Case Study Analysis: Acute & Complex Healthcare Needs - BN710711

This case study focuses on a 59-year-old patient, Max Johnston, presenting with acute chest pain, nausea, and breathlessness, indicative of a potential myocardial infarction (MI). The assessment includes an immediate electrocardiogram (ECG) to confirm the diagnosis. The student provides a detailed patient history, rationales for interventions, and SMART goals for the patient. The interventions include administering aspirin, nitroglycerin, and oxygen therapy, alongside continuous monitoring of blood pressure and cardiac enzymes (CKMB, Troponin I). The case also discusses the need for cardiac catheterization with percutaneous coronary intervention (PCI). The conclusion emphasizes the critical role of a comprehensive nursing approach in managing acute coronary events, considering the patient's lifestyle and risk factors. The student references relevant medical literature to support their analysis and interventions. This case study is written to fulfill the requirements of the BN710711 course assignment, demonstrating the student's ability to apply clinical reasoning and articulate the underlying pathophysiology of the presenting signs and symptoms, potential complications, and the patient's lived experience of this acute event.

Running head: NURSING
NURSING
Name of the student
Name of the university
Author note

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Max Johnston, a 59-year-old high school Primary, is stressful about his job-life. Max
came home from a business trip last night tired and went to sleep sooner. At the 0500 hours,
Max was awaked with extreme chest pain, nausea, and breathlessness with a pain score
of 9/10. His visible symptoms include pale skin color, excessive cold sweating.
DIAGNOSIS:
Max needs an immediate electrocardiogram assay (Chen, 2018).
It is essential to know the history of Patients, Max. The history of the patient involves
the summary of the current conditions, associated with the history of prior heart and other
disorders and the background of heart disorders running in the family (Biondi, 2012).
Rational:
The electrocardiogram (ECG) is the most important tool of clinical assessment and
measure the seriousness of the patient's condition who is suspected of developing acute
coronary syndrome (ACS) (Boden et al., 2012). The procurement of an ECG by emergency
medical services (EMS) personnel at the location of the first medical touch in patients with
signs associated with ST-increases myocardial infarction (STEMI) supports the diagnosis in
over 80 percent of cases. It also helps to diagnose life-threatening arrhythmias and, if
suggested, enables early and timely defibrillation therapy (Sampath, Sivasubramanian &
Lakshminarayanan, 2019).
Develop a full background of patients by open-ended questions, and careful listening
effectively reduces time by presenting crucial answers to the diagnosis. Studies measured the
relative significance of patient history, clinical evaluation, and diagnostic tests. Doctors are
instructed to estimate the patient's condition by only having the history and then again after
conducting the physical test concerning history. A correct diagnosis is expected in most of
the patients based primarily on medical history. Apart from being one of the oldest analytical

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methods, a detailed history is one of the most accurate strategies to get the idea of the
diseased condition (Muhrer, 2014).
SMART GOAL:
S – Max Johnston
M – will report of 50% reduction of the pain
A – after the first intervention application
R- as he will able to talk after getting relief from pain
T- within 12 hours of intervention application.
Rational:
The prior problem of the patient is the crushing pain he is experiencing that he scored
as 9 out of 10. The first intervention should be immediate, and the intervention should be
focused on the present condition of the patient. The patient will get intervention that will
reduce the pain quickly that the next intervention can take place. In myocardial infarction, the
heart becomes very weak to perform its regular work like pumping and oxygenating-
deoxygenating the blood. The condition can lead to many subside diseased conditions. So, it
is essential to reduce the load of the heart (France, 2015).
Knowledge and healthy living is the key to wellbeing and disease management. The
profound knowledge about own health condition is vital for one to prevent the potential
damage of health caused by the life-style, and sometime self-management helps the patient to

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apply primary home intervention in an emergency condition (Soutter, O’Steen & Gilmore,
2012).
Intervention 1:
Administration of aspirin to relieve the chest pain. Aspirin is administered to thin the
blood and decreased the chance of death. To administer a dose of 324 mg, either a single dose
of 325 mg can be given, or a combination of 4 small doses aspirin that contains 81 mg
formulation in each tablet can be administered (Chapman, Leslie & Sage, 2012).
Rational:
The elevation of ST in ECG indicates myocardial infarction, which is caused by a
plaque fracturing inside a coronary artery. This breakdown of the plaque causes a thrombus
or blood clot to develop inside the artery, which leads to blockage of the heart. The part of the
heart muscle that the artery supports starts dying (Wong et al., 2012). Lastly, the result is the
death of the heart muscle named myocardial infarction. Aspirin in low doses can suppress
platelet production immediately and effectively and hence can suppress blood clot formation
(Non, 2012). Hindering the development of the blood clot is vital in heart attack as ensuring
the supply of blood into the coronary artery at least at a minimal level will eliminate the death
of heart muscle cells.
Intervention 2:
Nitroglycerin, along with aspirin, is the primary drug provided in given
pathophysiology, which indicates myocardial fraction. This drug helps in the flow of impeded
blood by dilating the blood vessel. 0.4 mg of the sublingual tablet is recommended, and
repetition of the dose every five minutes is recommended for thrice (Boden et al., 2015).

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Rational:
The primary pharmacological function of Nitroglycerin is relaxing of the smooth
vascular muscle. While vein symptoms are prevailing, Nitroglycerin causes dilation of both
arteries and veins in a dose-dependent mechanism. This subsequently leads to the reduction
of preload or left ventricular end-diastolic pressure (Chiba et al., 2019). Nitroglycerin also
induces relaxation of the artery, which leads to the decrease of systemic vascular resistance
and arterial pressure or afterload. The drug also takes part in the dilation of large coronary
epicardial arteries. Nitroglycerin therapeutic doses can decrease diastolic, systolic, and mean
blood pressure of the artery (Ozdogru et al., 2013).
Intervention 3:
The next intervention for Max is oxygen therapy. The oxygen therapy generally
administrated when the patient is having shortness of breath or having oxygen saturation of
blood that is less than 94% in the room environment. The patient Max has the problem of
breathlessness, and his oxygen saturation is also less 91%. Both criteria match for applying
oxygen therapy to Max (Cabello et al., 2016, Saugstad & Aune, 2014).
Rational:
The shortness of breath or dyspnea is a classic symptom of cardiovascular diseases.
The patient fails to breathe properly as the heart muscle does not occur rapidly and rightly.
The oxygen therapy administrated to surpass the need for oxygen in the body that the body
can continue with the standard working mechanism (Berliner et al., 2016).
Intervention 4:
Continues monitoring of the blood pressure (BP) (Suchy-Dicey et al., 2013). The
estimation is calculated by the practitioner, who calculates that based on evidence-based

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science tied up with variables of patients factor. The systolic BP or the Mean Arterial
Pressure (MAP) can be quantified by this intervention. The arterial line can track that, too
(Verdecchia et al., 2015).
Rational:
Blood pressure monitoring is critical because the higher the blood pressure, the
greater the strain on a clot. One can have more than one clot in the myocardial infarction. The
added pressure may relieve a clot from being trapped somewhere, including in the neck,
extremity, brain, or lungs (Suchy-Dicey et al., 2013).
Intervention 5:
Monitoring of Cardiac Enzyme (CKMB), which includes Troponin I and Creatine
Kinase-MB (Flores Solís et al., 2012).
Rational:
These enzyme values are dependent on the methodology used in the academic
laboratory. If the marker enzymes are increased, it suggests tension or damage to the heart
muscle. Troponin I is a cardiac marker enzyme that makes myosin and actin interact in the
heart muscle. As myocyte necrosis occurs, the components of the cell may ultimately be
discharged into the blood circulatory system. An ischemic heart event can leads to the
elevation of Troponin even after 2-4 hours and can remain increased for the next 14 days
(Saravanan et al., 2013, Nzrc.org.nz, 2020).
Creatine Kinase MB is the enzyme present in the cells of the cardiac muscle and
catalyzes the transformation of ATP to ADP, which gives the cells the energy to perform
contraction. The enzyme is gradually introduced into the bloodstream when the cardiac
muscle cells get harmed. CKMB rates must be reviewed upon entry, and afterward in every 8
hours (Baird et al., 2012).

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Intervention 6:
Cardiac Catheterization with Percutaneous coronary intervention (PCI). A patient
with an ST elevated MI (STEMI) should be pushed to the cath laboratory to detect the clot
and put a stent to get blood flow back to the heart. A patient can still go to the cath laboratory
without having a STEMI, and can also get detected to have a clot (Gregory et al., 2013).
Rational:
PCI is a non-surgical procedure used to address the widening of coronary arteries in
the heart found during coronary artery disease. Primary PCI is PCI's immediate
pharmacological intervention in people with an acute cardiac arrest, primarily if the
electrocardiogram denotes the signs of heart damage. PCI can be seen in patients with certain
forms of myocardial infarction or angina disorder, where there is a substantial risk for further
events (Al-Lamee et al., 2018). The treatment includes combining coronary angioplasty with
stenting, which is the method of injecting a lasting wire-meshed tube with either medication
eluting (DES) or bare metal (BMS).
Conclusion:
It can be concluded from the assessment and the medical report of the patient Max
that the case can be a classic example of myocardial infarction (MI). The symptoms like pain
in the chest, diaphoresis –a case of excessive sweating, pale skin are the classic indicators of
coronary diseases. The blood component test indicates the increased level of LDL and the
marker of coronary diseases CK-MB and Troponin I is also elevate. The elevated SI found in
the ECG report also indicates the same condition. Max lived a stressful life, and he never had
a habit of exercise. His background also adds to the chance of myocardial infarction. These

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conditions kept in mind to design the SMART goals of nursing intervention methods for
improving the condition of Max (Heart Foundation NZ, 2020).

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References:
Al-Lamee, R., Thompson, D., Dehbi, H. M., Sen, S., Tang, K., Davies, J., ... & Nijjer, S. S.
(2018). Percutaneous coronary intervention in stable angina (ORBITA): a double-
blind, randomised controlled trial. The Lancet, 391(10115), 31-40.
Baird, M. F., Graham, S. M., Baker, J. S., & Bickerstaff, G. F. (2012). Creatine-kinase-and
exercise-related muscle damage implications for muscle performance and
recovery. Journal of nutrition and metabolism, 2012.
Berliner, D., Schneider, N., Welte, T., & Bauersachs, J. (2016). The differential diagnosis of
dyspnea. Deutsches Ärzteblatt International, 113(49), 834.
Biondi, B. (2012). Natural history, diagnosis and management of subclinical thyroid
dysfunction. Best practice & research Clinical endocrinology & metabolism, 26(4),
431-446.
Boden, H., Van der Hoeven, B. L., Karalis, I., Schalij, M. J., & Jukema, J. W. (2012).
Management of acute coronary syndrome: achievements and goals still to pursue.
Novel developments in diagnosis and treatment. Journal of internal medicine, 271(6),
521-536.
Boden, W. E., Padala, S. K., Cabral, K. P., Buschmann, I. R., & Sidhu, M. S. (2015). Role of
short-acting nitroglycerin in the management of ischemic heart disease. Drug design,
development and therapy, 9, 4793.
Cabello, J. B., Burls, A., Emparanza, J. I., Bayliss, S. E., & Quinn, T. (2016). Oxygen therapy
for acute myocardial infarction. Cochrane Database of Systematic Reviews, (12).
Chapman, A. R., Leslie, S. J., & Sage, D. K. (2012). New Guidelines for the Management of
Chest Pain: Lessons From a Recent Audit in Tauranga, New Zealand. Cardiology
research, 3(1), 8.

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Chen, W. (2018). Electrocardiogram. In Seamless Healthcare Monitoring (pp. 3-44).
Springer, Cham.
Chiba, T., Sakuma, K., Komatsu, T., Cao, X., Aimoto, M., Nagasawa, Y., ... & Takahara, A.
(2019). Physiological role of nitric oxide for regulation of arterial stiffness in
anesthetized rabbits. Journal of pharmacological sciences, 139(1), 42-45.
Flores Solís, L. M., Flores-Solís, L. M., Hernández Domínguez, J. L., Hernández-
Domínguez, J. L., Otero González, A., Otero-González, A., ... & González-Juanatey,
J. R. (2012). Cardiac troponin I and creatine kinase MB isoenzyme in patients with
chronic renal failure. Nefrología (English Edition), 32(6), 809-818.
France, K. (2015). Crisis intervention: A handbook of immediate person-to-person help.
Charles C Thomas Publisher.
Gregory, D. E. B. O. R. A. H., Midodzi, W. I. L. L. I. A. M., & Pearce, N. E. I. L. (2013).
Complications with Angio‐Seal™ Vascular Closure Devices Compared with Manual
Compression after Diagnostic Cardiac Catheterization and Percutaneous Coronary
Intervention. Journal of interventional cardiology, 26(6), 630-638.
Heart Foundation NZ. (2020). What is a heart attack and what causes one?. Retrieved 6 April
2020, from https://www.heartfoundation.org.nz/your-heart/heart-conditions/about-
heart-attacks
Muhrer, J. C. (2014). The importance of the history and physical in diagnosis. The Nurse
Practitioner, 39(4), 30-35.
Non, S. T. (2012). New Zealand 2012 guidelines for the management of non ST-elevation
acute coronary syndromes. The New Zealand Medical Journal (Online), 125(1357).
Nzrc.org.nz. (2020). Retrieved 6 April 2020, from
https://www.nzrc.org.nz/assets/Guidelines/ACS/All-ACS-guidelines-Jan-2016.pdf

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Ozdogru, I., Zencir, C., Dogan, A., Orscelik, O., Inanc, M. T., Celik, A., ... & Oguzhan, A.
(2013). Acute effects of intracoronary nitroglycerin and diltiazem in coronary slow
flow phenomenon. Journal of Investigative Medicine, 61(1), 45-49.
Sampath, S. K., Sivasubramanian, V., & Lakshminarayanan, S. (2019). Electrocardiography
changes in localizing the culprit vessel in acute myocardial infarction with
angiographic correlations. International Journal of Advances in Medicine, 6(3), 696.
Saravanan, G., Ponmurugan, P., Sathiyavathi, M., Vadivukkarasi, S., & Sengottuvelu, S.
(2013). Cardioprotective activity of Amaranthus viridis Linn: effect on serum marker
enzymes, cardiac troponin and antioxidant system in experimental myocardial
infarcted rats. International journal of cardiology, 165(3), 494-498.
Saugstad, O. D., & Aune, D. (2014). Optimal oxygenation of extremely low birth weight
infants: a meta-analysis and systematic review of the oxygen saturation target
studies. Neonatology, 105(1), 55-63.
Soutter, A. K., O’Steen, B., & Gilmore, A. (2012). Wellbeing in the New Zealand
curriculum. Journal of Curriculum Studies, 44(1), 111-142.
Suchy-Dicey, A. M., Wallace, E. R., Elkind, M. S., Aguilar, M., Gottesman, R. F., Rice,
K., ... & Longstreth Jr, W. T. (2013). Blood pressure variability and the risk of all-
cause mortality, incident myocardial infarction, and incident stroke in the
cardiovascular health study. American journal of hypertension, 26(10), 1210-1217.
Verdecchia, P., Reboldi, G., Angeli, F., Trimarco, B., Mancia, G., Pogue, J., ... & Yusuf, S.
(2015). Systolic and diastolic blood pressure changes in relation with myocardial
infarction and stroke in patients with coronary artery disease. Hypertension, 65(1),
108-114.

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Wong, C. K., Gao, W., Stewart, R. A., French, J. K., Aylward, P. E., & White, H. D. (2012).
The prognostic meaning of the full spectrum of aVR ST-segment changes in acute
myocardial infarction. European heart journal, 33(3), 384-392.