Primary Admission Diagnosis Nursing Assignment 2022

Nursing Assignment
Student Name:
Institutional Affiliation:

Introduction
Mr. George Orwell is a 68year old male who was admitted for chest pain investigations. On
admission, Mr. George Orwell was fully oriented but appeared slightly anxious. His vitals were
unremarkable and pitting edema on physical examinations with a diminished pedal pulse. Mr.
Orwell states to be breathless on exertion and had used GTN spay four times a day. He also
states to be having difficulty in remembering to take his medication and avoids fluid medication
as t makes him urinate a lot. He has a past medical history of type 2 diabetes mellitus,
hypercholesterolemia, hypertension, and anterior myocardial infarction 6 years ago. His past
surgical history had coronary artery bypass 5 years ago. He is obese and currently smoking 5
cigarettes per day. He is currently on the following medications, EtOH 50g daily, aspirin 300mg
daily, candesartan 4mg daily, metoprolol 50 mg twice a day, atorvastatin 80 mg daily,
spironolactone 50mg daily and GTN spray PRN. The patient is scheduled for a coronary
angiogram the following morning.
Upon commencement of our shift, Mr. Orwell was complaining of central chest pain. His vitals
were a pulse of 100b/min, BP of 170/90 mmHg, RR 18 b/min, SPO2 95% on the RA and
temperature of 36.5 degrees Celsius. His fluid balance chart had a positive balance of over a litre
in 24 hours. He is sweaty and very anxious and states to be feeling light-headed and very
nauseous. He has also been fasting overnight with a maintenance dose of fluids of normal saline
at 80mls/hr.

Primary admission diagnosis
Myocardial infarction is irreversible cellular injury and necrosis occurring as a result of
prolonged ischemia (Thygesen et al 2018 pp.2231-224). Patients with narrow coronary artery
have an increased rate of blockage by a thrombus. Myocardial infarction occurs when a small
branch of the coronary artery is blocked and cause the death of the hearth region supplied by the
artery (Smiths et al 2017 pp.1234-1244). Risk factors of myocardial infarction are
hyperlipidemia, systemic arterial hypertension, cigarette smoking, lack of exercise, emotional
stress, diabetes mellitus, alcohol intake and lack of sleep. Others include advanced age and male
gender for up to 40 years (Anna-Lise et al 2015 pp.209).
Pathophysiology: According to Heusch and Gersh (2016, pp.774-784), cardiac cells can
withstand ischemic condition for approximately 20 minutes before necrosis begins. The
contractile function of the heart stops in these areas of myocardial necrosis. The degree of altered
function depends on the areas of the heart involved and the left ventricle is mostly affected. The
body responds to the cell death through inflammation and within 24 hours leucocytes infiltrate
the area. Enzymes are released from the dead cardiac cells and are an important diagnostic test
for myocardial infarction. During the healing process, the proteolytic enzymes of neutrophils and
macrophages remove all the necrotic tissues by the end of 2-3 days. This makes the wall thin
hence the development of collateral circulation that improves the area perfusion. Once
infiltration has taken place, catecholamines mediate lipolysis and gluconeogenesis. Infarctions
can occur on the anterior wall, posterior or lateral wall. The most common are anterolateral and
anteroseptal (Carrick et al 2016, pp.e002834).

The primary clinical manifestation of myocardial infarction is severe pain in the left precordium
or substernal and it is usually described as the most severe pain one has ever experienced. The
pain is associated with nausea, vomiting, sweating and extreme distress (EUGenMed et al 2015,
pp.24-34). Other manifestations include: palpitation, syncope, breathlessness, decreased urine
output, pulmonary edema, the initial rise in BP then drop in BP signs of impaired myocardial
function and murmurs on auscultation (Balcioglu and Muderrisoglu 2015, pp.80).
From the case study, Mr. Orwell is suffering from myocardial infarction as he presents with
central chest pain, breathlessness on exertion, sweating, anxiety, lightheadedness, and nausea
which are clinical manifestations of myocardial infarction. He also has a history of type 2
diabetes mellitus, hypercholesterolemia, hypertension, smoking, obesity, and anterior myocardial
infarction 6 years ago. These are risk factors that predispose one to myocardial infarction. Mr.
Orwell's vital signs also suggest the condition as high BP of 170/90mmHg and pulse of
100b/min. The patient also has pitting edema on the lower limbs a clinical manifestation of a
cardiac condition.
Nursing problems
The two main nursing problems are pain and anxiety. Pain-related to the disease process
(myocardial infarction due to ischemia and necrosis of cardiac tissues) as evidenced by patient
verbalizing the pain. When tissues lack oxygen especially heart tissue due to blockage of
coronary artery pain is caused due to the non-physiological motion of the ischemic left
ventricular wall bulging and excitation of mechanical receptors by passive stretching. This
causes severe chest pain. It can also be due to excitation of nerve endings by chemicals such as
bradykinin, PGE, and adenosine (Lindegaard and Gleerup 2017, pp.119). Secondly, anxiety