Comprehensive Nursing Care Report: Myocardial Infarction Case Study

This report presents a comprehensive nursing care plan for a 68-year-old male patient, Mr. George Orwell, admitted with chest pain and diagnosed with myocardial infarction. The report details the patient's medical history, current presentation including vital signs, and risk factors, as well as the pathophysiology of the condition. It identifies and addresses two primary nursing problems: pain and anxiety, providing detailed interventions for each. For pain, the report discusses assessment tools like the Numeric Rating Scale and interventions such as positioning, oxygen administration, and medication. For anxiety, it covers the use of the Hamilton Anxiety Rating Scale, breathing techniques, patient education, and involvement of family. The report also emphasizes the nurse's role in medication management and patient evaluation. Furthermore, it outlines a discharge plan that involves a multidisciplinary approach, including the roles of nurses, nutritionists, physiotherapists, and doctors. The importance of patient and family education, medication adherence, and financial preparedness is highlighted. The report concludes by emphasizing the seriousness of myocardial infarction and the impact on daily living, underscoring the need for comprehensive nursing care.

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

related to fear of the unknown as evidenced by the patient looking very anxious, feeling
lightheadedness and increase in blood pressure (170/90mmHg) and pulse rate (100b/min). It can
also be related to his worsening condition or his loneliness (Stubbs, Aluko, Myint and Smith
2016, pp.228-235).
Nursing problem 1
Pain is an unpleasant feeling as reported by the patient. It is usually not possible to measure the
exact intensity of pain but it is usually according to how the patient reports. Pain can be mild,
moderate or severe. There are some tools that can be used to screen for pain and measure the
intensity of pain in adults and can be used by the nurse in order to manage the patient
accordingly. Methods that can be used include: verbally reporting, writing, finger span, pointing
yes or no answers, head movements and blinking (Finnerup et al 2015, pp.162-173). In cognitive
intact patients, a Numeric Rating Scale (NRS) tool can be used to assess for pain intensity in
adults. This is a tool where a patient is asked to score their pain intensity on a scale of 0-10
where 0 represents no pain and 10 worst pain. On this scale of 10, 1-3 represents mild pain, 4-6
represents moderate pain and more than 7 represents severe pain. This will help manage the
patient accordingly (Ismail et al 2016, pp.287-293).
According to Lukewich, Mann, VanDenKerkhof (2015, pp.2551-2562), the nurse can intervene
for pain by placing the patient in a semi-fowlers or fowlers position to relax; this will alleviate
the pain as relaxation reduces energy requirements. Administration of oxygen via nasal prongs
will also help relieve chest pain. This is because oxygen supply to the blood is increased and
therefore reduced the effort in breathing. The nurse can also reassure the patient and explain to

the patient what is happening and also being with the patient during this moment helps alleviate
anxiety and hence reduces pain intensity (Fleming et al 2016). The nurse also plays an important
role in the medical management of patient pain. This can be done through administering
medications prescribed to the patient in the right dosage at the right time. The nurse can also
assess the patient for any complications or any adverse effects that may arise from drug
administration. Evaluation of the patient's outcome after drug administration is also the nurse's
role to identify whether the drugs given are beneficial to the patient or not and therefore
appropriate action can be taken. Drugs that can be used include diamorphine an opioid analgesic
together with cyclizine an antiemetic. Glyceride trinitrate (GTN) a potent vasodilator can be
used. Thrombolyse with streptokinase can also be used to restore the patency and hence relieve
pain as blood flow is restored to the ischemic pair. Aspirin and other antiplatelets can also be
used to reduce clot formation and hence reducing necrosis occurrence (Doyle et al 2019, p.71).
Nursing problem 2
Anxiety related to fear of the unknown as evidenced by the patient looking very anxious, feeling
lightheadedness and increase in blood pressure (170/90mmHg) and pulse rate (100b/min). The
level of anxiety can be mild, moderate, severe or panic (Zimmerman et al 2017, pp.59-63). The
nurse can use the Hamilton Anxiety Rating Scale (HAM-A) to measure the severity of anxiety
symptoms. The scale consists of 14 items each defined by a series of symptoms and measures
both psychic anxiety and somatic anxiety. Some of the items include fears, tension, behavior at
interview and others. Each item is scored on a scale of 0-4 and a total score calculated with a
total score range of 0-56. A total score of <17 indicates mild severity, 18-24 mild to moderate
and 25-30 severe to moderate. Nursing interventions are given according to the severity of
anxiety (Hamilton 2015, pp.601).

According to Zimmermann et al (2016, pp.101-111), the nurse can help the patient alleviate
anxiety by teaching him breathing techniques of breathing in slowly through the nose keeping
shoulders relaxed and then exhaling through the mouth slowly with lips pursed. This helps with
relaxation. Patient education on his disease condition and a clear explanation of what is
happening to him can help reduce anxiety. The nurse should explain to the patient in a language
that he understands rather than using medical jargons. Giving company to the patient during
episodes of anxiety also helps the patient (Evans, Spiby and Morrell 2019, pp.1-18). The nurse
can also involve the patient's relatives to be there with the patient as this will help the patient not
to worry enough and hence reduce anxiety. The patient can also have dietary modifications only
take food that helps reduce anxiety such as eggs, pumpkin seeds, and dark chocolate. Patient
reassurance is also an important aspect in the nursing role to alleviate anxiety ( de Jager et al
2018, pp.43-48).
The nurse also has a role in the medical management of anxiety. The nurse should administer
the drugs as prescribed in the right dose, route and time. The nurse can also evaluate the patient
to note any changes and improvements. With evaluation also the nurse can identify whether the
drugs administered are working or not. Some medications used to alleviate anxiety are
benzodiazepines which include alprazolam, clobazepam, diazepam and others (Markota et al
2016, pp.1632-1639).
Discharge plan
It is important to plan for the patient's discharge home. Myocardial infarction can be a recurrent
condition and therefore the multidisciplinary approach is required in the management of this
patient. Most of the patient requires surgery which is performed by cardiologist surgeons. Nurses

play an important role in managing the patient pre-operatively and post-operatively. They also
play an important role in total patient care during hospital stay (Sauer et al 2016, pp21-25).
Nutritionists also play an important role in the dietary prescription of the patient during the
hospital stay and also after discharge home. The patient should adhere to the food that will
prevent an increase in cholesterol levels and food important in the management of diabetes
mellitus.
The nurses play an important role in the discharge plan as they educate the patient on what is
required of them after discharge including relatives. Relatives should be involved now that Mr.
Orwell has difficulty even remembering to take his medication. This is important ass adhering to
a medication regimen is core inpatient recovery. Physiotherapists also play a role in encouraging
the patient on appropriate exercise to perform upon discharge as obesity is a predisposing factor
to heart conditions. Doctors are also important team in prescribing appropriate medication to be
taken by the patient upon discharge and any other requirements that the patient needs to follow.
The patient should be informed properly concerning his medical condition and to report any
change in normal so that appropriate intervention is implemented as soon as possible (Biggs and
Biggs 2018, pp.0897190018795950). Financial preparedness is also important to relatives. This
plan helps to reduce hospital stay and proper stay upon discharge avoiding many complications.
Conclusion
In conclusion, myocardial infarction is a very serious condition and can affect activities of daily
living of a patient. The major symptom is severe pain that usually last for some time and is
mostly not responsive to medication. It therefore requires multidisciplinary intervention in order
to manage the pain. The nurse plays a very important role in pain management as he or she is the

one with the patient most of the time. Most of the patients also experience anxiety and it can
aggravate the pain more. Managing anxiety therefore helps the patient cop more easily. The
nurse should always ensure that the patient is calm and comfortable as it contributes a lot in
recovery.

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