Acute Myocardial

Infarction

INTRODUCTION
 Acute myocardial infarction (AMI or MI), more commonly known as a
heart attack, is a medical condition that occurs when the blood supply to a part of
the heart is interrupted, most commonly due to rupture of a vulnerable plaque. The
resulting ischemia or oxygen shortage causes damage and potential death of heart
tissue.
Important risk factors are a previous history of vascular disease such as
atherosclerotic coronary heart disease and/or angina, a previous heart attack or stroke,
any previous episodes of abnormal heart rhythms or , older age especially men over
40 and women over 50, smoking, excessive alcohol consumption, the abuse of certain
drugs, high triglyceride levels, high LDL ("Low-density lipoprotein") and low HDL
("High density lipoprotein"), diabetes, high blood pressure, obesity, and chronically
high levels of stress in certain persons.
The term myocardial infarction is derived from myocardium (the heart
muscle) and infarction (tissue death due to oxygen starvation). The phrase "heart
attack" is sometimes used incorrectly to describe sudden cardiac death, which may or
may not be the result of acute myocardial infarction.
Classical symptoms of acute myocardial infarction include chest pain
(typically radiating to the left arm), shortness of breath, nausea, vomiting,
palpitations, sweating, and anxiety. Patients frequently feel suddenly ill. Women
often experience different symptoms from men. The most common symptoms of MI
in women include shortness of breath, weakness, and fatigue. Approximately one
third of all myocardial infarctions are silent, without chest pain or other symptoms.
Immediate treatment for suspected acute myocardial infarction includes
oxygen, aspirin, glyceryl trinitrate and pain relief, usually morphine sulfate. The
patient will receive a number of diagnostic tests, such as an electrocardiogram (ECG),
a chest X-ray and blood tests to detect elevated creatine kinase or troponin levels
(these are chemical markers released by damaged tissues, especially the
myocardium). Further treatment may include either medications to break down blood
clots that block the blood flow to the heart, or mechanically restoring the flow by
dilatation or bypass surgery of the blocked coronary artery. Coronary care unit
admission allows rapid and safe treatment of complications such as abnormal heart
rhythms.

Myocardial infarction is the leading cause of death in the United States (US)
as well as in most industrialized nations throughout the world. Approximately
800,000 people in the US are affected and in spite of a better awareness of presenting
symptoms, 250,000 die prior to presentation to a hospital. The survival rate for US
patients hospitalized with MI is approximately 90% to 95%. This represents a
significant improvement in survival and is related to improvements in emergency
medical response and treatment strategies.

In general, MI can occur at any age, but its incidence rises with age. The
actual incidence is dependent upon predisposing risk factors for arteriosclerosis.
Approximately 50% of all MI's in the US occur in people younger than 70 years of
age. However, in the future, as demographics shift and the mean age of the population
increases, a larger percentage of patients presenting with MI will be older than 65
years

Characteristics of Acute MI

The characteristics of an acute MI depend on the following factors:

 1) Location, severity, rate of coronary artherosclerotic obstruction
2) Size of area perfuse by occluded coronary blood vessels
3) Duration of occlusion
4) Myocardial needs of affected area
5) Degree of development of collateral blood vessels
6) Site and severity of vasospasm (if present)
7) Changes in BP, HR, heart rhythm
Risk Factors for Acute MI

AGE: The incidence of heart disease increases with age since the intima of
musculoelastic arteries thickens progressively and correlates with lipid deposition.

GENDER: The incidence of IHD is higher in men, but the incidence in women
increases after menopause so that elderly men and women are equally affected.

SMOKING: Smokers double their risk of MI, sudden cardiac death, and stroke.
Smoking also leads to a 70% increase in mortality from coronary artery disease.

DIABETES MELLITUS: Diabetics have an increased incidence of arteriosclerosis.

There is no significant difference between men and women.
GENETIC: There is a familial predisposition due to known and unknown risk
factors. There are also differences in susceptibility and localization of disease
in different racial groups.

The onset of symptoms in myocardial infarction (MI) is usually gradual, over several
minutes, and rarely instantaneous.Chest pain is the most common symptom of acute
myocardial infarction and is often described as a sensation of tightness, pressure, or
squeezing. Chest pain due to ischemia (a lack of blood and hence oxygen supply) of
the heart muscle is termed angina pectoris. Pain radiates most often to the left arm,
but may also radiate to the lower jaw, neck, right arm, back, and epigastrium, where it
may mimic heartburn. Any group of symptoms compatible with a sudden interruption
of the blood flow to the heart are called an acute coronary syndrome. Other
conditions such as aortic dissection or pulmonary embolism may present with chest
pain and must be considered in the differential diagnosis.
Shortness of breath (dyspnea) occurs when the damage to the heart limits the output
of the left ventricle, causing left ventricular failure and consequent pulmonary edema.
Other symptoms include diaphoresis, weakness, light-headedness, nausea, vomiting,
and palpitations. Loss of consciousness and even sudden death can occur in
myocardial infarctions.
Women often experience markedly different symptoms than men. The most common
symptoms of MI in women include dyspnea, weakness, and fatigue. Fatigue, sleep
disturbances, and dyspnea have been reported as frequently occurring symptoms
which may manifest as long as one month before the actual clinically manifested
ischemic event. In women, chest pain may be less predictive of coronary ischemia
than in men.
Approximately half of all MI patients have experienced warning symptoms such as
chest pain prior to the infarction.
Approximately one fourth of all myocardial infarctions are silent, without
chest pain or other symptoms. These cases can be discovered later on
electrocardiograms or at autopsy without a prior history of related complaints. A
silent course is more common in the elderly, in patients with diabetes mellitus and
after heart transplantation, probably because the donor heart is not connected to
nerves of the host. In diabetics, differences in pain threshold, autonomic neuropathy,
and psychological factors have been cited as possible explanations for the lack of
symptoms.
PATIENT’S PROFILE

Name: Marimar
 Age: 74 y/0

Gender: Female

Date of Birth: February 22, 1933

Status: Widow

Address: Enrile, Cagayan

Nationality: Filipino

Religion: Roman Catholic

Date of Admission: November 9, 2007

Time of Admission: 1: 15 AM

Chief Complaint: Difficulty of breathing/ Chest

Pain

Attending Physician: Dr. Nanette Espanol

Admitting Diagnosis: Angina Pectoris

Final Diagnosis: Acute Myocardial Infarction

Gordon’s 11 Functional Health Pattern

HEALTH PERCEPTION/ HEALTH MANAGEMENT
Before hospitalization
According to Marimar, health is the absence of disease and having a strong
body. She used to take over the counter medicines (OTC). According to her SO,
 she sometimes forget to take her medicines that’s why she was asked to go to her
son’s house to be reminded of her medications. Sometimes, she used medicinal
plants (Ampalaya and Malunggay) as a treatment. She seldom seeks medical
advice whenever she feels ill.
During Hospitalization
Although she was advised to have CBR without BRP’s, she still insists to use
the comfort room but despite of that she is cooperative in other therapeutic
interventions. She sees her health as poor due to her present condition. She is
under low salt and low fat diet. Her medications are famotidine, metoprolol,
aspirin, lactulose, and diazepam.

NUTRITION - METABOLIC PATTERN

Before hospitalization:
The patient eats three meals a day. She loves to eat “adobo and dinuguan” also
banana and rice cakes. She dislikes eating sardines, noodles and pancit. She had no
known allergies. She drinks at least 6 glasses of water a day. She takes vitamins and
medicines prescribed by her doctor like ferrous sulfate.

During Hospitalization:
She has a low sodium and low fat diet as ordered. She drinks approximately 4
glasses a day without any fluid restriction. Most of the available foods for her are
served by the hospital. Her ongoing IVF is 1 D5W x KVO with side drip of D5W 90
cc + 10 mg isoket x 10 uggts/min during the shift.

SLEEP- REST PATTERN

Before hospitalization
The patient had at least 8 hours of sleep. She usually sleeps at 9PM and wakes
up at 5AM. Prior to sleeping, she watches television. She has at least 2 hours naptime
a day.

During Hospitalization:
She had difficulty in sleeping because of the environment especially when she
was still in the Holy Family ward where she is not comfortable seeing her fellow
patients. But she was transferred to floor 2 of SPH where she feels more comfortable
but still distracted when the staff or SN’s get vital signs and/ or do other
interventions.

ELIMINATION PATTERN
Before hospitalization:
According to Marimar, before hospitalization she voided 3-5 times a day but it
depends on her fluid intake. Her bowel movement was once a day. Her urine color is
clear but if she takes her vitamins and medications it turns yellow to tea color. Her
feces are semi-formed and light in brown in color.

During Hospitalization:
She voids almost every hour with a color of yellow. She didn’t defecate since
admission with a zero bowel sounds.

ACTIVITY-EXERCISE PATTERN
Before hospitalization:
The patient is a housekeeper. She loves to do some gardening and performing
household chores. Everyday, she walks about one block going to her son’s house to
take her medications.

During Hospitalization
 Patient Marimar is restricted on having CBR without BRP’s. Despite of her
condition she has still the strength to move out of bed just to use the comfort room
even when instructed to just have CBR.

COGNITIVE-PERCEPTUAL PATTERN
Before Hospitalization
She only reached Grade 4 in elementary. She already has difficulty in hearing.
She is pure “Itawes” and cannot understand Filipino language but can understand few
“Ilocano” words.

During Hospitalization
She is not well oriented on time and place. Due to her hearing difficulty, she
responds to verbal stimuli slowly.

SELF-PERCEPTION/ SELF- CONCEPT PATTERN

Before hospitalization
She believes that she is not beautiful. “ Hindi naman ako maganda”, as she
verbalized. She lives in a simple and contended life. She is a loving mother and
grandmother. She is hot-tempered woman, she easily get irritated to noise.

During the Hospitalization

She sees herself as unhealthy due to her illness.

ROLE/RELATIONSHIP PATTERN
Before Hospitalization
Marimar lives alone since the death of her husband. Her only companion is
her grandchild to one of her siblings. She doesn’t want to live with her son. She lives
in Lemu North, Enrile. She said that she has been a good wife, mother and
grandmother.

During the Hospitalization

Her family is her only source of support and strength. Her family showed that
they are always available to help her in times of problems like this.

SEXUALLY- REPRODUCTIVE PATTERN

Before Hospitalization
According to the patient she had her menarche when she was 14 years old.
She had her menopausal period when she was 55 years old. She said that she had her
coitarche with her husband when she was 16 years old. They had an only son. Her
husband died 15 years ago, since then she was sexually inactive.

During the hospitalization

Sexually inactive.

COPING STRESS PATTERN

Before Hospitalization
Marimar told that she doesn’t keep her problems on her own, she open it to
her family. She gets her strength from her family.

During Hospitalization
She seldom communicates to her SO to ask for help. At first she is hard to
keep on CBR but when fully explained to her the importance of CBR, she cooperated
enough to follow it.

VALUE- BELIEF PATTERN

Before Hospitalization
She is a Roman Catholic. She believes in God but seldom seek help to him
and goes to mass only on special occasions. She believes in superstitions like quack
doctors and “atang”

During Hospitalization:
According to the patient, she is thankful that her family is always there to help
and support her. She now then prays to ask God for her fast recovery.

PATIENT’S HEALTH HISTORY

PERSONAL AND SOCIAL HISTORY
She is a 74 year old who resides at Lemu Norte, Enrile. She only reached
Grade 4 and a housekeeper. She has only one child. Her husband died 15 years ago.
 She loves to eat meat, adobo, dinuguan, and banana and rice cakes. She dislikes
eating sardines, noodles and pancit. She is a loving mother and grandmother but she
is hot-tempered. She easily gets irritated especially when her grandchildren are noisy.
She also maintains a good relationship with her neighbors.

PAST MEDICAL HISTORY

She has been hypertensive and has arthritis and peptic ulcer. She also acquired
sickness like cough, cold, fever and flu. According to her SO, her Doctor advised her
to have her monthly check-up but the patient fails to do so because she believes that
herbal plants such as ampalaya and malunggay can treat her condition. She didn’t
complete her vaccinations because this didn’t prioritize their health before since they
have poor economic status. Moreover, according to her SO, it was only during her
hospitalization that she is well taken cared of.

FAMILY HISTORY
At her father side, they have a family history of high blood and her father died
because of hypertension. While on her mother side, they have a family history of
diabetes mellitus. No one on the family had an AMI before.

HISTORY OF PRESENT ILLNESS

One day PTA, patient experienced epigastric pain and DOB associated
with easy fatigability. Consulted patient and was given Famotidine and motilium.
Few minutes PTA, there is recurrence of shortness of breath associated with chest
aneurism. Activities that contributed to easy fatigability were her fondness of
gardening and cleaning the yard.

PHYSICAL ASSESSMENT
General Appearance: Marimar when interviewed, she was not well-groomed. She appears to be
at her stated age (74 y/o). Color tone is uneven. She is thin and can ambulate. During the
interview, she was lying in bed.
Initial Vital Signs: Temp: 36.3○ C; PR: 83 bpm; RR: 20 cpm BP: 130/100

AREA METHOD NORMAL ACTUAL

ANALYSIS
ASSESSED USED FINDINGS FINDINGS
SKIN
Color Inspection Accdg. to race Deep brown Normal

Temperature Palpation Warm to touch Warm to touch Normal

Texture Palpation Smooth, soft Rough, Dry Due to Aging

and decrease
blood
circulation

Turgor Palpation Skin snaps back Skin does not Due to Aging
to previous state immediately snaps
back to previous
state

Moisture Palpation Not too dry, Not Dry Due to Aging

too oily and decrease
water intake

NAILS
Curvature Inspection Convex Convex Normal

Angle Inspection 160 degrees 160 degrees Normal

Texture Palpation Smooth Smooth Normal

Color of Inspection Pinkish with Pale with dirty tip Decreased

Nail bed translucent tip oxygen supply
due to decreased
cardiac output;
impacted soil/
dirt
Normal
Size Inspection Short Short
Due to dec.
Capillary refill Palpation Should return Returns within blood supply
time within 2-3 secs. 4-5 secs. and oxygen

HAIR
Color Inspection Accdg. to race gray Normal
Smooth Smooth
Texture Palpation Normal
Evenly Evenly distributed
Distribution Inspection distributed Normal

Texture Palpation Silky, resilient silky, resilient Normal

HEAD
Scalp symmetry Inspection Symmetrical Symmetrical Normal
Size Inspection Normocephalic Normocephalic Normal

Shape Inspection Rounded Rounded Normal

& Palpation

Nodules / Lesions Inspection No nodules and No nodules and Normal

& Palpation lesions lesions
FACE
Symmetry Inspection Symmetrical Symmetrical Normal

Facial Inspection Symmetric facial Symmetric facial Normal

Movements movements movements

Color Inspection Same as body Pale Decreased blood

color supply/cardiac
output
EYES
Shape Inspection Almond-shape Almond-shape Normal
Eyebrows Inspection Symmetrical, Symmetrical, Normal
Equally Equally distributed
distributed
Smooth, same as
Eyelids Inspection Smooth, same as body color, no Normal
body color, no inflammation,
inflammation, blink at regular
blink at regular intervals
intervals

Equally
Eyelashes Inspection Equally distributed, Normal
distributed, Slightly curved
Slightly curved outward
outward
Pale, shiny and
Conjunctiva Inspection Pinkish, shiny smooth, no lesions Decreased blood
and smooth, no supply/cardiac
lesions output
Transparent, shiny
Normal
Cornea Inspection Transparent, black
shiny
No swelling Normal
Pupils Inspection black
Normal
Lacrimal Inspection No Swelling Free to move
Apparatus PERRLA
Normal
Movement Inspection Free to move Normal
Reaction to light Inspection PERRLA

EARS
Auricle color Inspection Same with skin Same with skin Normal
color color
Symmetry Inspection Symmetrical Symmetrical Normal

Texture Palpation Firm, non tender Firm, non tender Normal

Proportion and Proportion and

Position Inspection equal in size on equal in size on Normal
the head the head

The same with The same with

Size Inspection both sides both sides Normal

Presence of Inspection Free of lesions Free of lesions and Normal

lesions, cerumen and discharges, discharges,
cerumen minimal cerumen minimal

Hearing acuity Whisper test Can hear murmur Cannot hear Due to aging
sounds murmur sounds
NOSE
Symmetry Inspection Symmetrical Symmetrical Normal

Shape Inspection Bell shape Bell shape Normal

Tenderness Palpation No tenderness No tenderness Normal

Skin color Inspection Uniform with Uniform with Decreased

color of face color of face cardiac output
(pale) causing dec. O2
supply

Texture Palpation Smooth Smooth Normal

Ridge of nose Palpation Firm, stable to Firm, stable to Normal

palpation w/o palpation w/o
tenderness tenderness

Cilia Hair Inspection Evenly Evenly Distributed Normal

Distributed
Pale
Mucosa Inspection Reddish Dec. oxygen due
to dec. blood
circulation

At the midline, no Normal

Nasal septum Inspection At the midline, lesions
no lesions
Symmetric Normal
Nares Inspection Symmetric
No nasal flaring Normal
Nasal Flaring Inspection No nasal flaring

Non tender Normal

Sinuses Palpation Non tender
No discharges Normal
Discharges Inspection No discharges

MOUTH
Lips Inspection Accdg. to race, dark, Symmetrical Normal
Symmetrical

Gums Inspection pinkish, moist, pale, moist, tightly Decreased

tightly fit against fit against each oxygen supply
each tooth tooth

Mucosa Inspection pinkish, moist pale, moist Decreased

Oxygen supply

Tongue Inspection Pinkish, Pinkish, Normal

symmetrical, symmetrical, moist
moist and no and no lesions
lesions
Yellowish with
Teeth Inspection Color ivory black deposits(26 Due to poor
white, no tooth teeth) hygiene, tooth
decay(32 teeth) decay and aging

Midline, rise Normal

Uvula Inspection Midline, rise symmetrically
symmetrically
Pink, no Normal
Tonsils Inspection Pink, no discharges
discharges
NECK
Position Inspection Head- centered Head- centered Normal

Movement Inspection Neck moves Neck moves freely Normal

freely
Full range without
Range of Motion Inspection Full range discomfort Normal
without
discomfort No enlargement

Lymph nodes Palpation No enlargement Normal

TRACHEA
Symmetry Inspection Symmetrical Symmetrical Normal

Position Palpation Midline at the Midline at the Normal

suprasternal notch suprasternal notch
THYROID
Consistency Inspection Moves upward Moves upward Normal
when swallowing when swallowing
THORAX
Respiratory Inspection Even movement Even movement Normal
Movement occurs in occurs in
respiration respiration
Contour Inspection Almost round in Almost round in Normal
infants, expands adults, expands
bilaterally bilaterally

(POSTERIOR)
Symmetry Inspection Symmetrical Symmetrical Normal

Shape Inspection Elliptical Elliptical Normal

Color Inspection Same as body Same as body Normal

color color

Texture Palpation No nodules or No nodules or Normal

lesions lesions

Symmetry of Palpation Symmetrical Symmetrical Normal

chest expansion

Breath sounds Auscultation Resonant, clear Resonant, clear Normal

breath sounds breath sounds

Position of spine Inspection Straight with out Straight with out Normal
lateral deviation lateral deviation

(ANTERIOR)
Symmetry Inspection Symmetrical Symmetrical Normal

Shape Inspection Elliptical Elliptical Normal

Color Inspection Same as body Same as body Normal

color color

Texture Palpation No nodules or No nodules or Normal

lesions lesions
HEART
Sounds Auscultation No murmurs No murmurs Normal

ABDOMEN
Color Inspection Uniform with the Uniform with the Normal
rest of the rest of the body
body

Abdominal Inspection Flat(adult), Flat(adult), Normal

Contour protuberant protuberant (infant
(infant and child) and child)

No lesions No lesions
Lesions Inspection Normal
Symmetrical Symmetrical
Symmetry Inspection Normal

Umbilicus Inspection Midline with no Midline with no Normal

signs of signs of
 discoloration or discoloration or
hernia hernia

Bowel Sounds Auscultation High pitched, No bowel sounds Due to

gurgling sound, constipation and
5-30 times per intake of ferrous
minute sulfate
UPPER
EXTREMITIES
Symmetry Inspection Symmetrical Symmetrical Normal

Color Inspection Uniform with Uniform with skin Normal

skin color color

Texture Palpation Smooth rough Due to aging

LOWER
EXTREMITIES
Symmetry Inspection Symmetrical Symmetrical Normal

Color Inspection Uniform with Uniform with skin Normal

skin color color

Texture Palpation Smooth rough Due to aging

NEUROLOGIC
SYSTEM
Mental Status Interview Oriented to Disoriented to Psychologic
person, place, person, place, time stress
Time
 Anatomy & Physiology
The Cardiovascular System

Your heart and circulatory system make up your cardiovascular system. Your
heart works as a pump that pushes blood to the organs, tissues, and cells of your body.
Blood delivers oxygen and nutrients to every cell and removes the carbon dioxide and
waste products made by those cells. Blood is carried from your heart to the rest of your
body through a complex network of arteries, arterioles, and capillaries. Blood is returned
to your heart through venules and veins.

The one-way circulatory system carries blood to all parts of your body. This process of
blood flow within your body is called circulation. Arteries carry oxygen-rich blood away
from your heart, and veins carry oxygen-poor blood back to your heart.

In pulmonary circulation, though, the roles are switched. It is the pulmonary artery that
brings oxygen-poor blood into your lungs and the pulmonary vein that brings oxygen-rich
blood back to your heart.

Twenty major arteries make a path through your tissues, where they branch into smaller
vessels called arterioles. Arterioles further branch into capillaries, the true deliverers of
oxygen and nutrients to your cells. Most capillaries are thinner than a hair. In fact, many
are so tiny, only one blood cell can move through them at a time. Once the capillaries
deliver oxygen and nutrients and pick up carbon dioxide and other waste, they move the
blood back through wider vessels called venules. Venules eventually join to form veins,
which deliver the blood back to your heart to pick up oxygen.

Blood

Blood is the actual carrier of the oxygen and nutrients. Blood is made mostly of plasma,
which is a yellowish liquid that is 90% water. But in addition to the water, plasma
contains salts, sugar (glucose), and other substances. And, most important, plasma
contains proteins that carry important nutrients to the body’s cells and strengthen the
body’s immune system so it can fight off infection.

3 main types of blood cells that circulate with the plasma:

• Platelets, which help the blood to clot. Clotting stops the blood from flowing out
of the body when a vein or artery is broken. Platelets are also called
thrombocytes.
• Red blood cells, which carry oxygen. Of the 3 types of blood cells, red blood
cells are the most plentiful. In fact, a healthy adult has about 35 trillion of them.
The body creates these cells at a rate of about 2.4 million a second, and they each
have a life span of about 120 days. Red blood cells are also called erythrocytes.
• White blood cells, which ward off infection. These cells, which come in many
shapes and sizes, are vital to the immune system. When the body is fighting off
infection, it makes them in ever-increasing numbers. Still, compared to the
number of red blood cells in the body, the number of white blood cells is low.
Most healthy adults have about 700 times as many red blood cells as white ones.
White blood cells are also called leukocytes.

Heart Anatomy

The heart weighs between 7 and 15 ounces (200 to 425 grams) and is a little larger than
the size of your fist. By the end of a long life, a person's heart may have beat (expanded
and contracted) more than 3.5 billion times. In fact, each day, the average heart beats
100,000 times, pumping about 2,000 gallons (7,571 liters) of blood.

Your heart is located between your lungs in the middle of your chest, behind and slightly
to the left of your breastbone (sternum). A double-layered membrane called the
pericardium surrounds your heart like a sac. The outer layer of the pericardium surrounds
the roots of your heart's major blood vessels and is attached by ligaments to your spinal
column, diaphragm, and other parts of your body. The inner layer of the pericardium is
attached to the heart muscle. A coating of fluid separates the two layers of membrane,
letting the heart move as it beats, yet still be attached to your body.

Your heart has 4 chambers. The upper chambers are called the left and right atria, and the
lower chambers are called the left and right ventricles. A wall of muscle called the
septum separates the left and right atria and the left and right ventricles. The left ventricle
is the largest and strongest chamber in your heart. The left ventricle's chamber walls are
only about a half-inch thick, but they have enough force to push blood through the aortic
valve and into your body.

The Heart Valves

Four types of valves regulate blood flow through your heart:

• The tricuspid valve regulates blood flow between the right atrium and right
ventricle.

• The pulmonary valve controls blood flow from the right ventricle into the
pulmonary arteries, which carry blood to your lungs to pick up oxygen.

• The mitral valve lets oxygen-rich blood from your lungs pass from the left atrium
into the left ventricle.

• The aortic valve opens the way for oxygen-rich blood to pass from the left
ventricle into the aorta, your body's largest artery, where it is delivered to the rest
of your body.

Heart Wall

Epicardium

• The epicardium is the outer layer of the wall of the heart. It is composed of
connective tissue covered by epithelium. The epicardium is also known as the
visceral pericardium.

• Provides an outer protective layer for the heart.

Myocardium

• Myocardium is the muscular middle layer of the wall of the heart. It is composed
of spontaneously contracting cardiac muscle fibers which allow the heart to
contract.
• Stimulates heart contractions to pump blood from the ventricles and relaxes the
heart to allow the artria to receive blood.

Endocardium

• The endocardium is the inner layer of the heart. It consists of epithelial tissue and
connective tissue.
 • Lines the inner cavities of the heart, covers heart valves and is continuous with
the inner lining of blood vessels.
• Purkinje fibers are located in the endocardium. They participate in the contraction
of the heart muscle.

Heart Conduction System

The sinoatrial node (SAN), located within the wall of the right atrium (RA), normally
generates electrical impulses that are carried by special conducting tissue to the
atrioventricular node (AVN).

Upon reaching the AVN, located between the atria and ventricles, the electrical impulse
is relayed down conducting tissue (Bundle of HIS) that branches into pathways that
supply the right and left ventricles. These paths are called the right bundle branch
(RBBB) and left bundle branch (LBBB) respectively. The left bundle branch further
divides into two sub branches (called fascicles).

Electrical impulses generated in the SAN cause the right and left atria to contract first.
Depolarization (heart muscle contraction caused by electrical stimulation) occurs nearly
simultaneously in the right and left ventricles 1-2 tenths of a second after atrial
depolarization. The entire sequence of depolarization, from beginning to end (for one
heart beat), takes 2-3 tenths of a second.

All heart cells, muscle and conducting tissue, are capable of generating electrical
impulses that can trigger the heart to beat. Under normal circumstances all parts of the
heart conducting system can conduct over 140-200 signals (and corresponding heart
beats) per minute.

The SAN is known as the "heart's pacemaker" because electrical impulses are normally
generated here. At rest the SAN usually produces 60-70 signals a minute. It is the SAN
that increases its' rate due to stimuli such as exercise, stimulant drugs, or fever.

Should the SAN fail to produce impulses the AVN can take over. The resting rate of the
AVN is slower, generating 40-60 beats a minute. The AVN and remaining parts of the
conducting system are less capable of increasing heart rate due to stimuli previously
mentioned than the SAN.

The Bundle of HIS can generate 30-40 signals a minute. Ventricular muscle cells may
generate 20-30 signals a minute.

Heart rates below 35-40 beats a minute for a prolonged period usually cause problems
due to not enough blood flow to vital organs.

Problems with signal conduction, due to disease or abnormalities of the conducting

system, can occur anyplace along the heart's conduction pathway. Abnormally conducted
signals, resulting in alterations of the heart's normal beating, are called arrhythmias or
dysrrythmia.

The Coronary Arteries

Coronary Circulation

The heart muscle, like every other organ or tissue in your body, needs oxygen-rich blood
to survive. Blood is supplied to the heart by its own vascular system, called coronary
circulation.
The aorta (the main blood supplier to the body) branches off into two main coronary
blood vessels (also called arteries). These coronary arteries branch off into smaller
arteries, which supply oxygen-rich blood to the entire heart muscle.

The right coronary artery supplies blood mainly to the right side of the heart. The right
side of the heart is smaller because it pumps blood only to the lungs.

The left coronary artery, which branches into the left anterior descending artery and the
circumflex artery, supplies blood to the left side of the heart. The left side of the heart is
larger and more muscular because it pumps blood to the rest of the body.

Myocardium

Myocardium is the muscular tissue of the heart.

The other tissues of the heart are:

• the endocardium (inner lining, effectively a specialized endothelium)

• the epicardium (a connective tissue layer around the heart with a serous surface. It
may be considered as the inner (visceral) layer of the pericardium)

Composition

The myocardium is composed of specialized cardiac muscle cells with an ability not
possessed by muscle tissue elsewhere in the body. Cardiac muscle, like other muscles,
can contract, but it can also carry an action potential (i.e. conduct electricity), like the
neurones that constitute nerves. Furthermore, some of the cells have the ability to
generate an action potential, known as cardiac muscle automaticity.

The blood supply of the myocardium is by the coronary arteries. The myocardium is
subject to two opposed electrical subsets of control. First order electrical control of the
myocardium is derived from the sinoatrial node. Propagation of first order control from
the sinoatrial node is closely tied to sympathetic discharge. Second order electrical
control of the myocardium is closely tied to parasympathetic influence from the spinal
vertebral ganglia and vagus nerves.
Anatomy of the heart and associated vesels

Cardiac Enzymes

There are several enzymes that are released when heart cells are damaged. A
specific, sensitive marker that is present in 1-2 hours after the cardiac muscle injury
continues to be sought.

Troponin T and I

These are contractile proteins of the myofibril. The cardiac isoforms

are very specific for cardiac injury and are not present in serum from
healthy people. Current guidelines from the American College of
Cardiology Committee state that cardiac troponins are the prefered
markers for detecting myocardial cell injury.

Troponin I (cTnI) or T (cTnT) are the forms frequently assessed.

Rises
 2 - 6 hours after injury
Peaks
 in 12 - 16 hours
cTnI stays elevated for 5-10 days, cTnT for 5-14
days
Creatine Kinase (creatine phosphokinase)

This enzyme is found in heart muscle (CK-MB), skeletal muscle (CK-

MM), and brain (CK-BB). Creatine kinase is increased in over 90%
of myocardial infarctions. However, it can be increased in muscle
trauma, physical exertion, postoperatively, convulsions, delirium
tremens and other conditions.

Time sequence after myocardial infarction

begins
 to rise 4-6 hours
 peaks
 24 hours
returns
 to normal in 3-4 days

Creatine Phosphokinase Isoenzymes

MM
 fraction - skeletal muscle
MB fraction - heart muscle
BB  fraction - brain

MB fraction
Rises
 and returns to normal sooner than total CK
Rises
 in 3-4 hours
Returns
 to normal in 2 days
CK - MB subforms

This test is becoming more popular. MB2 is released from heart

muscle and converted in blood to MB1. A level of MB2 equal or
greater than 1.0 U/L and an MB2/MB1 ratio equal or greater than 1.5
indicates myocardial infarction.
Myoglobin

Found in striated muscle. Damage to skeletal or cardiac muscle

releases myoglobin into circulation.

Time sequence after myocardial infarction

Rises
 fast (2 hours) after myocardial infarction
Peaks
 at 6 - 8 hours
Returns
 to normal in 20 - 36 hours

Have false positives with skeletal muscle injury and renal failure.
Lactic Dehydrogenase

This enzyme is no longer used to to diagnose myocardial infarction.

Laboratory Examination

Date: 11/9/07
Examination requested: Na, K, CREA

Actual results Normal Analysis Significance

Results
Creatinine 106.5 50-100 F Due to To evaluate renal
(mmol/L) 65-120 M increased function
30-70 C muscle
production and
excretion by
kidneys
Na 136.3 135-155 Normal To determine
mmol/L electrolyte status
and for muscle
contraction
K 2.97 3.6-5.5 Due to efflux of To determine
mmol/L potassium electrolyte status
and for muscle
contraction

Date: 11/09/07
Examination Requested: TROPI, CKMB

Spec. Exam results

Cardiac Panel Test Result

Test: CKMB Significance: An increase indicates
heart tissue injury
Result: 6.10
Normal Range: Less than 6.8 mg/ml
Analysis: Due to myocardial tissue injury

Test: Troponin I Significance: An increase indicates

heart tissue injury
Result: 4.23
Normal Range: less than 0.10 ug/L
Analysis: Due to anaerobic metabolism of the cardiac muscles

Date: 11/09/07
Examination Requested: CBC

Actual Result Normal Results Analysis Significance

WBC 5.2 5-10 x 10^9/L Normal Indicator of
immune system
status
HGB 10.5 12.0-16.0g/dL Due to decrease Indicates
F O2 supply destruction/
13.0-18.0 g/dL production of
M RBC
HCT 31 37-48%F Due to Indicates
39-54% M decreased O2/ destruction/
oxygenation of over production
the blood of RBC

Due to Indicator of
Differential myocardial occurrence of
Count 0.80 0.60-0.70 injury inflammation
Segmenters
Lymphocyte 0.20 0.20-0.30 Normal Indicator of
presence of
infection/
inflammation

Date: 11/12/07
Examination Requested: FBS Lipid

Actual Results Normal Results Analysis Significance

Fasting Blood 6.41 3.89-5.84 Elevated with Increased amts.
Sugar mmol/L pt’s having DM Further
contribute to
MI
Cholesterol 2.80 3.87-6.71 Due to previous To evaluate
physical levels affecting
activities and the occurrence
drug of plaques
intake( medicati deposited in
ons) artery walls.

Triglycerides 1.06 0.66-1.60 Normal To evaluate

mmol/L metabolism of
fats instead of
glucose for
energy.
HDL-C 1.1 >1.7 mmol/L Due to physical To evaluate
exercise before levels affecting
and to the occurrence
medications of plaques
deposited in
artery walls.
LDL-C 1.23 3.88 mmol/L Due to physical To evaluate
exercise before levels affecting
and to the occurrence
medications of plaques
deposited in
artery walls.

Date: 11/12/07
Examination Requested: K
Actual Results Normal Results Analysis Significance
K 3.79 3.6-5.5 mmol/L Normal To determine
 electrolyte
status and for
muscle
contraction

Date: Nov.9,2007

Impression:
Cardiomegaly with pulmonary congestive changes.
Pneumonia, Bilateral. Intercurrent pleural effusion.
considered atherosclerotic aorta.

Analysis:
Cardiomegaly is due to inflammation in the heart and injury. Pulmonary
congestive changes are due to d ecrease plasma pressure in the interstitial spoaces in
the alveoli because of decreased cardiac output. Atherosclerotic aorta is due to plaque
formation and deposits of cholesterol/ other lipid components.
Significance: To evaluate respiratory status and heart size.
DRUG STUDY
ASPIRIN
Brandname: Bayer Aspirin, aspilets

Action: relieves pain and reduces inflammation by inhibition of peripheral prostaglandin

synthesis. It also inhibits the synthesis or action of other mediators of inflammation. It
acts on the hypothalamic heat-regulating center to relieve fever, by promoting sweating
and vasodilatation, leading to heat loss and cooling by evaporation. Also decreases
platelet aggregation by preventing formation of thromboxane A, a platelet aggregating
substance.

Indication: Treatment of mild to moderate pain; fever, various inflammatory conditions;

reduction of risk of death or MI in patients with previous infraction or unstable angina
pectoris or recurrent transient ischemia attacks or stroke in men who have had transient
brain ischemia caused by platelet emboli.

Dosage: 50 mg/ tab; 1 tab OD

Contraindications: Hypersensitivity to salicylates or NSAIDs; hemophilia, bleeding

ulcers or hemorrhagic states.

Precautions: GI disorders: can cause gastric irritation and bleeding. Hepatic impairment:
May cause hepatoxicity in patients with impaired liver function. Hypersensitivity:
reaction may include bronchospasm and generalized angioedema; patients with asthma or
nasal polyps have greatest risk. Renal impairment: may decrease renal function or
aggravate kidney disease.

Adverse Reaction: dizziness, nausea, heartburn, bleeding, anemia, decreased iron

concentration, rashes, angioedema and anaphylactic shock.

Drug interaction: Antacids, Anticoagulants, oral and heparin, Carbonic anhydrase,

methotrexate, insulin

Nursing considerations:
Assess pain: character, location, intensity, ROM before and 1 hr after administration
Identify prior drug history
Assess allergic reactions
Assess visual changes (blurring)
Monitor liver function/ hepatotoxicity: dark urine, clay-colored stools, yellow skin and
sclera
Monitor input-output

METOPROLOL
Brand name: betaloc, betazok, cardiosel, Cardiostat, Cardiotab

Action: Exerts mainly beta-1 adrenergic blocking activity but also blocks beta-2
receptors at high doses. It reversibly and competitively combines with beta-1 adrenergic
receptors to block sympathetic nerve impulses, resulting to decreased myocardial
contractility, heart rate, cardiac output and myocardial oxygen consumption. These
effects lead to decreased blood pressure and reversal of cardiac arrythmias, consequently
preventing myocardial tissue damage.
Indication: Moderate to severe congestive heart failure (CHF); migraine prophylaxis and
hyperthyroidism. Hypertension; angina pectoris; cardiac arrhythmias especially
supraventricular tachycardia, reduction of ventricular extra systoles; myocardial
infraction; heart disorders with palpitations, migraine

Dosage: 50 mg/ tab; ½ tab BID

Contraindication: Atrioventricular (AV) blocks 2 and 3; marked clinically relevant

sinus bradycardia; sick sinus syndrome and cardiogenic shock. Digitalis refractory heart
failure; severe kidney/ liver failure; gout; pregnancy; lithium therapy, uncompensated
cardiac failure (CHF), chronic obstructive pulmonary disease (COPD), patient with
inadequate myocardial infraction (MI), Metabolic acidosis.

Precaution: Adjust hypoglycemic therapy in labile and insulin-dependent diabetics

(IDD); digitalization in patients with history of heart failure or cardiac reserve, COPD,
hypotension. Patients undergoing elective or emergency surgery. Employ beta-blocker as
pre-medication. Dose reduction in cases of renal and hepatic dysfunction. Patient with
hormone produced tumor of adrenal medulla.

Adverse Reaction: Fatigue, Dizziness, Headache, Bradycardia, and postural disorders,

GI disturbances, skin rashes, heart failure, heart block and bronchospasm. Loss of
hearing, fatigue and coldness of extremities. Depressive moods, lightheadedness,
sweating, sleep disturbances, increased dream activity and hallucinations may occur
especially at the start of therapy.

Drug Interaction: Antiduretic effect following co-administration with diuretics and

lithium; selective beta-blockers may counteract tendency to hyperglycemia which
diuretics may provoke. Increased risk of myocardial depression with verapamil,
dilitiazem, class I antiarrythmics. Insulin and oral hypoglycemic.
and apical/ radial pulse before therapy
Obtain baseline kidney and liver function tests before beginning therapy.
Monitor for possible drug induced adverse reaction.
Monitor urine output, input-output ratio and weight daily.
Assess hydration status: skin turgor and mucous membranes especially elderly patients
Assess patient’s and family’s knowledge on drug therapy.

FAMOTIDINE

Brand Name: famtine, H2 Bloc, Motid, Pepcidine

Action: Competitively inhibits histamine h2 receptors in the gastric acid secretion. Both
basal and nocturnal gastric acid secretion stimulated by food or pentagastrin is inhibited.

Indication: Short term treatment and maintenace therapy for duodenal ulcer,
gastroesophageal reflux disease (GERD), including erosive or ulcerative disease, benign
gastric ulcer, and treatment of pathologic hypersecretory conditions.

Dosage: 20 mg OD

Contraindication: Hypersensitivity to other H2- antagonists

Precaution: Lactation, Children: Safety and efficacy not established. Elderly: Hepatic/
renal function impairment.
Adverse Reaction: Palpitations, headache, fatigue, dizziness, confusion, hallucinations,
depression, insomia,alopecia, rash, pruritus, acne, dry skin, constipation, nausea,
vomiting, abdominal discomfort, anorexia, dry mouth

Drug interaction: Ketoconazole

Nursing Considerations:
Assess patient’s GI disorder before starting therapy and reassess regularly (ulcers or
suspected ulcers, abdominal pain). Monitor gastric pH (pH 5 must be maintained)
Assess renal status and function before and during therapy. Monitor urine output, input-
output ratio
Monitor adverse reactions
Assess patient’s and family’s knowledge of drug therapy

DIAZEPAM
Brand name: Valium

Action: Facilitates/ potentiates the inhibitory activity of GABA at the limbic system and
reticular formation to reduce anxiety, promote calmness and sleep. This inhibition also
suppresses the spread of seizure activity produced by epileptogenic foci in the cortex,
thalamus and limbic system. Enhancement of GABA-mediated presympathetic inhibition
at the spinal level and brain stem reticular formation results to skeletal muscle relaxation

Indication: Symptomatic relief of anxiety, agitation, tension due to psychoneurotic states

and transient situational disturbances; relief of reflex muscle spasm due to local trauma;
combats spasticity due to damage to spinal and supraspinal interneurons.

Dosage: 5 mg/tab; 1 tab OD @ HS

Contraindications: Dependence in other substances including alcohol, except in

management of acute withdrawal reactions. Severe chronic hypercapnia.

Precaution: cardiorespiratory insufficiency, pregnancy, lactation, myasthenia gravis

Adverse Reactions: Blurred vision, paradoxical reactions, dependence, withdrawal

symptoms.

Drug Interaction: other centrally acting drugs; alcohol

Nursing Considerations:
Obtain history of patient’s underlying condition before therapy and reassess regularly
thereafter
Assess degree and precipitating factor of anxiety. Monitor signs of anxiety
Monitor the type, duration, intensity and precipitating factors of seizures.
Assess for alcohol withdrawal symptoms
Monitor possible adverse reactions
Monitor v/s. hold drug if systolic BP drops 20 mmhg and monitor respiration every 5-15
mins if drug given IV
Monitor renal, hepatic and hematologic status and function of patients on long term
therapy
Assess mental status and ability of the drug to control symptoms
Assess patient’s and family’s knowledge of drug therapy.
LACTULOSE

Brand name: Duphalac, Lilac

Action: Causes an influx of fluid in the intestinal tract by increasing the osmotic pressure
within the intestinal lumen. Bacterial metabolism of the drug to lactate and other acids
which are only partially absorbed in the distal ileum and colon augments the osmotic
effect of lactulose. The distention of the colon due to increased fluid enhances intestinal
motility and secretion. These results to soft stool. It lowers intestinal absorption of
ammonia presumably due to increased utilization of ammonia by intestinal bacteria.

Indications: Constipation, salmonellosis, treatment of hepatic encephalopathy

Dosage: 30 ml at HS

Containdication: Patients who require a low lactose diet. Galactosaemia or disaccharide

deficiency, intestinal obstruction.

Precaution: Lactose intolerance, diabetes. Do not use if in the presence of abdominal

pain, nause, fever or vomiting. Should not be taken for more than 1 wk without the
advice of the physician. Pregnancy and lactation.

Adverse Reaction: abdominal discomfort associated with flatulence and intestinal

cramps. Nausea, vomiting, diarrhea on prolonged use.

Drug interaction: Neomycin and other anti-infectives may interfere with the desired
degradation of lactulose and prevent acidification of colonic contents.

Nursing Considerations:
Assess patient’s condition before therapy and reassess regularly thereafter to monitor
drug’s effectiveness.
Monitor for possible adverse GI reaction
Monitor fluid and electrolytes status
Monitor for increased glucose levels in diabetic patients.
Assess patient’s and family’s knowledge of drug therapy.

MOTILIUM

Classification:
GIT Regulators, Antiflatulents & Anti-inflammatories / Antiemetics & Antivertigo Drugs

Indication:
Dyspeptic symptom complex associated w/ delayed gastric emptying, GERD, esophagitis
eg epigastric sense of fullness, early satiety, feeling of abdominal distension, upper
abdominal pain; bloating, eructation, flatulence; heartburn w/ or w/o regurgitations of
gastric contents in the mouth. Nausea & vomiting of functional, organic, infectious or
dietetic origin or induced by radio- or drug therapy.

Contraindications
GI hemorrhage, mechanical obstruction or perforation; in patients w/ prolactin-releasing
pituitary tumor (prolactinoma). Known intolerance to the drug.
Dosage
10 mg TID

Precautions:
Hepatic impairment, renal disorders. When antacids or antisecretory agents are used
concomitantly, they should be taken after meals & not before meals.

Adverse Reaction:
Rarely, mild abdominal cramps. Raised serum prolactin levels & allergic reactions.
Extrapyramidal phenomena.

Interactions:
Antagonized by anticholinergic drugs. Antacids or antisecretory agents, CYP3A4
inhibitors.

Nursing Considerations:
Should be taken on an empty stomach (Take 15-30 mins before meals.).

GENERIC NAME: SPIRONOLACTONE

Brandname: Aldactone, Aldezide

Classification:Potassium sparing diuretics

Action
Spironolactone acts on the distal renal tubules as a competitive antagonist of aldosterone.
It increases the excretion of sodium chloride and water while conserving potassium and
hydrogen ions.

Contraindications
Anuria, hyperkalaemia, acute or progressive renal insufficiency, severe hepatic
impairment; Addison's disease; hypersensitivity to thiazides.

Precautions
Patients at risk of developing hyperkalaemia and acidosis; monitor serum electrolytes;
renal and hepatic impairment; gout, diabetes, long-term use in young patients, elderly;
pregnancy.

Adverse Drug Reactions

Fluid or electrolyte imbalance, gynaecomastia, GI upset, drowsiness, headache,
hyponatraemia; tachycardia, hypotension, oliguria, hyperkalaemia; confusion, weakness,
paraesthesia, hirsutism, mental disturbances, menstrual irregularities, loss of libido and
impotence.

Interaction
Sodium excretion effect may be inhibited by aspirin. Inhibits ulcer-healing properties of
carbenoxolone

Nursing Responsibilities
1. Assess for allergies in drugs and foods
2. Use combination with extreme caution.
3. Monitor renal function.
4. Monitor serum potassium.
5. Evaluate Side Effects

Generic Name: ISOKET

Classification: Anti-Anginal Drugs

Indications
Unresponsive left ventricular failure secondary to acute MI. Severe or unstable angina
pectoris.

Contraindications
Cardiogenic shock, circulatory collapse, severe hypotension, marked anemia, head
trauma, cerebral hemorrhage, severe hypovolemia. Avoid sildenafil, tadalafil, vardenafil.

Precautions
Predisposition to closed-angle glaucoma; hypothyroidism, hypothermia, malnutrition,
severe renal or liver disease. Pregnancy & lactation. Close attention to pulse & BP
required.

Dosage: D5W+10 mg isoket x 10ugtts/min

Adverse Drug Reactions

Severe cerebral flow deficiency & decreased coronary perfusion may develop; nitrate
headache & nausea.

Interactions
Hypotensive effects may be enhanced by alcohol, β-blockers, antihypertensives, tricyclic
antidepressants, sildenafil, tadalafil, vardenafil.

Side Effects
Nitrate headaches, especially at the beginning of treatment. These may largely be avoided
by slowly increasing the dose until the required daily dose has been attained. Headaches
usually subside after a few days of continuous treatment, and are best relieved with
analgesics. A reduction of blood pressure, a feeling of dizziness and weakness, and
elevation of the pulse rate may occur on initial administration. These may largely be
avoided by slowly increasing the dose until the required daily dose has been attained.
Nausea, vomiting or eryt
hema (flush) may also occur in very sensitive patients. occasional facial flushing,
cutaneous vasodilation, dry rashes, drowsiness, orthostatic hypotension or reflex
tachycardia were reported. In rare instances, vascular collapse, occasionally accompanied
by bradycardic rhythm disturbances, may develop. A drastic blood pressure fall, which
occurs very seldom, may possibly trigger anginal symptoms

Actions
Isosorbide dinitrate is a smooth muscle relaxant. It is particularly effective on vascular
and bronchial smooth muscle. Its systemic cardiovascular effects are mainly due to a
decrease in venous return (pooling of blood in the peripheral venous system).
Consequently, ventricular end-diastolic pressure and volume are diminished, thus
reducing cardiac work and implicitly myocardial oxygen requirements. The arterial
vessels are dilated as well, though to a lesser degree. This results in a slight drop in aortic
and systemic blood pressure relieving the myocardium from a part of its afterload. These
nitrate-induced changes account for both the antianginal effects of isosorbide dinitrate
and for its beneficial effects in the treatment of congestive heart failure.

Nursing Responsibilities:
1. Assess for allergies of patient in foods and drugs
2. Assess patient’s condition before therapy and regularly thereafter to monitor drug
effectiveness
3. Assess Blood pressure and apical/ radial pulse before therapy
4. Monitor for possible drug induced adverse reaction.
5. Evaluate for Side effects
Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective Data: Altered body comfort: At the end of 20 > Noted pathological > to know underlying > Goal met. The
“Sumsakit and dibdib ko”, as acute pair related minutes, the pt. will be factors patient verbalized pain
verbalized by the pt. tissue ischemia able to report pain as >Performed > To provide baseline as tolerated with a pain
to tolerated with a comprehensive data scale of 1/10
Objective Data: pain scale of 1/10 assessment of pain
 grimaced face
 Guarded behavior > Encouraged
 Restless verbalization of feelings > To know further
 BP: 160/100 mmhg about pain intervention
 PR: 120 bpm
> Provided calm > to provide comfort
 RR: 28 cpm
environment and and to increase
 Pain scale: 4/10 comfort measures like oxygenation
 Location: chest focused breathing/
 Quality: crushing purse lip breathing
exercise
> Encouraged > To divert feelings of
diversional activities pain
such as socialization

> Encouraged adequate

rest period > To reduce energy
> administered expenditure
supplemental O2 as > To increase oxygen
indicated (2 LPM) supply to heart tissues
Assessment Diagnosis Planning Interventions Rationale Evaluation
Subjective Data: Impaired gas At the end og  Assessed pathological  To know Goal partially
“ Nahihirapan akong huminga”, as exchange the shift, the condition underlying met. The pt.
verbalized by the patient related to patient will be  Monitored v/s factor registered latest
alveolar- able to  Noted areas of  To establish PR of 78 bpm
Objective Data: capillary demonstrate cyanosis ( nailbede baseline data and RR of 24
 RR: 28 cpm membrane adequate and face)  To determine cpm but still
 Pr: 120 bpm changes ventilation and  Maintained O2 therapy degree of appears pale
 Restlessness oxygenation as @ 2 LPM via nasal cyanosis and with crt of
 Pale manifested by cannula as ordered  To increase 4-5 seconds
 CRT of 4-5 seconds RR of 80-100  Positioned pt. to semi- alveolar O2
bpm, PR of 16- fowler’s concentration
20 cpm, ABG’s
 Advised to do deep-
within the  To lower
breathing exercise
normal range diaphragm,
and absence of  Encouraged to have
enough rest and follow thereby
respiratory increasing
distress CBR without BRP’s as
ordered lung
 Provided restfulk and expansion
comfortable  To improve
environment oxygenation
 To limit
energy
expenditure
and oxygen
consumption
 To promote
rest and sleep
Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective Data: Altered Bowel At the end of the shift , > Ascertained client’s > To obtain baseline data > Goal not met. The
“ Hindi pa siya tumatae Elimination: the patient will be beliefs, practices and the patient didn’t defecate.
since noong naadmit Constipation related to maintain usual pattern of frequency of bowel
siya” , as verbalized by decreased metabolioc bowel functioning elimination
the SO. rate and intake of iron
sulfate > Identified the latest > To obtain baseline data
Objective Data: elimination pattern for comparison
> absence of bowel
sounds > Evaluated current > To note deficits and
dietary and fluid intake obtain data for
 and implications for appropriate nursing
effect on bowel function considerations

> Advised patient to have

balanced fiber and bulk > To promote moist/ soft
diet stool

> Encouraged to have > To stimulate intestinal

adequate fluid intake contractions

> Administered lactulose > To aid in softening the

as ordered ( 30 ml @ stools for good bowel
HS) elimination

Assessment Diagnosis Planning Interventions Rationale Evaluation

Subjective Data: Decreased Cardiac At the end of the shift, > Assessed for skin > to determine degree of Goal Particularly met.
“ Nahihirapan akong huinga”, Output related to stroke the pt. will be able to : color, moisture and CRT compromise Patient registered
as verbalized by the patient volume >Display hemodynamic cardiac rate of 78 bpm,
stability > Monitored v/s every 2 > To track changes Bp at 110/90, RR of 24
Objective data: >Demonstrate decreased hrs, BP every 1 hour as cpm but still appears
 PR: 120 Bpm episodes of dyspnea ordered restless and with CRT
 RR: 28 Cpm ( RR: 16-20 cpm) and of 4-5 seconds
 BP: 160/100 ( PR: 60-80 Adult), Crt >Administered > To increase available
 CRT: 4-5 sec. of 2-3 seconds supplemental O2 as O2 to heart tissue
indicated ( 2 LPM)
> Note presence of > Reflecting Cardiac
pulsus paradoxus Tamponade

> Instructed to have > To reduce physical

CBR without BRP’s as stress and tension
oredered
> To increase lung
> Maintained in semi- expansion and decrease
fowler’s position cardiac stress/ workload
> To avoid
> Instructed pt. to avoid furthercardiac stress/
stimulation of valsalva workload
maneuver

> Instructed to have low > To avoid increase in

Na and Fat diet BP and narrowing of
arteries
> Monitored I & O
> To track changes in
> Regulated IVF/ SD fluid balance and
elimination
> To provide adequate
fluid
Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective data: Anxiety related At the end of an hour, > Discussed with the > to have baseline data Goal partially met.
“ Gusto ko nang umuwi”, as verbalized situational crises the patient will appear client their The patient was still
by the patient relaxed and report understanding of the unable to sleep and
anxiety is reduced to situation appears restless.
Objective data: a manageable level. > To establish open
 Restlessness > Listened to client’s communication
 Increased BP: 160/100 complaints
mmhg > Reduces anxiety
 Poor eye contact > Explained the attributed to fear of
importance of order, unknown procedures/
 Extraneous movement tests and procedures. prognosis
 Sleeplessness > for correction and
 Urinary frequency > Identified coping improvement
skills the individual is
using currently > Helps client to
> provided accurate identify what is really
information about the based
situation. Oriented pt.
about time, date and
place > To provide support
> Provided physical > To relieve anxiety by
contact relieving tension
> Encouraged the
patient to do
diversional activities > To provide support
like socialization

> Stayed with patient > To reduced stimuli

maintaining a calm,
confident manner > Helps client to relax
> Provided non
threatening, consistent
environment
> Administered anti
anxiety medications.
Diazepam 5 mg/tab, 1
tab OD as ordered.
PATHOPHYSIOLOGY OF ACUTE MYOCARDIAL INFARCTION

Predisposing Factors Precipitating Factors

>Gender: male >Lifestyle
>Age: 40-70 -High Fat and sugar intake
>Genetics - Smoking
>Race

↑ deposition of blood cholesterol in the arteries +

deposition of fibrous proteins, complex carbohydrates
products & calcium
 Lipid streaks attracts Low-density protein

Smooth muscle cells enter intima & attach

S. muscle produce collagen, with muscle cells

& lipids form PLAQUES

Small Blood vessels grow into the

plaque

Rupture of small blood

vessels

Bleeding/ hemorrhage
a Through sear tissue formationFurther enlargement of
& fibrosis plague
↑size plaque a

Thrombus formation Narrowing of artery lumen

Rupture of ↑ Blood flow ↓ Blood supply to the myocardial

thrombus resistance

Embolism
Stimulation of sympathetic
NervousMyocardial
System cell death
↓ O2 supply to the heart tissue/ O2 starvation of heart tissue Substernal/precordial pain radiating to
CHEST PAIN & tightness or the back/shoulder jaw or down left arm
↑ ANGINA
d acidPECTORIS
Lactic
Dyspnea production c
Myocardial
AnaerobicIschemia b
glycolysisVenricular atrophy
 d
c
b

Afterload ↑ HR ↑ Myocardial O2
Consumption

Vasoconstriction/↑
BP

>Dyspnea on exertion
>Ventricular hypertrophy Substernal pressure

Acute Myocardial Infraction

Circumflex branch > Tachycardia, palpitations, Vomiting,
of left coronary Hiccoughs, Weakness, Nausea, Fatigue in
Lateral wall Anterior descending
Inadequate
Anteriortissue
branch
wall of Left Severe pulmonary
Posterior/ inferiorAcute
wall infraction
pulmonary
artery ↓ Cardiac arms & legs
Output hypovolemic
↓ Plasma Pressure Renal Hypoxia
Right coronaryOliguria
artery
infraction e coronary perfusion
artery
infraction congestion edema f
 e

Myocardial necrosis/ destruction of

myocardial tissue

Inflammatory process
> low-grade fever accompanied by
leukocytosis, elevated f
sedimentation rate, LDH & AST

↓ stoke volume & ↑ residual

volumeCHF
Inadequate bloodsided)
(left/ right to meet Anoxia
DEATH
metabolic needs of the body