The Researcher presents to you a case study regarding a cardiac problem associated with Type II Diabetes Mellitus. Both are major diseases found in most parts of the world. This paper will discuss about a client who is diagnosed with ST Elevation Myocardial Infarction (STEMI).To begin with Myocardial Infarction which in simple terms is known as Heart-attack. It occurs when an area of the heart muscle is damaged or dies because a coronary artery has been blocked and the oxygen rich blood supply to that area of the heart has been drastically reduced. The damaged muscle tissue of the heart is replaced with scar tissue, which affects the hearts future performance. Brown & Edwards (2005).states that "A Myocardial Infarction occurs as a result of sustained ischeamia, causing irreversible cellular death". Cardiac cells can withstand ischaemic conditions for approximately 20 minutes before necrosis begins. Diabetes Mellitus is widely recognized as being perhaps the most significant risk factor for the above. The relation between diabetes and acute coronary thrombosis is multifactorial; with the interaction of plaque disruption. Patients with diabetes demonstrate enhanced platelet aggregation that correlates cardiovascular events. (Valentin, R.Wayne, &Robert, 2004 p 2101) This paper deals with the preventative intervention for the individual patient.
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This case study is about Mr.B who is a forty nine years old Indian male who was admitted in coronary care unit in Labasa Hospital, Fiji Islands on 21/04/2011.The above presented in accident and emergency department with complaints of Left sided chest pain radiating to left arm Profuse sweating with epigastric pain, burning in nature. According to patient he came back from gardening when he developed severe chest pain associated with sweating and radiation to left arm. Pain was heavy in nature. Upon taking the history of patient's condition, the clients' wife informed us that patient has been having chest pain on and off for a while, especially working in farm but did not come to hospital for treatment. Had similar chest pain at 10 am in the morning which settled after one hour. Patient is married and has three children. Farmer by profession. Has never smoked nor consumed alcohol. Not a known case of hypertension nor Myocardial Infarction but has Diabetes for three years now, was not booked for clinic, was on diet control. About fifteen years before he developed facial weakness, fortunately it improved. Currently not on any medications. Nil known allergies. While asking about the sexual history, patient remained quiet due to cultural barriers. Positive family history of Ischaemic Heart Disease and Diabetes. Father had diabetes while mother had Ischaemic Heart Disease.
Review of systems was done quickely since patient was in pain and distressed in Accident and Emergency Department. Vital signs taken as follows: Blood pressure of 141/88MmHg, Pulse rate of 97 beat per minute, Respiration rate of 25breaths per minute. Oxygen saturation of 80% in room air. Random Blood Sugar of 19.3 mmol/l.
Temperature of 36 degrees Celsius. Patient was given six litres of oxygen via Hudsons mask. One GNT tablet given sublingually, 30mls of MMT, 3OOmg of oral Ranitidine and Aspirin was given stat. Pain not relieved and patient got restless so Morphine 2.5mg together with 10mg of maxlone given intravenously. Investigations that were done as follows: Full Blood count, Urea & Electrolytes, Random blood sugar, Lipid profile, and cardiac enzyme. Chest x-ray and electrocardiogram was also done to make diagnosis easier. The above patient was seen by Medical Registrar and diagnosed as Acute Anterior ST Elevation Myocardial Infarction together with Diabetes. Patient was transferred to coronary care unit for further management.
Patient was made comfortable in bed and ward layout was explained to allay anxiety. Coronary care protocols were also explained to patient. Health history is the first step of patient assessment. Health assessment is an integral component of nursing and is the basis of nursing process. Estes (2002, p 7) states "assessment is the first step of the nursing process." " Assessments are used to plan, implement, and evaluate teaching and care in order to promote and optimal level of health through interventions to prevent illness, restore health, and facilitate coping with disabilities death"(Taylor,Lillo,Lemone .2005 p 561).
In this assignment I have done a history taking and physical assessment on a patient with a cardiovascular disease. The purpose of the cardiovascular examination is to access the organs and structures of the cardiovascular system. The preparation that I did before starting the cardiac assessment was handwashing.It is done before equipment preparation and examination to reduce the transmission of micro-organisms. The equipments used were, stethoscope and electrocardiogram machine. It was made sure that the equipments were in good working condition. Physical examination requires privacy. Curtains were screened. A room with adequate light, warmth and quiet environment was prepared.
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On examination Patient is a forty eight year old Indian male, medium built weighing eighty kilograms with a height of six feet and two inches. In general appearance Mr. B has brown skin with no skin lesions, warmth and sweaty upon touch. Slight cyanosis seen on nail beds. Oral mucosa moist. All pulses felt. Capillary refill is slightly more than two seconds, nil pallor, and nil jaundice seen. Good auditory senses. Visual acuity for both eyes is good. Nil physical deformity. Nil pedal oedema seen in both extremities. Central nervous system: the head is normocephalic and symmetrical. Skull is smooth, non tender, without masses or depressions. Patient is oriented to time, place and people. Speech is clear and understandable. Muscle tone and strength normal with smooth gait and symmetrical body movements. Power of 5/5 in upper and lower extremities. No apparent ordor from patient. Slight headache and feeling of nausea. Nil Lymphadenitis.
Cardiovascular system: Vital signs as follows. BP of 130/80MmHg, Pulse Rate of 90 b/min .Pulse is of good volume and regular but tachycardiac.The pulses on both sides of the patients body was palpated simultaneously with the exception of carotid pulse. .Assessment of the pericardium (the area on the anterior surface of the body overlying the heart, great vessels, pericardium, and some pulmonary tissue) and assessment of the periphery was done. Inspection, palpation and auscultation were performed in a systematic manner, using certain cardiac landmarks.
Inspection of the Jugular Venous Pressure (JVP) done as patient was in a supine position with head elevated to 45 degrees angle. JVP reading was less than 4 centimeter which was normal. Peripheral arterial pulses were palpated systematically with the use of the cephalocaudal approach in the following sequence: carotid, brachial, radical, femoral, popliteal, posterior tibial, and dorsalis pedis.The above pulses were normal and in good volume. The third most important examination was auscultation of heart sounds.
Auscultation of heart sounds enables a nurse to establish baseline data for identifying current and future cardiac problems that require nursing intervention. (Medical Surgical Nursing. Pg 1079). Stethoscope was placed on the Aortic, Pulmonic, Erbs point, Tricuspid and mitral areas to listen to the heart sounds from base to apex of the heart.S1 S2 normal. Nil murmur heard. Chest- clear lung fields with fine creps anteriorly. Electrocardiography report was obtained which showed sinus rhythm of 90b/min with T wave inversion in leads I, AVL, V5 to V6 and ST elevation in V1 to V3. Respiratory system: R/Rate of 20 b/min. The normal depth of inspiration is non exaggerated and effortless. SpO2 98% with 5litres of oxygen via hudsons mask. Gastrointestinal Tract: Abdomen soft and non tender. Nil palpable masses. Bowel sounds present. Nil problems in defecating. Genitourinary tract: Passing good amount of urine, slightly concentrated, 200mls in hour. Urea & Electrolyte Reports normal. Refer to appendix.
Diagnostic data which was done to support the clinical diagnosis were as follows: Chest x-ray showed cardiomegaly in left field blunting of costophrenic angles with patchy opacity. On admission electrocardiogram showing sinus rhythm with a heart rate of ninety beats per minute. T wave inversion in leads I, AVL, V5 to V6 and ST elevation in V1 to V3. Laboratory data was equally important as it showed abnormal values. Cardiac enzyme I, II, lipid profile, Full Blood Count, Urea & Electrolytes and coagulation profile was done. (Refer to appendix).The patients' clinical history, presenting symptoms, cardiac biomarker levels, and electrocardiographic results are all evaluated.
According to AJN cardiac biomarkers show injured Myocardial cells which release proteins and enzymes known as cardiac biomarkers in the blood. For the above patient cardiac enzymes, low density lipoprotein and serum cholesterol levels were all elevated.
These markers helped the researcher to determine whether the patient is having or has recently had an acute Myocardial Infarction.
Upon day one of admission in Coronary Care Unit, general condition of patient was critical since chest pain was persistent, squeezing in nature. Woods. L Susan (2005 p 229) suggested that pain control is a priority and the pain is usually treated with intravenous (IV) morphine. Pain also stimulates the autonomic nervous system and increases preload, which in turn increases myocardial oxygen demand.Mr.B, was given 2.5mg of IV Morphine together with 10mg of IV maxlone to alleviate pain, nausea and vomiting. Six litres of oxygen was given continuously through Hudson mask to maintain oxygen saturation of 98%.Oxygen is used to treat hypoxia. Black .M Joyce, Hawks Hokanson Jane, (2005) stated that "the heart requires a balance between oxygen supply and oxygen demand in order to function properly." It was made sure that patient had two large bore cannula in both hands for emergency purpose. Intravenous site was checked in each shift for inflammation, tissue infiltration. Patient was hooked on to cardiac monitor in order to monitor heart rate and the changes that might occur within twenty four hours.
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The head of the bed was elevated in forty five degrees angle so that the patient is comfortable and can breathe easily. According to Potter, Perry (2005 p 641) sitting erect promotes full ventilatory movement. Bed railings were put up on both sides to restrict movement and prevent accidents. Four hourly vital sign monitoring was done. Strict monitoring of fluid balance chart was done. Crisp, Taylor (2005 p 1115 ) suggested that " measuring and recording all liquid intake and output during a twenty four hour period is a vital part of the patients assessment database for fluid and electrolyte balance." This information helps maintain an ongoing evaluation of the patients' hydration status to prevent severe imbalances. Bedpan and urinal was given to patient to void and open bowel.Mr B was started on Heparin infusion as per CCU protocol after sighting the coagulation profile during admission.( refer to appendix ).50000 units of heparin was mixed in one litre of normal saline and titrated at 20mls/hr.Repeat bloods for prothrombin time (PT), Partial thromboplastin time (PTTK), Activated Partial Thromboplastin Time (aPTT) was done six hourly to see the coagulation profile.Mr B was also started on the following medication: Aspirin 150mg daily, Ranitidine 300mg nocte, Enalapril 2.5mg two times a day, Atrovastatin 40mg daily, Soluble insulin 5 units subcutaneously (sc) 3 times a day, Isophane 8 units sc at night. Random blood sugar was 19.3mmol/l.
Heparin Infusion was increased to 22mls/hr after 12 hours and 2,500 units of bolus heparin was given IV since PI was 107%, PTTK control 36seconds, test 42seconds.During transfusion chest pain subsided slowly and patient looked at ease. Tolerated half of the special meals served (low sodium, low fat Diabetic diet).After six hours repeat bloods was done by medical intern to compare the coagulation profile.PTTK 36 seconds so heparin infusion rate was increased to 24ml/hr and another 2,500 units of bolus heparin was given as per protocol.Ecg was done which showed ST elevation in leads V1 , V2 , V3 and q waves in V1- V3, AVL.( Refer to appendix ).Heparin infusion was continued for 24hours as per doctors order. The skin and mucous membranes was inspected for petechiea, ecchymoses, or hematomas.Also patient was monitored for hematuria, bleeding gums, and melena.Stock.N Yvome, Harroun. D Renae (2007 p 441) states "patient receiving full- dose heparin therapy should be monitored for hematocrit, platelet counts, APTT, and signs of bleeding." Mr. B did not develop any of the symptoms above.
Patient looked better on day two. Vital signs as follows: BP of 115/67, P/Rate of 73b/min, Temperature of 36.5 degrees Celsius, random blood sugar of 15.9mmol/l, SpO2 of 98% in room air. Patient lying comfortably in bed with neither nil complaints of chest pain nor shortness of breath. Upon auscultation chest is clear. S1S2 is normal with nil murmur.Ecg showing Q waves with STelevation in leads V1 to V5, T wave inversion in AVL. (Refer to appendix).Diagnosed as Acute Anterior STEMI with Diabetes Mellitus Type II .Reviewed by the medical consultant. Heparin infusion tapped off and beta blockers added that is tablet Atenolol 12.5mg daily. According to Woods.L Susan, Froelicher Sivarajan.S Erika et al., (2005) "Beta - Adregenic Blockers help reduce the workload of the heart, decrease Myocardial oxygen demand, and may decrease the number of anginal attacks."Mr.B was informed about his current condition and treatments given to him in order to allay anxiety and confusion.Counselled by dietitian regarding the amount of calories to be taken. Diet sheet was given to patient on how to maintain low salt and low fat diet since patient had elevated blood cholesterol of 5.9mmol/l .Attended by physiotherapist who educated patient on how to cope or continue with the daily activities of life.
On day three patient was much better. Nil complaints of chest pain nor shortness of breath. Vital signs were stable. BP of 110/70, P/ Rate of 70b/min, Temperature a febrile. Random blood sugar of 9.9mmol/l. ECG showed sinus rhythm with a heart rate of 74b/min with q wave formation in AVR, T wave inversion in AVL, ST elevation in V2 to V4. Patient alert sitting in bed. Upon auscultation chest is clear. Nil basal creps. S1S2 normal. Nil bipedal oedema.Insulin treatment was discontinued as blood glucose level was stabilizing.Glipizide tablet 5mg twice a day was added. Tolerating oral fluids and meals well. Passing good amount of urine but has not opened bowel since admission. Laxatives were given to patient orally to avoid constipation and to prevent straining that would create pressure on the heart.Mr.B was told that he can sit out of bed now and can do passive exercise. Patient was transferred to Men's Medical Ward on fourth day as general condition was stable. Electrocardiogram showed settling ST elevation in anterior leads with q wave formation.
Finally this paper summarizes about the client who suffered Anterior Myocardial ST elevation Infarction which was shown in precordial leads from V2 TO V4.The extent of injury to myocardial tissues in the anterior surface of the heart is improved but a scar still remains which will affect the future performance of the heart.Thrombolytic therapy was initiated with the use of Heparin which showed a positive outcome in patients condition.
( Fuster, Alexander,& O'Rourke, 2004 p 2097 ) suggests that, one of the strong risk factor for the development of coronary artery disease is Diabetes which accelerates the natural course of atherosclerosis in all groups of patients and involves a greater number of coronary vessels with more diffuse atherosclerotic lesions.