Case Study of Mr. Papas

This case study examines the risk factors, pathophysiology, and nursing treatments for acute myocardial infarction in Mr. Papas. It discusses the role of smoking and sedentary lifestyle in the development of the condition, as well as the pathophysiological mechanisms involved. The study also explores nursing interventions such as aspirin administration, percutaneous coronary intervention, and clot-bursting medications.

Running head: CASE STUDY OF MR. PAPAS
CASE STUDY OF MR. PAPAS
Name of the student:
Name of the university:
Author note:

1
CASE STUDY OF MR. PAPAS
Risk factors for the disorder and health promotion:
Acute myocardial infarction results in an emergency and life threatening situation for a
patient where the blood flow to the heart gets reduced and even might get stopped. Lack of blood
flow results in damaging the muscles of the heart resulting in heart failures. Researchers have
associated smoking as one of the risk factors that increase the chance of the person to develop
this disorder (Anderson & Morrow, 2017). Smoking is seen to contribute in the development of
plaques in the arteries and prevents the smooth flow of blood through the arteries. The arteries
become less flexible and their openings also narrow down in such ways that blood faces
obstruction to flow through them. Many other studies are of the opinion that chemicals that are
found in the cigarette smokes make the cells lining the arteries to get swollen. These cells
undergo inflammation and this contributes to the development of narrow passage for the blood in
the arteries reducing the diameter of the blood vessels and making it harder for the blood to flow
through the vessels to the heart (Cequier et al., 2017). Therefore, smoking is seen to contribute in
the obstruction of blood flow to the heart for which oxygen do not get supplied to heart muscle
making them gradually damaged. Many of the researchers are also of the opinion that smoking
causes thickening of the blood that result in development of blood clots inside the veins as well
as the arteries obstructing blood flow to the heart. Mr. Papas has been found to be smoking 15
cigarettes per day which thereby makes him more prone to the development of the conditions
like acute myocardial infarctions (Defteroes et al., 2015). Another risk factor that also
contributes to the development of AMI in the patient is his sedentary lifestyle. He is an IT
professional who remains busy throughout the day in the office and rarely gets the scope of
conducting physical exercise. Lack of exercises acts as one of the risk factors that contribute to
development of acute myocardial infarctions. Exercises are seen to help individuals in living a

2
CASE STUDY OF MR. PAPAS
fitter life and also keep the blood pressure level under control. Exercises are also seen to be
intricately associated maintaining a fitter and healthier body weight that prevents obesity and
overweight issues which also contribute to heart disorders. Mr. Papas had been found to live
sedentary lives where his work pressure might have not allowed him enough time to undertake
exercises for himself. Another possibility might be that he has low health literacy for which he
might have not been able to understand the importance of engaging in physical activities and
exercise and maintaining healthy diets (Engstrom et al., 2015). He nursing professional should
first try to develop the health literacy of Mr. Papas so that he can identify the specific actions and
lifestyle choices which might have contributed to the occurrence of AMI. Advices on stopping
smoking, changing the dietary patterns and also undertaking exercises and physical activities are
the three main domains on which the nurses should educate the patient. Following this, the nurse
could also refer the patient to the healthcare agencies who conduct smoking cessation programs
which would help the patient to overcome the habit of smoking. The nurse can also collaborate
with substance abuse counselors and help the patient with cognitive behavioral therapies to help
him modify his smoking behaviors.
Pathophysiology:
A ST elevation myocardial infarction is called the STEMI. This is mainly seen to take
place because of the formation of thrombus that contributes in occluding the main epicardeal
coronary vessels completely. STEMI is considered to be one of the most acute syndromes
resulting in life threatening heart conditions in individuals. Studies opine that such symptoms
need to be treated with various interventions of coronary revascularization and also through that
of the percutaneous coronary interventions (Goldsweig et al., 2018). Researchers are of the
opinion that atherosclerosis can be one of the main concerning factor that causes development of

3
CASE STUDY OF MR. PAPAS
the situation of vulnerable plaque. This plaque becomes the main contributing factor that causes
acute coronary syndromes and ultimately coronary artery thrombosis is seen to take place. These
conditions mainly mimic the STEMI and distinguishing them becomes very critical. Studies have
stated that a substance namely tissue factor remains located in mainly in the necrotic core of the
plaques. At the particular time, when such substances are found to get burst in the bloodstream,
the clotting cascades get activated (Levine et al., 2016). This causes development of thrombosis.
The fibrous cap that covers the plaque might undergo ulceration or that of disruption mainly
expose the tissue factors resulting in the plaque erosion or that of the plaque rupture. Mannverk
et al. (2019) had been of the opinion that plaque rupture astonishingly takes place in the site of
the modest coronary stenosis and therefore even if stress testing becomes normal, the risk of the
cause coronary syndromes remain present. The occurrence of STEMI is mainly because of the
result of coronary thrombosis after rupturing of the plaque and less often from the fixed
obstruction. Comparative studies have revealed that unstable angina has much lower level
incidences of the occurrence of coronary thrombosis to that of the NSTEMI as well as STEMI
and mainly takes place from situations like fixed atherosclerotic stenosis. Rupturing and erosion
of the plaques contribute to coronary occlusion and is the main predominant mechanism of
STEMI and NTSEMI (Niccoli et al., 2015). Unlike that of unstable angina and that of the non ST
segment elevation (NSTEMI), STEMI is seen to show a marked elevation of the ST segment in
particular aspects. It has been found in case of STEMI, angina symptoms are seen to take place
which contributes myocardial necrosis and can be characterized by the elevated levels of
different cardiac markers along with that of the elevation of ST segment on that of the 12-lead
electrocardiogram. In case of the N-STEMI, it is seen that angina symptoms are seen to occur

4
CASE STUDY OF MR. PAPAS
that contribute to the myocardial necrosis that can be characterized by increased amount of
cardiac biomarkers but never shows the elevated ST segment on the 12-lead electrocardiogram.
Homeostasis mechanisms:
In case of the patient named Mr. Papas, it was seen that he was suffering from pain that
radiated through his left arms and shoulders. Studies are of the opinion that people who are seen
to undergo acute myocardial infarctions experience pain in the back, shoulders, neck, left and
right arms and even in stomach and lower jaw. An interesting factor that had been noted in many
of the studies is that the women are seen to experience the pain in both the arms whereas men are
seen to experience the pain mainly in the left arms (Parodi et al., 2015). During the time of
myocardial infarction, the heart is seen to feel the sensations of pain and thereby it is seen to
send the pain signals to that of the brain and the spinal cord through the same pathways where
many other nerves are also seen to be present. During this time, the nerves that are present in the
shoulders and the arms remain absolutely stable but just because the signals of the heart travel to
the brain and spinal cord through the same pathways where these nerves of the arms and
shoulders travel, the brain seems to get confused about the source of the signal. This is often
termed to be the referred pain. Therefore, the pain sensations are also felt in the arms and the
shoulders even when they do not directly take part in any physiological aspect of the heart injury
(White et al., 2015). The patient named Mr. Papas might have been gone through the same
physiological situations that had resulted in the symptoms of pain in arms and hands. Nursing
professionals can identify these cues to make preliminary ideas about the patient being affected
by acute myocardial infarctions.

5
CASE STUDY OF MR. PAPAS
Pallor:
Pallor as well as paleness can be explained as the development of an abnormal coloration
of the skin which seems to be much paler when compared with the normal complexion if the
skin. Pallor might not only take place all over the body but in many cases might be localized to a
particular situation. It has been found that such paleness of the skin can be observed when the
oxygen cannot reach to the surfaces of the skin (Gershlick et al., 2015). During the times of
myocardial infarction, it has been found that blood cannot reach the heart muscles for which the
heart muscles are seen to become devoid of oxygen. They lose their ability to pump for which
oxygenated blood that leaves the hart cannot be distributed successfully to all over the body. In
course of time, the extremities of the body like the skin specially and then the different internal
organs stop receiving oxygen as lack of pumping ability of heart cannot make the blood reach the
different areas (Moretti et al., 2015). For this reason, lack of oxygen results in development of
paleness and therefore, the patient named Mr. Papas had experienced pallor when he was
affected by acute myocardial infarction.
Clamminess:
Clammy skin can be described as the condition where the skin remains wet as the result
of excessive sweating. Researchers have observed that acute myocardial infarctions often
accompany cold sweats. This symptom can be analyzed by the healthcare professionals where
they can use this symptom as a cue to determine the chances of developing AMI in the patients.
in case of these patients, it can be seen that less blood flow to the heart makes the heart muscles
devoid of oxygen for which the muscles start to get damaged (Yudi et al., 2016). They lose their
pumping ability for which blood cannot reach successfully to the different organs of the body

6
CASE STUDY OF MR. PAPAS
even to that of the skin. Therefore, the heart tries to provide more efforts for regaining the
pumping ability to send oxygen carrying blood equally all over the body. It can be seen that as
the heart tries to put extra effort for which more ATP gets burned. As more ATP gets burned,
huge amount of heat is produced and this increases the body temperature in the affected
individuals (Elliot et al., 2017). The homeostatic system of the body tries to make the body
pressure come under control and hence, in order to release the body heat, it becomes important to
initiate perspiration so that the heat gets released in the form of sweat through evaporation.
Hence, such patients are seen to suffer from sweaty skin and hands that result in development of
the symptom of clamminess.
Nursing treatments:
The nursing professional should try their best to manage the excessive pain that is
suffered by the patient and hence should initiate the administration of the aspirin. The nurse in
this situation can provide a 325 mg of nom-enteric coated which can be given to the patient for
chewing. In this situation, the nurse can be seen to administer a loading dose of about 300 to 600
mg of clopidogrel to the patient. One of the most important interventions that need to be initiated
is the taking of the patient to the PCI units (Richard et al., 2018). Many of the researchers
support reperfusion therapy as one of the most important intervention that needs to be considered
for the first line of treatment for the STEMI patients. This therapy should be initiated within the
12 hours from the onset of the disorder. Percutaneous coronary intervention is also known as PCI
where the nurses have the aim of finding out the position of the clot that had taken place and
have clogged the arteries and then try to dissolve it within the first one and half hour after being
admitted to the emergency (Hudzick et al., 2018). The nurses, after locating the clot should be
placing a stent thereby helping the blood to flow easily once again through the arteries. In case,

7
CASE STUDY OF MR. PAPAS
in the hospital where the patient named Mr. Papas had been admitted, does not have PCI, the
second line of treatment should be immediately initiated is the emergency ward. The nursing
professionals should immediately start the administration of the clot-bursting medications in the
patient. The main rationale would be to dissolve the clots within that of the 30 minutes of the
admission to the emergency ward from that of the time of the arrival. As soon as the blood clots
would be dissolved, the blood would start flowing successfully. Here the nurse has the option of
providing various fibrinolytic agents (Lange et al., 2017). This may comprise of streptokinase or
that of the Tenecteplase. Recent studies are of the opinion that the later medication is found to
more fruitful as it is found to be fibrin-specific and also can be given as the bolus. There would
be also lower chances of any types of the hypersensitivity reactions. This fibrinolytic agents are
seen to be administered at the dose of the dose of 0.5 mg/kg of the patient who is affected. The
nurse also needs to initiate the Antiplatelet treatment and for this they can utilize the
Glycoprotein IIb/IIIa antagonists. They can be seen to be providing this medication along with
that of the PCI treatment. Following this, they can also initiate the anti-coagulant therapy as well
which might contain the administration of that of the UFH or bivalirudin (Franchi et al., 2017).
This can be provided in the catheterization laboratory through that of the specific procedure
when huge amount of thrombus are seen to have been formed or when the patient might have
developed the inadequate thienopyridine loading. Studies have indeed stated that the application
of the low molecular weight heparins (LMWH) would be of better advantage than that of the
unfractionated heparin (UFH). Here, nurses can be seen to be providing the evidences for the
treatment of the patient named Mr. Papas. In addition to these, oral beta blockers can also be
provided to the patients. Studies suggest that for those people who are suffering from reduction
of the left ventricular ejection fraction (LVEF ≤40%) or those who had faced heart attack after

8
CASE STUDY OF MR. PAPAS
STEMI could be benefitted from ACE inhibitors (Matthias et al., 2016). Such drugs are seen to
work by the production of that of the angiotensin II and thereby, it is seen to result the blood
vessels to undergo dilation and blood pressures also gets reduced.
Activities of the daily living:
In case of Mr. Papas, it can be observed that he had suffered an AMI and the heart would
require time for its recovery from the shock it had gone though. Lack of flow of oxygen to
different parts of the body would take place in the preliminary days after developing from the
AMI because the heart would require time to gain back its normal rate of the pumping
mechanism. During these days the heart would be able to send less blood to the different body
regions for which oxygen supply might be slow to the different organs. For this reason, the
patients might feel fatigued (So et al., 2016). Nursing professionals during this time advises the
individuals to undertake complete bed rest till the body receives back its normal active pace of
working. In such situations, Mr. Papas might find it difficult in conducting various household
activities like washing and maintaining his own hygiene. The heart might also not be able to send
enough blood to the lungs for its working mechanism for which the cells of the lung might
remain oxygen deprived. This action should not be confused with the gaseous exchange system
that takes place between lungs and air capillaries. The cells of the lungs might also not get proper
oxygen for which appropriate exchange of gases cannot take place. This might also cause the
patient to suffer from mild breathing issues (Yudi et al., 2016). Hence, taking of proper bed rest
is excessively important for the patients. The patient would be weaker in the first few days and
this might increase the chances of the fall. Hence, the nursing professionals should be allocating
social care aides from support services to help Mr. Papas in the first few days in his activities of
daily living like helping him while he is mobilizing, washing, bathing and many others. The

9
CASE STUDY OF MR. PAPAS
patients should also try to maintain his body temperature and for that he should avoid any places
that are quite hot or have heat waves. When the temperature become shot outside like during the
times of heat waves, the body tries to maintain the internal body temperature by increasing the
flow of blood and also by the process of sweating. Such stressful body situations might affect his
heart conditions and hence Mr. Papas should try to reside in comfortable environments in his
house. The nursing professionals can help the patient to learn about simple free hand exercises.
The social care aid can take the patient for the brisk walking in the fields and the parks so that he
can come out of any boredom of staying inside the house for bed rest.

10
CASE STUDY OF MR. PAPAS
References:
Anderson, J. L., & Morrow, D. A. (2017). Acute myocardial infarction. New England Journal of
Medicine, 376(21), 2053-2064. DOI: 10.1056/NEJMra1606915
Cequier, Á., Ariza-Solé, A., Elola, F. J., Fernández-Pérez, C., Bernal, J. L., Segura, J. V., ... &
Bertomeu, V. (2017). Impact on mortality of different network systems in the treatment
of ST-segment elevation acute myocardial infarction. The Spanish experience. Revista
Española de Cardiología (English Edition), 70(3), 155-161.
https://doi.org/10.1016/j.rec.2016.07.005
Deftereos, S., Giannopoulos, G., Angelidis, C., Alexopoulos, N., Filippatos, G., Papoutsidakis,
N., ... & Cleman, M. W. (2015). Anti-inflammatory treatment with colchicine in acute
myocardial infarction: a pilot study. Circulation, 132(15), 1395-1403.
https://www.ahajournals.org/doi/full/10.1161/CIRCULATIONAHA.115.017611
Elliott, J., Wang, T. K. M., Gamble, G., Williams, M., Matsis, P., Troughton, R., ... & French, J.
(2017). A decade of improvement in the management of New Zealand ST-elevation
myocardial infarction (STEMI) patients: results from the New Zealand Acute Coronary
Syndrome (ACS) Audit Group national audits of 2002, 2007 and 2012. The New Zealand
Medical Journal (Online), 130(1453), 17.
https://search.proquest.com/openview/6863ad0e92c7182d7e600d65091a8a3f/1?pq-
origsite=gscholar&cbl=1056335
Engstrøm, T., Kelbæk, H., Helqvist, S., Høfsten, D. E., Kløvgaard, L., Holmvang, L., ... & De
Backer, O. (2015). Complete revascularisation versus treatment of the culprit lesion only

11
CASE STUDY OF MR. PAPAS
in patients with ST-segment elevation myocardial infarction and multivessel disease
(DANAMI-3—PRIMULTI): an open-label, randomised controlled trial. The
Lancet, 386(9994), 665-671. https://doi.org/10.1016/S0140-6736(15)60648-1
Franchi, F., Rollini, F., & Angiolillo, D. J. (2017). Antithrombotic therapy for patients with
STEMI undergoing primary PCI. Nature Reviews Cardiology, 14(6), 361.
https://www.nature.com/articles/nrcardio.2017.18
Gershlick, A. H., Khan, J. N., Kelly, D. J., Greenwood, J. P., Sasikaran, T., Curzen, N., ... &
Wang, D. (2015). Randomized trial of complete versus lesion-only revascularization in
patients undergoing primary percutaneous coronary intervention for STEMI and
multivessel disease: the CvLPRIT trial. Journal of the American College of
Cardiology, 65(10), 963-972. DOI: 10.1016/j.jacc.2014.12.038
Goldsweig, A. M., Wang, Y., Forrest, J. K., Cleman, M. W., Minges, K. E., Mangi, A. A., ... &
Curtis, J. P. (2018). Ventricular septal rupture complicating acute myocardial infarction:
Incidence, treatment, and outcomes among medicare beneficiaries 1999–
2014. Catheterization and Cardiovascular Interventions, 92(6), 1104-1115.
https://doi.org/10.1002/ccd.27576
Hudzik, B., Budaj, A., Gierlotka, M., Witkowski, A., Wojakowski, W., Zdrojewski, T., ... &
Gasior, M. (2018). P831 Quality indicators of health care services in the management of
patients with ST-elevation myocardial infarction. European Heart Journal, 39(suppl_1),
ehy564-P831. https://doi.org/10.1093/eurheartj/ehy564.P831
Lange, D. C., Larson, D. M., Hildebrandt, D., & Henry, T. D. (2017). Creating Networks for
Optimal STEMI Management. Manual of STEMI Interventions, 299.

12
CASE STUDY OF MR. PAPAS
https://books.google.co.in/books?
hl=en&lr=&id=ImwtDwAAQBAJ&oi=fnd&pg=PA299&dq=STEMI+management+in+p
atients&ots=BkhLjzQlul&sig=TaVkNcepmuXUE2Zgv4MuAOxcBZ4#v=onepage&q=S
TEMI%20management%20in%20patients&f=false
Levine, G. N., Bates, E. R., Blankenship, J. C., Bailey, S. R., Bittl, J. A., Cercek, B., ... & Khot,
U. N. (2016). 2015 ACC/AHA/SCAI focused update on primary percutaneous coronary
intervention for patients with ST-elevation myocardial infarction: an update of the 2011
ACCF/AHA/SCAI guideline for percutaneous coronary intervention and the 2013
ACCF/AHA guideline for the management of ST-elevation myocardial
infarction. Journal of the American College of Cardiology, 67(10), 1235-1250.
http://www.onlinejacc.org/content/67/10/1235.abstract
Mannsverk, J., Steigen, T., Wang, H., Tande, P. M., Dahle, B. M., Nedrejord, M. L., ... &
Gilbert, M. (2019). Trends in clinical outcomes and survival following prehospital
thrombolytic therapy given by ambulance clinicians for ST-elevation myocardial
infarction in rural sub-arctic Norway. European Heart Journal: Acute Cardiovascular
Care, 8(1), 8-14. https://doi.org/10.1177/2048872617748550
Mathias, W., Tsutsui, J. M., Tavares, B. G., Xie, F., Aguiar, M. O., Garcia, D. R., ... & Rochitte,
C. E. (2016). Diagnostic ultrasound impulses improve microvascular flow in patients
with STEMI receiving intravenous microbubbles. Journal of the American College of
Cardiology, 67(21), 2506-2515. http://www.onlinejacc.org/content/67/21/2506.abstract
Moretti, C., D'Ascenzo, F., Quadri, G., Omedè, P., Montefusco, A., Taha, S., ... & Gaita, F.
(2015). Management of multivessel coronary disease in STEMI patients: a systematic

13
CASE STUDY OF MR. PAPAS
review and meta-analysis. International journal of cardiology, 179, 552-557.
https://doi.org/10.1016/j.ijcard.2014.10.035
Niccoli, G., Scalone, G., Lerman, A., & Crea, F. (2015). Coronary microvascular obstruction in
acute myocardial infarction. European heart journal, 37(13), 1024-1033.
https://doi.org/10.1093/eurheartj/ehv484
Parodi, G., Bellandi, B., Xanthopoulou, I., Capranzano, P., Capodanno, D., Valenti, R., ... &
Alexopoulos, D. (2015). Morphine is associated with a delayed activity of oral
antiplatelet agents in patients with ST-elevation acute myocardial infarction undergoing
primary percutaneous coronary intervention. Circulation: Cardiovascular
Interventions, 8(1), e001593.
https://www.ahajournals.org/doi/full/10.1161/CIRCINTERVENTIONS.114.001593
Richard, C., Leurent, G., & Auffret, V. (2018). Characteristics, management, and prognosis of
patients under 35 years old with ST-segment elevation myocardial infarction: Insights
from the multicenter prospective ORBI registry. Archives of Cardiovascular Diseases
Supplements, 10(1), 15. https://doi.org/10.1016/j.acvdsp.2017.11.025
So, D. Y. F., Wells, G. A., McPherson, R., Labinaz, M., Le May, M. R., Glover, C., ... & Tran,
L. (2016). A prospective randomized evaluation of a pharmacogenomic approach to
antiplatelet therapy among patients with ST-elevation myocardial infarction: the RAPID
STEMI study. The pharmacogenomics journal, 16(1), 71.
https://www.nature.com/articles/tpj201517
White, S. K., Frohlich, G. M., Sado, D. M., Maestrini, V., Fontana, M., Treibel, T. A., ... &
Davies, J. R. (2015). Remote ischemic conditioning reduces myocardial infarct size and

14
CASE STUDY OF MR. PAPAS
edema in patients with ST-segment elevation myocardial infarction. JACC:
Cardiovascular Interventions, 8(1 Part B), 178-188. DOI: 10.1016/j.jcin.2014.05.015
Yudi, M. B., Jones, N., Fernando, D., Clark, D. J., Ramchand, J., Jones, E. F., ... & Farouque, O.
(2016). Management of patients≥ 85 years of age with ST-elevation myocardial
infarction. http://ahro.austin.org.au/austinjspui/handle/1/13774
Yudi, M. B., Jones, N., Fernando, D., Clark, D. J., Ramchand, J., Jones, E., ... & Farouque, O.
(2016). Management of patients aged≥ 85 years with ST-elevation myocardial
infarction. The American journal of cardiology, 118(1), 44-48.
https://doi.org/10.1016/j.amjcard.2016.04.010