CASE PRESENTATION

ON

MYOCARDIAL

INFARCTION

Bandana Budhathoki

Bsc Nursing 4th year

Roll no. 06

PATIENT PROFILE

Name : Ram Bahadur Basyal

Age/Sex: 49 years/Male

Education: Illiterate

Religion: Hindu

Marital status: Married

Date of admission: 2017-05-07

IP.NO: 1702100357

Diagnosis: Myocardial Infarction ( anteroseptal)

CHIEF COMPLAINTS

Central chest pain * 1 day

Shoulder pain * 1 day

Vomiting * 1 episode

Shortness of breathe * 1 day

HISTORY COLLECTION

a) Present illness

Mr. Ram bahadur basyal was apparently well 1 day back ,

then he gradually developed the central chest pain radiating

to the shoulder. He had an episode of vomiting non projectile

in nature, no any blood composition. He also developed the

history of shortness of breathe.

Past illness

Mr. Ram Bahadur Basyal had a history of Diabetic Mellitus

Type II and had been controlling it through exercise and

diabetic diet.

Present Surgery

There is no any significant history of present surgery.

Past Surgery

There is no any significant history of past surgery.

Family history

- Nuclear family

- 7 members in family

- Health: All members are healthy except cilent himself

Personal History

Smoking : Smoker, smoke 12 sticks per day from 20 years

Alcohol: Alcoholic

Food habbit: Mixed diet , 2-3 times a day

Food allergy : not known

Drug allergy: Not Known

Bowel and Bladder: Regular

Sleeping pattern: Disturbed due to hospitalization

Hobbies: He likes to watch TV, listen radio

Socio –Economic History

Type of house: Pakka type

No. of rooms: 4 rooms

Kitchen : separate

Type of drainage: open drainage

Type of toilet used: water seal

Sources of water: Hand pump and tap

Type of fuel: wood and gas

Adequate lighting: present

Facilities available in surrounding: medical shops, schools

available

Monthly income: Rs 37000

Bread winner : Self, Son

INVESTIGATION

S.N Investigation Patient value Remarks

1 Hemoglobin 10.2mg/dl Anemia

2. Total RBC count 3.74 million/ cu mm Anemia

3. Neutrophils 82% Neutrophilia

4. lymphocytes 15% leukopenia

S.N Investigation Patient value Remarks

5. Total bilirubin 0.69 g/dl Jaundice

6. Conjugated bilirubin 1.61mg/dl Indicate

hepatobiliary

7. Unconjugated

bilirubin

2.0 mg/dl Indicate blood

or liver

problem

8. SGPT/ALT 85 ou/l Liver injury

9. Alkaline phosphate 3.4u/l Problem with

gall bladder

Echo :

Moderate MR

Dilated LV

Mild TR

ECG:

ST segment elevation

MEDICATION

S.N Name of Drug Dose Route Frequency Classification

1. Inj. Tazopip 4.5g

m

I/V TDS Antibiotic

2. Inj. Luponex 40m

g

Subcu

taneo

us

BD Low molecular

weight heparin

group

3. Tab. clonaz 0.25

mg

P/O HS Benzodiazepine

S.N Name of Drug Dose Route Frequency Classification

4. Tab. Ecospirin 150

mg

P/O BD Antiplatelet agent

5. Tab. Clopidet 75

mg

P/O BD NSAIDS

6. Tab. Lipicure 20m

g

P/O HS Lipid lowering

agent

7. Tab. Pantocid 40m

g

P/O BD Proton pump

inhibitor

PHYSICAL EXAMINATION

Findings

i. Dull , ill looking.

ii. Lean and thin body.

iii. Physical hygiene not maintained well.

iv. Self care deficit.

v. Oxygen supplementation 3L/m through nasal prong

vi. Neck vein visible

vii. Edema present at cannula site over right dorsal palm

DISEASE CONDITION

ANTEROSEPTAL MYOCARDIAL INFARTION

DEFINATION

Antero septal myocardial infraction is a heart problem where part

of the heart muscle dies and scars due to poor blood supply. In

this case tissue damage is around the anteroseptal wall , the area

between the left and right ventricles.

- Wikipedia

ETIOLOGICAL FACTORS

S.N Book’s picture Patient’s picture

1. Smoking Smoking habit present

2. Stress Stress

3. Exposure to air pollution Exposure to air pollution

4. Alcohol Consumption Alcohol consumption

5. Diabetes mellitus Diabetes mellitus type II

6. Coronary artery diseases,

High blood pressure

Absent

7. High level of blood

cholesterol

Absent

CLINICAL FEATURES

S.N Book’s picture Patient’s picture

1. Chest and shoulder pain Chest and shoulder pain

2. Shortness of breathe Shortness of breathe

3. Diaphoresis Diaphoresis

4. Decreased urinary output Decreased urinary output

5. Weakness , fatigue Weakness , fatigue

6. Vomiting Vomiting

S.N Book’s picture Patient’s picture

7. Lack of consciousness Absent

8. Sleep disturbance Sleep disturbance

9. ECG elevation ECG elevation

( ST segment elevated)

10. Tachypnea Tachypnea

DIAGNOSTIC EVALUATION

S.N Book’s picture Patient’s picture

1. History collection History collection

2. Physical examination Physical examination

3. Electrocardiogram Electrocardiogram

4. Lab test i.e Blood test,

Troponin I , II., HDL, LDL

Lab test i.e Blood test :- CBC, Hb

5. Chest X-ray Chest X-ray

MEDICAL MANAGMENT

Open IV access

High flow oxygen

ECG monitoring

IV analgesia: 5-10 mg morphine

Thrombolytic therapy (streptokinase,alteplase)

Antiplatelete therapy :- aspirin 75-300mg, clopidegrel 75 mg

Anticoagulants ( heparin)

Beta blockers ( propanolol , esmolol, labetolol)

• M= morphine

• O = oxygen

• N = nitrates

• A = aspirin

• T = thrombolytic agent

• A = anti- coagulants

• S = stool softener

NURSING MANAGMENT• Balancing of myocardial oxygen supply as per demand

• Medication administration as per order

• Continuous monitoring of cardiac function

• Continuous ECG monitoring, hemodynamic monitoring

• Monitoring and recording input/ output.

• Provide emotional support

• Nutritional support

• Bed rest for couple of days, reduce stress factors

• Provide heath education

• Asses the patient level of pain, location, duration.

• Prevention of the complication

COMPLICATION• Angina

• Re-infarction

• Infarct extension

• Heart failure

• Cardiogenic shock

• Mitral valave dysfunction

NURSING DIAGNOSIS

1. Acute pain related to tissue ischemia as evidenced by patient

reporting of chest pain, facial grimacing.

2. Decreased cardiac output related to changes in myocardial

contractility.

3. Impaired gas exchanges related to interruption of blood flow to

pulmonary alveoli.

4. Imbalanced nutrition less than the body requirements related to

inadequate intake, anorexia.

5. Activity intolerance related to imbalance between myocardial

oxygen supply and needs

6. Anxiety related to hospitalization and fear of death

7. Risk of ineffective tissue perfusion related to reduction of blood

flow

HEALTH EDUCATION ON:

• About disease condition “ Myocardial Infarction”

• Rest and sleep

PROGRESS REPORT

Day 1 Day 2

•Patient general condition looks

ill

•Vital sign were unstable ( fever

100.6 F)

•Shortness of breathe

•SpO2 was maintained via face

mask of 3L/m

•Kept on liquid diet

•Patient general condition looks

satisfactory

•Vital sign were unstable (Spo2

fluctuating)

•Shortness of breathe

•SpO2 was maintained via face

mask of 3L/m

•Kept on liquid diet

PROGRESS REPORT

Day 3 Day 4

•Patient general condition looks

fair

•Vital sign were stable

•SpO2 was maintained via

room air

•Kept on soft diet

•Patient general condition looks

fair

•Vital sign were stable

•SpO2 was maintained via

room air

•Kept on soft diet

PROGRESS REPORT

Day 5

•Patient general condition looks

fair

•Vital sign were stable

•SpO2 was maintained via

room air

•Kept on Normal diet

•Mobilization was done

SUMMARY

A patient named Ram bahadur Basyal 59 years of male was

admitted in college of medical sciences- TH on 2017-05-07 with

chief complains of chest pain radiating towards shoulder, shortness

of breathe and vomiting.

He was admitted on CCU for proper treatment and care. He

was undergone the medication i.e Tab. Ecospirin, Tab. Clopid, Inj.

Ondem.

His general condition was much improved through out the

treatment procedure being hospitalized.

BIBLIOGRAPHY

• Brunner and suddharth “ A Textbook of medical surgical nursing”, 3th edition; page no. 1032-1034

• Kumar and clarks “ Clinical Medicine”, 7th edition; page no. 732-735

• Net sources:

• www.healthline.com/health/acute-myocardial-infarction

• https://www.floridahospital.com/medical-management-myocardial-infarction