Non-ST Elevation Myocardial Infarction - Case Study Example

SЕ STUDY RЕРОRT: NОN SТ ЕLЕVАTIОN МYОСАRDIАL INFАRСTIОN (NSТEМI) Name Institution Instructor Date Introduction The patient is a sixty years old male with the origin of Causia. He is divorced and lives with the younger of his two sons. He is currently retired with an education background of up to third year in high school. He is a Christian by faith and engages in gardening as a social activity. He is alcoholic and a smoker who does not use tobacco but smokes cannabis on a daily basis. He does walking exercises but has got a poor dietary pattern with only two meals a day. He is stressed by financial and financial issues and is on Oxycontin (Oxycodone Hydrochloride) prescribed chronic back pain medication. The content of this document basically issues a report on the analysis of the data that is obtained from the patient assessment with regard to the Non ST elevation Myocardial Infarction [NSTEMI] condition. The report further contains the discussion and analysis of the clinical elements presented case study of the condition of the patient. It is in the content of this report that that the signs and symptoms of that re associated with the Non ST elevation Myocardial Infarction [NSTEMI] illness are identified, presented and interpreted with regard to pathophysiology. Analysis of clinical presentation elements The signs and symptoms that are associated with the Non ST elevation Myocardial Infarction [NSTEMI] illness are usually noticed and identified gradually and they are never instantaneous. The most common symptom of this particular illness is the presence of pain in the chest. The chest pain is usually noticed as feeling of squeezing, pressure of tightness in the chest. It kind of feeling in the chest basically results from inadequate blood supply and therefore inadequate supply of oxygen as well to the muscles of the heart. The pain experienced in this case is mostly felt through the arm on the left hand side, but there are also possibilities that the pain could be felt towards the right arm as well, neck, lower jaw, epigastrium and also the back. There is also the presence of sign that is identified as the Levine’s sign where the pain in the chest is localized by the patient through the clenching action of their fist above the sternum (Colbert, 2010). This action of fist clenching is perceived to be a way of predicting the chest pain that is associated with the cardiac, although it has been shown through perspective observational studies that the positive value of prediction that is obtained from the process in very poor and therefore not reliable. Another symptom is that which is described as the breath shortness otherwise known as dyspnea which takes place when the damage that is caused to the heart causes limitation to the left ventricle output and therefore resulting into failure of the left ventricle and hence leads to a condition known as pulmonary edema. Other symptoms that are associated with Non ST elevation Myocardial Infarction [NSTEMI] illness includes a form of seating that is excessive and which is referred to as diaphoresis, a feeling of weakness in the body of the patient, nausea that is accompanied by vomiting, light headedness as well as palpitations (Abdulla, 2011). The symptoms that are experienced with regard to this illness have a likelihood of being induced by severe catecholamine surge from the nervous system that is sympathetic in nature and which takes place as a result of abnormalities related to hemodynamic occurrences and pain associated with the cardiac dysfunction. In cases of increased levels of severity of the illness loss of consciousness is experienced and this is as a result of cardiogenic shock and inadequacy in cerebral perfusion sudden death could eventually occur in most case as a result of the occurrence of ventricular fibrillation mainly in infractions of myocardial. Elderly female patients who suffer from diabetics more frequently experience symptoms that are typical in comparison to male patients who are younger in age. Women also experience a lot of symptoms in comparison to their male counterparts. Statistics based on research have been able to show that on average about 2.5 symptoms are experienced by women compared to about 1.7 symptoms experienced by men (Bowden and Sinatra, 2012). The symptom that is however commonly experienced by women includes the shortness of breath, fatigue and weakness. Sleep disturbance, fatigue and shortness of breath are the symptoms that have been found to be common and may take up to a one month to manifest. The chest pain sign is mostly experienced by men than it is with women. However the jaw or back pain is most likely experienced by women during an episode as a sign associated with this illness. At least one out of four cases of Non ST elevation Myocardial Infarction [NSTEMI] illness goes unnoticed with no pains experienced at all and no symptoms either. The illness can however be discovered at a later date through the use of electrocardiograms which involve tests of blood enzymes or it can also be discovered through autopsy with no prior history that is associated with any complaints. The estimation with regard to the prevalence of Non ST elevation Myocardial Infarction [NSTEMI] illness varies in the range of 23 and 65 percent. A quiet course is commonly experienced by the elderly patients who suffer from diabetes mellitus (Cannon and Vierck, 2009). This is probably the case because the diabetes patients usually are affected by factors such as autonomic neuropathy, the threshold of pain as well as the psychological conditions which explain why these patients do not experience any symptoms at all. Clinical reasoning in prioritized plan of care for NSTEMI illness The prioritized plan for care of the Non ST elevation Myocardial Infarction [NSTEMI] illness for patients is performed with standard goals. Some of these standard goals and objectives are associated with the elimination of breathing difficulties and preventing adverse cases of the illness condition such as recurrent ischemia or even death. The strong point of long term as well as short term medical plans in all the involved cases of symptoms as observed is prioritized to include the prescription of anticoagulant and antiplatelet medication. The medication is meant for the antiplatelet function by causing the aggregation of platelets to decrease and prevent the formation of thrombus. The antiplatelet therapy in the prioritized plan clinical care towards the NSTEMI and is carried out as a long term planning initiative especially during hospitalization as also as a management strategy. This is believed to aid in the reduction of cardiovascular events that may be seen to take place in the future that are associated with the illness (Wyszynski, Correa-villaseñor and Graham, 2010). Anticoagulant clinical care and medication are made to work through putting a stoppage to the clotting of blood. This is achieved by inhibiting or blocking thrombin or by setting up antagonism to the results of vitamin K. The process of making use of the traditional heparin or the anticoagulants is a standardized clinical care for the patients suffering from NSTEMI and there has not been any development of that is aimed at improving the results or brings about risks of bleeding in a manner that is the same as heparin. Current guidelines with regard to prioritized planning for the clinical care of the NSTEMI illness are focused on the recommendation of a quick process of angiograph which should then be followed by quick opening of coronary artery in order to ensure a restoration of flow in the coronary. This kind of planned strategy has been proven to play major role in the reduction of mortality that is experienced as a result of the illness (Mirchandani, 2011). Integration of management across nursing and inter professionals The integration of management across nursing as well as inter professional with regard to the Non ST elevation Myocardial Infarction [NSTEMI] illness involves to a larger extent the performance of the requirements of the interdisciplinary management. The integration of interdisciplinary management in this case involves element sand components such as physiotherapy which involves activities like the teaching and encouraging of patients to participate in the exercises that assist in enhancing their deep breathing functionality. Patients in this case are also properly educated on the importance and how to make use of inhalers. The other thing that takes place under the physiotherapy element of inter professional management across nursing is the pre bronchodilators as well as post bronchodilators spirometry examinations that are carried out basically to analyze and evaluate the risks that are associated with the level of severity of illness. Integration of management across inter professional sand nursing has also got the component of social workers under which the patients involved are subject to a continued depression episode that is communicated by themselves (Acs, Bánhidy and Czeizel, 2010). In the case of social work with regard to the patient in the case study under consideration, the patient is going through a series of conflicts with his younger son who is who is under his care and responsibility. This kind of a situation has got adverse impact on the already deteriorated health of the patient due to the fact that he experiences depression, stress and worries as a result this nature of social life. It is also clear that the patient requires with regard to solving the problems he experiences that are associated with alcohol and drug abuse. As part of social life and work management, the patient is also in need of a lot of assistance and support in managing the manner in which his son aggressively behaves towards him. This is especially so because he has not been able to take any necessary steps in reporting the matter to the necessary authorities for prompt action. This could be professionally managed by involving the social workers to communicate with his son probably on phone and try to establish the real cause of trouble between the patient and his son before embarking on resolving the ongoing problems and issues in the family that are leading the patient turn to the misuse of drug and alcohol. The other element under the integration of management with reference to the patient’s case study is the discharge planning which should involve appropriate plans and arrangements for the patient to be attending a cardiac center of rehabilitation to help restore the situation back to normal (Cannon and Vierck, 2009). The other way of discharging planning could be through referring the patient to a nurse in the community to make special follow ups on his health generally and particularly the issues to do with his misuse of alcohol and drugs. In the cardiac rehabilitation, the patients it expected to attend the sessions at the rehabilitation center following his discharge his diagnosed medical condition which is the Non St elevation MI, NSTEMI Pharmacology application The pharmacology application in with regard to the NSTEMI condition with which the patient is diagnosed basically involves the appropriateness of medication as well as the as well as both the identification and management of alternative pharmacology. For the patients diagnosed with NSTEMI there are certain medications that are appropriate and some of these include the antiplatelet agents which are recommended to the patients even though it is only considered in the absence of complications. Medications are also appropriate especially with consideration of the situation of the patient in the case study who is put on medication both at home as well as at the hospital admission. Medication essentially reduces the severity of the illness and when administered at early stages it plays a significant role in completely eradicating the signs and symptoms associated with the illness. The appropriateness of medication is determined through factors such as the ones that cause the pro drugs to become less ideal through the biotransformation into metabolites that are active (Cannon and Vierck, 2009). Similarly the management of alternative pharmacology involves the introduction of anticoagulant agents as which are applied in the management of the patients and this include the unfractionated heparin (UFH) which is subcutaneously administered on a daily basis with the requirement of frequent blood monitoring. The patients suffering from NSTEMI have been continually involved in a debate for the last one decade with regard to whether early or immediate revascularization and angiography is of more benefits in comparison to an a approach that is more selective invasive or conservative. It is recommended as a planned clinical care guideline that the process of assessing risks associated with bleeding and ischemic with the use of risk score that are validated in each patient individually in order to make decisions regarding the invasive as well as the pharmacological management is a an important initiative. It is further suggested from the prioritized care guidelines that immediate or urgent transfer of patients undergoing treatment should be carried out on the basis of the symptoms and signs of ischemia in patients who are suffering from hemodynamic or electric instability. A previous management of clinical care in patient with a high risk of contracting the NSTEMI is widely recommended. This is done in consideration of features of higher risk which include the myocardial necrosis evidence which brings about elevations in troponin as well continuous myocardial ischemia having ST-segment changes that are dynamic n nature. The controlled randomized trials have been seen to under represent elderly patients as well as female patients but despite of that, they are believed to be faced with higher risks of complications that are procedural. The evidence that is available has suggested that following the stratification of appropriate risks, the benefits that are associated with the early management of inversion is distrusted among all other subgroups (Abdulla, 2011). Conclusion In conclusion it is demonstrated from the analysis of the Non ST elevation Myocardial Infarction [NSTEMI] illness case study report on the basis of patient information that in order appropriately address the illness, it is important to take into consideration certain elements. These elements involve the biographical data and nursing history of the patient, the assessment and analysis of the signs, symptoms as well as associated pains, the nursing management and also the appropriateness of pharmacology application. References ABDULLA, R.-I. (2011). Heart diseases in children: a pediatrician's guide. New York, Springer ÁCS, N., BÁNHIDY, F. G., & CZEIZEL, E. (2010). Congenital abnormalities and preterm birth related to maternal illnesses during pregnancy. Dordrecht, Springer. BOWDEN, J., & SINATRA, S. T. (2012). The great cholesterol myth why lowering your cholesterol won't prevent heart disease-- and the statin-free plan that will. Beverly, MA, Fair Winds Press. CANNON, C. P., & VIERCK, E. (2009). The new heart disease handbook everything you need to know to effectively reverse and manage heart disease. Beverly, Mass, Fair Winds Press. COLBERT, D. (2010). The new bible cure for heart disease. Lake Mary, Fla, Siloam. MIRCHANDANI, D. (2011). Healing heart disease naturally holistic techniques for total well-being. New Delhi, Pustak Mahal WYSZYNSKI, D. F., CORREA-VILLASEÑOR, A., & GRAHAM, T. P. (2010). Congenital heart defects: from origin to treatment. Oxford, Oxford University Press. Appendices Appendix 1: Patient assessment data Biographical Data/Nursing History: Pseudonym: Mr. Johnny. Age: 60years. Sex: Male. Ethnicity:Caucasian Education: finished high school 3rd year. Occupation: retired. Social Activities: Gardening. Religion/Spiritual: Church of England. Marital Status: divorced. Family/relationships: Have two sons and live with the younger one. Roles/Responsibilities: Look after the younger son and taking care of the house. Self-concept: stressed out and depressed for not fulfilling his role as a father and a guardian to his younger son. Personal/Financial Stressors: His younger son stresses and worries him too much; in addition to some financial worries. Housing: Owned a stone built house. The closest town is 20 Km away. Substance Use: * Alcohol: history of alcohol abuse, currently 6-8 cans of scotch and coke. * Cigarettes: Not smoking Tobacco. *Other Drugs: 6x cones of cannabis daily. Sleep Patterns: Interrupted and waking up tired. Exercise Patterns: good walk every day approximately 40 min. Dietary Patterns: poor appetite, often skipping breakfast and having 2 meals a day with little food on them. Medications: • Normally on Oxycontin (Oxycodone Hydrochloride) 40mg twice a day prescribed for his chronic back pain. Elimination Patterns: regular but sometimes constipated due to the use of opioids for his chronic back pain. Allergies: nil known. Past Medical History: 1. Bowel obstruction laparotomy done when he was two days old. 2. Chronic back pain due to car accident 12years ago. 3. Chronic airway limitation (COPD) 4. IV drug user 5. Tetrahydrocannabinol (THC) user. Family History: • There is no significant or chronic illness or diseases in the family history that the patient is aware of except for his grandmother who died at home after having stroke. Presenting Problem/s: 1. Chest pain (diagnosed as Non ST elevation Myocardial Infarction [NSTEMI] evident by positive troponin test) 2. ? Extended period of confusion 3. ? seizure episode at home Pain assessment: The patient has chronic back pain and acute chest pain when he was admitted to emergency department. 1. The chronic back pain assessment: Patient have chronic back pain due to the car accident he had 12years ago Precipitated by bending and heavy activities, patient stated “ I stay on bed for 2 to 3 days if the pain start to increase due to done heavy activities and the medication will not work if that happened” The patient described the pain as continues dull or aching pain. On admission, back pain was not noticed because the patient had greater pain in his chest. At time of assessment, pain 2/10 The pain originated from the sacral area and shooting down to both legs with little numbness. 2. The acute chest pain assessment: Patient had acute chest pain due to low blood perfusion in the heart muscle (NSTMI). Precipitated by heavy activities and emotional stress, patient stated “ I heard my son broke the bathroom and I started to feel chest pain like the day I was admitted” The pain had compression quality. Patient reported that it felt like ‘something compressing and pushing down over my chest’ Pain originated in the chest, but radiated towards the right and left shoulders. Pain 8/10 on admission but at the time of assessment was 1/10 only. Mental Status Appearance and Behaviour: calm, quiet, relaxed and cooperative; however, he looks unkept and untidy, uncombed long scalp hair and long facial hair (unshaved for long time). Speech: clear and continuous with normal volume and rate. Mood: appropriate. Judgment: good and positive Thought: Normal and coherent. Perception: clear and normal. Cognition: alert and orientated Insight: depressed and stressed. Risk assessment: 1. Increase alcohol intake. 2. Increased drug and THC use. 3. Potential for recurrent chest pain and heart problems. 4. Ongoing emotional, psychological, psychosocial and financial issues. 5. Tendency to develop depression and isolation 6. Prone to develop constipation episodes. 7. Risk of drug overdose and toxicity. Vital signs: Temp: 37.2Co. BP: 120/60. SaO2: 93% on room air and 98% on 3L O2 via nasal cannula. Pulse Rate: 70/min Resp Rate: 18/min. Weight: 68.6 kgm. Height: 1.79 m. BMI: 19 (low). Neurological assessment: Face: symmetrical, full range of facial expressions (frowning, smiling, puffing out cheeks, raising eyebrows), no lesions noted in the face. Eyes: nil jaundice or reddens noted, pupils-size 2-equal and reactive to light, extraocular movements normal and full range evident. Wears reading glasses. Nose: airways clear, nil deviation or lesions noted, both nostrils patent, nil smelling problems reported. Ears: nil blockages noted, equal bilateral hearing. Mouth: Tongue strength equal and gag reflex present. Mucosa and gums moist and stained, teeth-several missing, only 7 teeth on the lower gum with cavities and evidence of poor oral hygiene, he reported nil problems with taste sensation. Lymph glands non palpable and no abnormalities detected on the thyroid gland site. Tempero-mandibular joint normal GCS: 15 (eyes open spontaneously, oriented to person, place and time, obeys commands) Balance, gross motor and fine motor movements: nil abnormalities noted despite the injury from the car accident. Gait: patient had normal gait and movements. Cardiovascular assessment: Colour: face and peripheries with normal colour Pulses: equally strong, bounding pulses bilaterally Apical pulse- normal rhythm and sounds. Apical and radial pulses congruent in timing Capillary refill less than three seconds in all assessable extremities. Blood pressure: with in normal ranges No oedema noticed in any part of the body. Respiratory assessment: Regular rate, rhythm of respirations. Deep respiration but not using any accessory muscles or tracheal tug noted Patient feels distressed if he lie flat for a long period of time. Saturating at 93% on room air and 98% on 3L O2 via nasal cannula. Bilateral air entry in upper lobes of lungs but minimized and wheezing sounds on lower lobes on auscultation Normal resonance over the top lobes of the lungs; however, Hyper-resonance on both lower lobes on percussion. Nil nodules, tactile fremitus or other abnormalities noted on palpation Sputum production with frequent rough cough evident-possibly related to history of COPD. Abdominal/gastrointestinal assessment: On inspection, nil distension noted in abdomen. Laparotomy scars noted in the umbilical. Normal bowel sound present in all four quadrants. Dense and dull sounds upon percussing the right hypochondriac area in the liver site. Palpation: tenderness noted in umbilical regions where the laparotomy scar located and on right upper quadrant when palpating the edge of the liver. Deep palpation on the not attended due to presence of pain on gentle palpation. Spline is not palpable. Integumentary assessment: Tattoos on the right arm and on the back. Over all warm and dry skin with decreased turgor Nil oedema noted Thick gray hair. Stained and smooth nails.   Musculoskeletal assessment: Full range of motion in joints despite history of joint injury. Does experience some pain in the back during lifting and heavy activities Bilaterally equal force, resistance and gravity Nil atrophy, nodules, crepitus, heat or tenderness All sensations functional Elimination assessment: Patient reported constipation sometimes due to the use of opioids for his chronic pain and also his low food intake. Nil abnormalities reported regarding Voiding. Urinalysis attended: Colour: yellow, Clarity: clear and watery, Specific gravity: 1.015, pH: 7.5, Blood: negative, Leukocytes: negative, Ketones: negative, Glucose: negative, Nitrite: negative, Proteins: negative, Urobilinogen: 2.0 E.U/dl, Bilirubin: negative. Interdisciplinary management: 1. Physiotherapy: Encourage and teach the patient deep breathing exercises. Educate the patient about the use of inhalers Pre and post bronchodilators Spirometry test done to assess the level of COPD risks. 2. Social workers: Patient has an ongoing episode of depression as stated by him. Have an ongoing conflicts with his younger son which psychological impacts on his health such as worries, stress and depression Patient needs a lot of support on his drug and alcohol abuse issues. Patient need more support in the management of his son aggressive behaviours towards him because he does not want to report the domestic violence to the authorities. Social workers going to phone and talk to the son for further information about him and the patient to resolve the ongoing family issue and advocating him to seek help for his drug misuse. 3. Discharge planning: Appointment will be arranged for the patient to attend cardiac rehabilitation centre. Referred to the community nurse to follow up his general health, drug and alcohol misuse issues. 4. Cardiac rehabilitation: Patient will have to attend cardiac rehabilitation sessions after discharge due to his medical diagnosis (Non St elevation MI, NSTEMI). Diagnostics: a) Pathology results: 1. Haematology. Full blood count include: Haemoglobin: 162 g/L White cells: 12.0 109/L (H) Platelets: 248 109/L Red cell count: 4.85 1012/L Haematocrit: 0.474 L/L MCV: 97.8 fl MCH: 33.3 pg (H) MCHC: 341 g/l RDW: 14.5 % Neutrophils: 8.0 109/L (H) Lymphocytes: 1.9 109/L Monocytes: 1.7 109/L (H) Eosinophils: 0.4 109/L Basophils: 0.1 109/L 2. Blood biochemistry include: Sodium: 138 mmol/L Potassium: 3.7 mmol/L Chloride: 99 mmol/L (L) Bicarb: 30 mmol/L Urea: 4.0 mmol/L Creatinine: 53 umol/L (L) GFR Est. : >90 mL/min Anion Gap: 13 mmol/L Calcium: 2.32 mmol/L Phosphate: 1.10 mmol/L T.Protein: 69 g/L Albumin: 36 g/L Calc. Glob: 33g/L Total bilirubin: 33 umol/L (H) GGT: 17 U/L Alk. Phos.: 88 U/L ALT: 21 U/L AST: 44 U/L (H) LD 170 U/L Creatine Kinase: 195 U/L (H) Glucose: 6.4 mmol/L Lactate: 1.3 mmol/L Fasting Cholesterol: 3.9 mmol/L Fasting Triglycerides: 0.95 mmol/L Fasting LDL – Cholesterols: 2.49 mmol/L Fasting HDL – Cholesterols: 0.98 mmol/L Fasting Total/HDL Ratio: 4.0 Troponin: Troponin I (Tam, Arm): 0.45 ng/mL (H) Troponin I (iStat): 0.64 ng/mL (H) Troponin comments: healthy subject: 0.10 ng/mL TnI is strongly recommended after 8 hours from the onset of chest pain to assess its nature. 3. Arterial blood gases: on room air findings: pH: 7.502 pCo2: 42.4 pO2: 51 BE: 10 HCO3: 33.2 TCO2: 35 sO2: 89% Na: 140 K: 3.2 Hct: 0.49 Hb: 167 4. Microbiology studies: Nasal and Perianal swabs for MRSA: Negative. 5. CT Brain with Contrast: Findings: No evidence of abnormal enhancement pattern. No hydrocephalus. Normal CT scan of the brain with no evidence of cerebral abscess. 6. Chest X-Ray: Finding: white shadow patches all over the lungs confirming COPD and heavy smoking habits. 7. Electrocardiogram studies (ECG): Finding include: Sinus rhythm. Rate: 55 Prolonged QT intervals = 547 Left axis deviation. Inferior wall infarction = T wave inverted in lead II, III and aVF Lateral leads ST-T abnormality may due to myocardial ischemia. Early medical diagnosis: Non ST Elevation Myocardial infarction. Medications: a) At home: 1. Oxycontin 40mg tab BID. 2. Salbutamol 5mg inhaler QID and PRN b) At the hospital admission: 1. Metaprolol 12.5mg tab BID 2. Oxycontin 40mg tab BID 3. Nicotine Patches 21mg daily 4. Diazepam 2mg tab BID 5. Clexan S/c 40u daily 6. Aspirin 80mg tab daily 7. Clopidogrel 75mg tab daily 8. Spiriva 18mg inhaler daily 9. Seretide 250/25 inhaler two buffs BID 10. GTN 300mcg tab SL PRN 11. Morphine 5mg S/c PRN 12. Metoclopramide 10mg tab PRN 13. Diazepam 5mg tab PRN Medical diagnosis and findings: 1. NSTEMI, bradycardia 2. COPD 3. ? cerebrovascular disease 4. Substance withdrawal Read More