Nursing Care for Acute MI Patient

This assignment focuses on providing comprehensive nursing care for a patient suffering from an acute myocardial infarction (MI). It outlines the necessary steps to assess the patient's condition, administer medications like morphine, nitroglycerin, and beta-blockers, and monitor vital signs, ECG, and laboratory data. The document emphasizes the importance of creating a calm environment, providing supplemental oxygen, managing potential complications, and educating patients on dietary restrictions and post-MI care.

Nursing - M.G 1
Nursing - M.G
Student's Name:
Instructor's Name:
Date:

Nursing - M.G 2
1. Describe the pathophysiology, health assessment and clinical
findings of M.G’s condition.
Pathophysiology of Congestive Heart Failure
Congestive heart failure (CCF) occurs when there is excessive strain on the myocardium to
meet the metabolic demands of the body, but it is unable to compensate for it. It may be
systolic dysfunction, diastolic dysfunction or both. Systolic dysfunction ensues when there is
pump failure. This causes a decreased ejection fraction and hence, a reduced stroke volume.
Poor stroke volume further strains the myocardium.
On exertion, such as exercise, the demand for oxygen increases multifold. The myocardium,
which was already under strain to maintain the cardiac output at rest, is further strained to
compensate for the increased demand for higher cardiac output. The myocardium now fails to
do so, resulting in exercise intolerance in these patients.
Diastolic dysfunction is due to failure of ventricular filling, which occurs mainly due to
cardiac remodelling. This causes ventricular stiffening and a reduced ability for ventricular
relaxation and filling. Due to this, there is a back pressure which is generated, that causes
elevated pulmonary pressures. High pulmonary vascular pressure ultimately results in
pulmonary oedema. This causes dyspnoea and orthopnea in the patients. In diastolic
dysfunction, ejection fraction is maintained.
Heart failure can also be classified into right heart failure, left heart failure, or both.
In right heart failure, the back pressures increase in the inferior vena cava and, hence, results
in congestive hepatomegaly. The patient presents with abdominal pain and pedal oedema as
the chief symptoms.
In left heart failure, the back pressures increase in the pulmonary circulation causing
pulmonary hypertension and pulmonary oedema, presenting as dyspnoea and orthopnea.

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Continuous strain on the myocardium causes ventricular hypertrophy, which results in
remodelling. This causes cardiomegaly, detectable on chest x-ray. Elevated pulmonary
pressures cause prominence of blood vessels in the lung fields on chest x-ray.
To compensate for the failing heart, several mechanisms come into
play, which include-
1. Sympathetic stimulation causing vasoconstriction and, hence, increased peripheral
vascular resistance; straining the myocardium further;
2. The reduced kidney perfusion due to poor cardiac output stimulates the renin–
angiotensin–aldosterone pathway. This helps maintain the blood pressure and reduces
salt and water excretion. This causes salt and water retention, which helps maintain
the blood pressure and volume, but also leads to oedema.
3. Sympathetic stimulation and receptors in the hypothalamus detect the changed
osmolarity and volume of the plasma and cause anti-diuretic hormone (ADH)
secretion. ADH reduces diuresis and that further worsens oedema.
This patient is hypertensive and a known case of chronic renal failure on medications, but not
following dietary restrictions. She presents with dyspnea and pedal oedema. Her labs show
elevated creatinine and BUN indicative of renal failure. X-ray is suggestive of pulmonary
oedema and cardiomegaly. Hence, the findings are suggestive of CCF.
Dyspnoea is present due to pulmonary oedema, since exchange of gases in the pulmonary
circulation is now impaired. Pedal oedema due to salt and water retention caused due to the
uncontrolled diet and also contributed by the cardiac failure. Poor renal circulation in the
patient who is a known case of renal failure is responsible for the renal dysfunction.
Cardiomegaly on x-ray is due to remodelling caused by chronic cardiac failure.

Nursing - M.G 4
2. What risk factors does she have for cardiovascular disease?
Family History of IHD as a risk factor
The patient has a family history of ischemic heart disease as evidenced by the death of her
mother due to stroke, and death of father due to myocardial infarction. Her brother has
coronary artery disease, diabetes, and hypertension. This indicates the patient has a high risk
for ischemic heart disease.
Ischemic heart disease is a condition in which the cardiac myocytes receive impaired
oxygenation due to impaired circulation. This causes ischemia, which reduces the efficiency
and functioning of the myocytes. However, this is reversible, if detected and treated early.
Failure to treat ischemia results in irreversible hypoxic injury to the myocytes, i.e. infarction,
and death of these cells.
Thus, the overall efficiency of the cardiac muscle is severely reduced, and the heart is unable
to pump blood to maintain the cardiac output required for the metabolic demands of the body.
In CCF, there is already an undue strain on the myocytes to maintain the cardiac output.
Initially compensatory mechanisms help tide over the strain. These try to maintain the normal
cardiac output and the patient is relatively asymptomatic. However, continuous strain on the
myocytes causes hypertrophy, especially of ventricles and cardiac remodelling. This makes
the ventricles less pliable – they do not fill completely during diastole, further aggravating the
diastolic dysfunction. The sympathetic stimulation causes increased vascular resistance and
increased heart rate since it needs to pump against a higher resistance to maintain the cardiac
output. Soon the myocytes are unable to handle this strain despite the compensatory
mechanisms, and symptoms of cardiac failure ensue.

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3. What other complications does MG present with and why have
these occurred?
Complications in This Patient Due To Risk Factor Profile
Hypertension
The heart needs to exert more force to maintain stroke volume when there is high systemic
vascular resistance. This results in ventricular hypertrophy, which eventually causes poor
ventricular filling i.e. diastolic failure and pulmonary oedema.The heart is unable to exert the
required force to maintain adequate circulation and cannot meet the metabolic needs,
resulting in heart failure.
Type 2 diabetes
Diabetes is associated with vascular changes, macrovasculopathies, atherosclerosis and
hypertension, which further contribute to decreasing the cardiac efficiency resulting in heart
failure.It can also predispose to ischemic heart disease, which is also a risk factor for CCF as
explained above.
Chronic kidney disease
Kidneys regulate the renin–angiotensin–aldosterone cycle that responds to changes in blood
pressure. It helps maintain the blood pressures required for normal cardiac output. In renal
dysfunction, this cycle gets impaired; blood pressure is not regulated, and this further strains
the myocardium.
Hyperlipidemia
This majorly contributes to atherosclerosis which then results in hypertension and contributes
to cardiac failure.
Further, the patient has a family history of ischemic heart disease which is a risk factor.
Myocardial ischemia reduces the efficiency of myocytes to maintain the stroke volume, and

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cardiac output. Thus, it cannot satisfy the metabolic demands. Increased myocardial strain
causes increased oxygen demand, contributing to heart failure.
The patient has also not followed the dietary restrictions. Increased salt intake contributes to
elevated blood pressure, which strains the already over worked myocardium as well as
contributes to oedema, responsible for her current symptoms of dyspnoea and oedema.
4. Differential Diagnosis
a. Flash pulmonary oedema due to cardiac failure
Goals:
 to reduce patient discomfort due to orthopnea and dyspnoea
 to elucidate the possible underlying cause by thorough detailed history
 to monitor vitals and maintain input output chart for early recognition of
complications and its timely prevention
 to record the dose and frequency of medication administered
 to keep emergency set ready, so that if patient decompensates, early life saving
interventions maybe performed
Interventions and Rationales
 Place patient in high fowler’s position (Promotes improved lung expansion hence
decreases discomfort from orthopnea and dyspnoea)
 Help the patient relax and administer oxygen (To maintain oxygen saturation to avoid
hypoxia related complications – dizziness, disorientation, ischemia),
 Administer morphine as instructed by physician (Analgesia to reduce sympathetic
stimulation caused by pain, preventing tachycardia and further stress on the
myocardium),

Nursing - M.G 7
 Record dose and frequency of administration (To avoid morphine overdose which
causes respiratory depression and worsens the condition of the patient),
 Check for dry cough, rales on auscultation (Early diagnosis and management of
complications due to pulmonary oedema)
 Monitor vitals and oxygen saturation regularly
 Monitor input output chart, and electrolytes, and check for pedal oedema, monitor
creatinine and blood urea nitrogen (To recognise symptoms of kidney dysfunction
early, so that complications can be prevented by timely intervention),
 Monitor ABG, look for signs of hypoxia (To recognise inadequate ventilation
perfusion, inform the physician and intervene early to prevent complications from
hypoxia),
 Monitor ECG (Early diagnosis of cardiac dysrhythmias secondary to CCF), and
 Educate patient about signs of decompensation, importance of strict dietary
regulations and drug therapy (Ensures better compliance, early recognition of
decompensation, early intervention and prevention of complications).
Chronic Kidney Disease Causing Renal Dysfunction
Goals:
 To educate the patient about recognising symptoms for timely intervention
 To stress the importance of dietary regulation in maintaining patient’s
condition
 To regulate the fluid intake by the patient
 To be calm and polite and reassure the patient and his family because this will
ensure better patient compliance
 Explain the possible necessity for dialysis in case the kidney dysfunction
continues to worsen

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 To weigh the patient daily, and pre and post dialysis to monitor oedema
 to record the dose and frequency of medication administered
 to keep emergency set ready, so that if patient decompensates, early life saving
interventions maybe performed
Interventions and Rationales
 Monitor input output chart, electrolytes, record weight daily, look for signs of oedema
(Helps recognise if kidney function is resuming or worsening);
 Monitor vitals regularly (To recognise development of complications for early
intervention);
 Record medications given and doses (To avoid administration of nephrotoxic drugs or
doses which will worsen the renal dysfunction);
 Ensure salt and fluid restricted diet (To avoid worsening of renal dysfunction);
 Assessing weight, vitals, site of dialysis before and after (To avoid dialysis related
complications);
 To prep the patient for dialysis, shift him to the dialysis unit and administer post
dialysis care (Monitoring of patient is required and reassurance needs to be given to
ensure patient compliance)
Silent Myocardial Infarction (Seen In Diabetics) Causing Decompensated
Cardiac Failure
Goals:
 To ask patient to verbalise if chest pain develops, and localise it
 To demonstrate relaxation techniques to the patient which helps reduce angina
pain
 To check for activity induced angina in the patient which indicates ischemia
 To demonstrate signs of adequate peripheral perfusion, and if absent to inform
the treating physician for early intervention and prevention of complications

Nursing - M.G 9
 looking for signs and monitoring the weight of the patient
 To set up pulse oxymetry, and ECG leads to detect and prevent life
threatening complications
 to elucidate the possible underlying cause by thorough detailed history
 to keep emergency set ready, so that if patient decompensates, early life saving
interventions maybe performed
 to reassure the patient and the relatives that adequate care will be provided
 to prevent crowding around the patient by the relatives as this will impair
proper monitoring and increase patient anxiety
 to draw blood prior to administration of medication to check ABG, cardiac
enzymes, electrolytes etc which helps determine the treatment measures to be
provided
 to discuss the financial status of the family so that interventions required can
be planned accordingly
 to ask for risk factors such as diabetes, hypertension, smoking, family history
of sudden cardiac deaths or stroke or myocardial infarction
Interventions and Rationales
 Take detailed history regarding symptoms, onset, progression (History indicates what
the possible diagnosis can be, and helps consider various complications caused by
predisposing risk factors);
 Provide quiet environment, and make patient calm and relaxed (External disturbances
can instigate anxiety and myocardial strain);
 Regularly monitor vitals and ECG (For early intervention in case of dysrhythmias,
hypoxia);

Nursing - M.G 10
 Record dose of narcotics administered and monitor pre and post narcotic vitals (To
rule out respiratory depression caused by overdose);
 Administer supplemental oxygen via nasal prongs or mask (Reduces myocardial
strain by improving the oxygenation, hence reduces complications due to ischemia
and hypoxia);
 Administer medications as instructed
o Morphine, (Pain causes sympathetic stimulation which increases heart rate,
thus increasing myocardial work load);
o nitroglycerine, (To ease pain and reduce stress on the heart);
o beta blockers (Reduces the heart rate and workload).
 Auscultate chest to check for rales, murmurs, friction rubs (Pericardial effusion,
pulmonary oedema, ruptured chordae may occur as complications of an infarction);
 Keep emergency tray ready (Patient may develop sudden fatal dysrhythmias)
 Monitor laboratory data for cardiac enzymes, electrolytes, ABG (Enzymes indicate
time of infarction, Electrolyte disturbances can cause fatal dysrhythmias, ABG to
recognise hypoxia and supplement oxygen)
 Prepare for reperfusion techniques by administering anti platelet agents as instructed,
taking patient for angioplasty (These drugs dissolve the clot causing ischemia hence
reverse myocardial hypoxia and restore its function)
 Ensure patient follows a strict diet, Light food and fluids on the first day (Foods rich
in potassium like banana and coconut water are avoided since it adversely affects the
myocardium in these patients;
 rule out constipation, and if present, give laxatives as instructed by the treating
physician (Constipation will cause strain and increase cardiac work);

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 Transfer to critical care unit if required (For more aggressive intervention and
monitoring in patients who have high risk, or show symptoms of decompensation and
ensuing complications like dysrhythmias and cardiac failure).
References
Silverberg, D., Wexler, D., Blum, M., Schwartz, D. & Iaina, A. 2004. The association
between congestive heart failure and chronic kidney disease. Curr Opin Nephrol Hypertens.,
13(2), 163-70.
Mayo Clinic 2017. Heart failure - Complications. Available
athttp://www.mayoclinic.org/diseases-conditions/heart-failure/basics/complications/con-
20029801. [Accessed on 4 Apr. 2017].

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Cleveland Clinic. 2017. Chronic kidney disease. Available at
http://my.clevelandclinic.org/health/articles/chronic-kidney-disease [Accessed on 4 Apr.
2017].
Tang, W.H., Maroo, A., & Young, J.B. 2004. Ischemic heart disease and congestive heart
failure in diabetic patients. Med Clin North Am, 88(4), 1037-1061.