complications such as angina, free wall rupture, reinfarction, extension of infarct, heart failure, aneurysms, cardiogenic shock, valve dysfunction, arrhythmias, central nervous system (CNS) or peripheral embolisation, pericarditis, and psychosocial complications. Mr. Jones developed arrhythmias which were corrected by administration of drugs.Myocardial Infarction Care Plan Essay

The ECG is the common procedure for diagnosis of myocardial infarctions. However, other diagnostic tests can be carried out on Mr. Jones. They include blood and urine tests, swabs, diagnostic and lab tests, and pathology testing. Pathology testing is important as myocardial infarction could have been caused by a certain underlying pathogen. These tests are performed in order to confirm presence of myocardial infarction because an ECG cannot provide a comprehensive assessment of the condition. Myocardial Infarction Care Plan Essay

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