Nursing Case Study: Holistic Care Approach for Acute Myocardial Infarction

This nursing case study analyzes the condition of a patient with acute myocardial infarction and provides a holistic care approach through the Clinical Reasoning Cycle. It includes assessment, diagnosis, planning, intervention, rationale, and evaluation. The case study also discusses the importance of monitoring heart rate, blood pressure, and cardiac enzymes.

NURSING CASE STUDY
STUDENT ID
[DATE]
HP

Contents
Contents.................................................................................................................................................1
TASK 1.................................................................................................................................................2
TASK 2.................................................................................................................................................3
TASK 3.................................................................................................................................................4
TASK 4.................................................................................................................................................5
TASK 5.................................................................................................................................................7

TASK 1
The present case study of Miss Paterson reveals that she is suffering from multiple
ailments among which the major health issue is the Acute Myocardial Infarction (AMI).
Therefore the nursing care plan to be designed for her should be guided by holistic care
approach. In order to do so the case study will be analysed through Clinical Reasoning Cycle
consisting of 6 steps namely assessment, diagnosis, planning, intervention, rationale and
evaluation (Gibbs reflective cycle, 2016). The first step of this cycle requires analyzing the
condition of the patient. In the case of Miss Paterson it is evident that she is having multiple
issues which are interlinked. This potentially indicates that her cardiac health might worsen.
While assessing the client the major aspects to be considered are the intensity, location and
radiation of the chest pain. This is also evident from the facial expression and behaviour of
the client. Grimacing facial expression, restlessness, anxiety and clutching of the chest are
some of the clear indications of pain. Acute chest pain due to restricted blood flow to heart is
the common feature of acute myocardial infarction (Cardinale, Volpicelli, Lamorte, Martino
& Veltri, 2012), therefore the priority in planning care for the client is to reduce the acute
pain within one hour through pharmacological approach. The rationale for doing this is that
the acute pain is an indication of exaggerated condition of myocardial infarction (Smits, et al.
2017) therefore the client should be assisted in quantifying the pain and differentiating the
pre-existing pain from the current pain patterns. Within one hour of drug administration pain
score of the client should be evaluated to measure the impact of the drugs in reducing pain.
Secondly the irregular breathing pattern or forced breathing, feeling of fatigue and weakness
by the client are the symptoms of myocardial infarction (Stevens & Thomas, 2012). The
client should be asked and analysed if she has to put extra efforts in breathing and whether
she is having chest pain while breathing deeply. The cardiac dysfunction changes the oxygen

supply and consumption in the body which is evident by the shortness of breath. The nursing
care planning for this should be to make the client tolerate without excessive dyspnea and
will be able to utilize the breathing techniques efficiently to control her breathing pattern.
The primary intervention should include monitoring the heart rate in regular interval, measure
the blood pressure level and to identify the causative agents leading to intolerance (Friedman
et al., 2011). The client here should be encouraged to actively participate in the planning
activities and to learn techniques to conserve energy. The rationale for doing this is to
monitor the physiological responses with increasing activities and to identify the factors or
agents that elevate the breathing issues and reduce or eliminate those factors (Chew et al.,
2016).
TASK 2
In order to carry out assessment of Miss Paterson, at first I will go through the clinical
reasoning cycle steps to identify the priority assessments required for her. For the patients
with cardiac issues and acute chest pain, rapid access to case is required which would include
recognition of the issues and an early ECG. In the present case ECG measurements should be
taken in every thirty minutes (Sun, Lu, Yang & Li, 2012). Within 10 minutes of chest pain
complaint, ECG should be performed. This would help in assessing the degree of cardiac
dysfunction and is a highly specific assessing technique. Patients with any changes or
deviation from normal ECG measurement should be immediately recognized and treated
straight away.
My second assessment will be monitoring the blood pressure. Since the health history
of Miss Paterson indicates that she is suffering from high blood pressure from long time
therefore this may contribute significantly in developing myocardial infarction. Due to
deposition of fats and cholesterol the blood vessels narrow down leading to restricted blood

flow and thus exerting excessive pressure on heart to pump blood and this might lead to
cardiac failure (Rapsomaniki, et al. 2014) thus assessing blood pressure of Miss. Paterson at
regular interval is extremely important.
My third assessment would be assessing the cardiac enzymes such as Troponin I
Creatine Kinase –MB (CKMB) since the elevated level of troponin in the blood stream is
observed first 2-4 hours after the acute myocardial infarction. Similarly Creatine Kinase MB
level is elevated in the blood stream when cardiac muscles cells are damaged. Level of this
enzyme should be checked after 7-8 hours of admission.
TASK 3
In the present case study, Mrs. Patterson suffers from multiple issues that warrant
proper nursing assessment and diagnosis. The physical or mental health conditions that affect
her quality of life and health on priority basis are categorised appropriately under nursing
diagnosis.
Diagnosis 1 – Osteoarthritis is a degenerative bone disease prevalent in female
population of older age. Since, the degeneration process of bone exceeds the regeneration
progressive loss occurs. The patient will feel acute or chronic pain that might limit their
functionality and mobility. When functionality and mobility is affected, it leads to poor
quality of activity of daily living (Poole, 2012). For example, the nutrition, elimination,
washing, personal hygiene is restricted. Therefore, osteoarthritic pain is a major diagnosis in
the present case warranting nursing intervention. Secondly, research indicates osteoarthritic
patients are more prone to fall thus risk of injury is high. Therefore, improvement of bone
health and strength is the mainstay for current patient (Anderson et al., 2019).
The second diagnosis is activity intolerance due to acute myocardial infarction. The
condition occurs, when the blood flow to the heart reduces. This leads to poor oxygen supply

and increase in myocardial demand. As a result patient feels extremely fatigue and unable to
complete the work as intended. The heart rate and rhythm also changes warranting proper
exercise (Pereira, et al. 2016). But in the present situation, client is having osteoarthritis thus
excessive physical exercise cannot be recommended. Therefore, this is the second diagnosis
that demands attention.
Third diagnosis is the high blood pressure that acts as a risk factor for all other health
conditions of Miss Paterson. Already, the patient has weak bones due to osteoarthritis. With
high blood pressure symptoms, dizziness can lead to fall and breakage of bones. Secondly,
the pain medications can hamper the blood pressure. Thus, to regulate the blood pressure
proper pharmacological and non-pharmacological care must be taken.
TASK 4
In the present case study, the client Mrs. Patterson has multiple health issues that
encompass acute myocardial infarction, hypertension and osteoarthritis. Presently, the major
issue faced by the client is osteoarthritic pain and hypertension. The following patient
education framework is developed to address her primary illness with co-morbidities.
Discharge education regarding AMI – Must not venture into active life suddenly.
Since, she is older now it is recommended to take adequate rest and not to exhaust. Playing
with pets can put more pressure due to mobility. It must be reduced for initial 2-3 weeks
before starting a normal life.
The medication must not be stopped until asked by the physician. If any dose is
missed the patient must be advised to call the GP or nurse for further instruction. Same
procedure must be followed for wrong medication or overdose (David, Britting & Dalton,
2015).

As she is suffering from osteoarthritis her mobility is limited. Hypertension is a risk
factor in such situations as pain medications can increase blood pressure. This will put
pressure on heart. Thus, the medications must be taken in a timely manner.
The patient is advised to avail residential care services to manage her day to day
work, medication adherence, personal hygiene, cooking and assistance in other works. Both
acute myocardial infarction and osteoarthritis warrants rests and less pressure on heart and
legs (Kogan, Wilber & Mosqueda, 2016).
If feasible, joining a rehabilitation program will help in recovering faster from heart
ailments for Miss Paterson. This has an added advantage of preventing depression and
carrying out self-management. In such situation, a residential care service must be referred
and patient must be taught on what services they provide in their area (Doll et al., 2015).
The diet need to be modified and inclusion of low fat, low oil, low salt and more
fibres are recommended. The effect of nutrition on bones, heart health and blood pressure
must be made to understand to prevent the patient from suffering any complications post-
surgery (Doll, et al. 2016).
Although rigorous exercise is usually recommended, but in the present case the
patient must be taught about effect of rigorous exercise on her health. The advantage of
physiotherapy and simpler exercise to increase her bone strength and improve heart health
must be facilitated.
Osteoarthritis education – The disease and simple mechanism must be made to
understand in context of age and bone degeneration process. Knowing the disease will help
Mrs. Patterson in taking self-care as well as co-operating the care persons in day to day
activities. Secondly, knowing about the disease improves medication adherence and
empowerment (Olsen, Strand, Skjaerven, Sundal, & Magnussen, 2017).

Nutrition – In case osteoarthritis, the nutrition plays an important role. Role of
calcium, vitamin D and other bone building minerals must be recommended with health
benefits properly explained. The sources of such vitamins and minerals must be explained
(Zheng et al., 2017).
Alcohol and Smoking – Although, not evident from the case but major risk factors
that can worsen Mrs. Patterson life is alcohol and smoking. The bad effects of both smoking
and alcohol must be made to understand with simple explanation of mechanism (Kähkönen,
Kankkunen, Miettinen, Lamidi, & Saaranen, 2017).
In case of any emergency, such as shortness of breath, adverse medication reaction, or
chest pain she is advised to ring 911 as emergency service.
Discharge medications – Each medication with time of administration, dose & routes
of administration, side effects and benefits must be explained. The medication are mainstay
of symptomatic management of osteoarthritic pain. Similarly, the blood pressure medication
must be advised to take regularly without any break in between. Knowing the medication and
effects as well as side effects will make her aware and she can plan out her actions as per the
medication timing and dose (Dominsky et al., 2016).
If any assisting walker or mobility device has been recommended it must be used
meticulously and proper instructions. Patient education is imperative in case of older adults,
as any discrepancy can have serious effect on their overall health.
TASK 5
As per the present condition the client Miss Patterson has primary issue of AMI. But
post treatment she is stable. The next priority issue identified from case study is osteoarthritic

pain that can affect her quality of living and high blood pressure which can further worsen
her cardio-vascular condition (Veronese et al., 2018). The social condition assessment
implicates she has no family, stay’s with her cat Molly at third floor. Thus, the patient has
both physical and social care needs that need to be addressed. During admission the
following team members must be involved.
Emergency physician – The role of emergency physician is to assess the patient health
status by ABCDE approach and look for abnormalities. Once identified, the interventions can
be ordered (Frost & Wise, 2018).
Emergency nurse – The nurse need to carry out initial assessment of patient such as
vital monitoring and supplementary oxygenation facilitation. Bed side ECG can be conducted
as per the requirement (Pizzini & Martini, 2017).
Healthcare Assistant – The healthcare assistant will help in transferring the patient
safely to units for further evaluation or diagnostic tests and prevent fall (Gunathilake and
Nair, 2018).
During discharge, however the following team member’s suggestions or intervention
is required.
Discharge nurse/Physician – To provide discharge summary, medications, precautions
and other non-pharmacological interventions. Patient education in context of fall, nutrition
maintenance, fluid intake, medication intake is an absolute necessity.
Medicine specialist – Addressing osteoarthritis in patients having hypertension is a
challenging task. The reason is non-steroidal anti-inflammatory medications can lead to
change in blood pressure. Thus discharge medications must be prescribed by a medicine
specialist (Kendzerska et al., 2017).

Physiotherapist – Will help Mrs Patterson to carry out simple exercise that will help
her in mobility and maintenance of flexibility (Roberts and Busby, 2017).
Referral service – Since, Mrs Patterson has osteoarthritis the pain can reduce the
quality of life drastically. Secondly, she has hypertension that act as risk factor for heart and
brain disorders. Medication, nutrition, mobility, fall issue due to osteoarthritis are major
concerns. Thus members from referral units must be involved to assess Mrs. Patterson
requirement and provide appropriate residential healthcare as well as assisting services.
Transfer assistance to market places and other place of her choice can provide overall holistic
care to the patient that will improve her quality of life (Steel et al., 2019).
Psychological Counsellor – Older patients with debilitating illness are more prone to
depression and loneliness. Therefore, to prevent any type of mental health issue in the patient,
she must be facilitated psychological counselling. This will also help her to understand the
essence of self-management and benefits of availing referral residential aged care service
(Landman et al., 2013).
Thus, both admission and discharge care warrants multi-disciplinary and collaborative
care in the case of Mrs. Patterson

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