Nursing case study

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Case studies are employed in the medical field to teach students and nurses. Case studies are supposed to stimulate the thinking of the trainee without significantly increasing their workload. A case study may serve several purposes since it covers all aspects of clinical practice. It is a good way to determine the decision-making ability of the student. Good case studies should be informative. This paper shall focus on one medical case about myocardial infarction. The patient is a 57-year old male who presented to the emergency department with a chest problem. The patient is quickly assessed to determine the problem. The history is taken. The patient’s name is Chris. Chris states that pain began about half an hour after dinner while he was playing with his kids. Chris describes the pain as a crushing pressure that is located midsternally and radiates to his left arm and to the back. When asked to rate the pain on the scale, he gives it a 4/10. The patient reports that he is finding it difficult to breath (SOB). On assessment, the patient is diaphoretic and pale. The doctor suspects myocardial infarction but recommends further check-ups to rule out angina, heart failure, and other lying conditions.

The tests are performed by a nurse. There are several tests that are conducted such as heart sounds, vital signs, lung sounds, pulse, signs of edema, and skin condition. MI happens when blood flow to a segment of the myocardium ceases or decreases. It results in necrosis of the heart. MI is a common presentation of CAD. About 13% of the world population died from ischemic heart disease in 2016. Most of these deaths occur in developed countries (Thygesen et al., 2019). The disease is common among wealthy people who tend to do less physical exercises. Tissue death occurs due to ischemia when the section of the heart does not receive oxygen and nutrients. Troponin is a specific marker of MI useful in diagnosis. Troponin rises within three hours of a tissue injury peaking in 1-2 days. The electrocardiogram is a useful standard procedure in the diagnosis of MI. The ECG is used by clinicians to differentiate between the two types of MI. The two types are ST-elevation MI and non-ST elevation MI. STEMIs form the least prevalent of the three types. The STEMI occurs in 25-40% of MI patients. The current guidelines have categorized myocardial infarction into five types (Reed, Rossi & Cannon, 2017).

The most predominant source of MI is atherosclerosis. Atherosclerosis occurs when a plaque on a coronary artery ruptures, leading to clot formation which further blocks the artery. Myocardial infarction proceeds in minutes. MI may also arise when the heart has limited blood supply as a result of increased oxygen demand by the rest of the body (Anderson & Morrow, 2017). Conditions such as hyperthyroidism, anemia, coronary artery spasms, and PCI failure predispose the person to MI. The risk factors for MI include the following: old age, active smoking, hypertension, diabetes mellitus, and total cholesterol. Several of these risks factors are shared with CAD. The other causes include low physical activity, past family history of MI, obesity, and alcohol consumption. Men are more predisposed to MI than women.

The patient reported that his father had died of CAD and that his aunt was currently on treatment for diabetes mellitus. Chris is a rare visitor to the hospital. Chris reports that he underwent a medical checkup the previous year, where the doctor recommended that he start doing physical activity. Chris had a high BMI, high LDL, and high total cholesterol. He says that he has not been following the doctor’s recommendations because he does not get time. As part of the empirical therapy, Chris was put on oxygen. His medical check-up report came back and the following were observed. There was no jugular vein distention. Chris had normal S1 and S2 sounds, the lungs were clear with scattered wheezes on auscultations. The vital signs also came and were as follows: the BP was 140/91, SpO2 90%, HR 93bpm, regular Ht 174cm, RR 33bpm, 110kg, and the temp was 37.0 C. Chris’s 12-lead EKG report reads as follows: “a regular sinus rhythm with repeated PVCs and three to four-beat runs of ventricular tachycardia”. ST-segment elevation in leads 1, aVL, and V2 through V6. The cardiac function tests were done but the results are yet to be available. The chest x-ray was also ordered. The doctor prescribes Aspirin 324mg PO, nitroglycerin 0.4 mg SL q5min TDS, morphine 4mg IVP when needed for the chest pain, and Oxygen to maintain the SpO2 above 92%. Statins were recommended but were to be used after discharge (Anderson & Morrow, 2017).

As the nurse in charge, it is important to immediately put this patient on oxygen therapy. Oxygen improves oxygenation and decreases myocardial oxygen demands. When the medications are availed, put the patient on nitroglycerin and aspirin. Nitroglycerin is a potent coronary vasodilator that increases blood flow to the heart muscle. However, the medication may be ineffective for MI patients and this may prompt substitution. Aspirin serves as an anticoagulant and thus decreases mortality (Anderson & Morrow, 2017).

The nurse needs to monitor the patient. Mr. Chris was still in pain after the three doses of sublingual NTG and the nurse put him on morphine 5mg and baby aspirin. However, the pain was still persistent and required further interventions. The cardiac enzymes were as follows: CK 255U/L, CK-MB 10%, troponin I 3.5ng/mL. The nurse reports to the physician who recommends a PCI. The PCI helps to relieve blockage (Reed, Rossi & Cannon, 2017). Four hours after the PCI, Mr, Chris states that he does not feel any chest pain. His vital signs have also improved. The nurse needs to advise the patient to change their lifestyle. The nurse should set targets with the patient. Advice the patient on the diet, the importance of exercise, and reduce caffeine intake. Advice the patient of the importance of compliance. The patient should seek medical attention when symptoms exacerbate.

References

Anderson, J. L., & Morrow, D. A. (2017). Acute myocardial infarction. New England Journal of Medicine, 376(21), 2053-2064.

Reed, G. W., Rossi, J. E., & Cannon, C. P. (2017). Acute myocardial infarction. The Lancet, 389(10065), 197-210.

Thygesen, K., Alpert, J. S., Jaffe, A. S., Chaitman, B. R., Bax, J. J., Morrow, D. A., … & Bucciarelli-Ducci, C. (2019). Fourth universal definition of myocardial infarction (2018). European heart journal, 40(3), 237-269.