A 65-year-old male farmer presented with central chest pain, shoulder pain, vomiting, and shortness of breath and was diagnosed with a myocardial infarction (heart attack). He had a history of smoking 12 cigarettes per day for 20 years and drinking alcohol. Physical examination revealed an unhealthy general appearance with normal vital signs. Electrocardiogram and bloodwork confirmed the diagnosis. He was treated with oxygen, analgesics, antiplatelet/anticoagulant medications, and beta blockers. Nursing care involved monitoring, medication administration, dietary support, and health education on hygiene, diet, medication compliance and follow-up.

1. 2nd
Myocardial
infarction
(heart attack )
CASE PRESENTATION
ON
PRESENTED BY :-
MR. ROMAN BAJRANG
BASIC BS.C NURSING 2ND YEAR
RELIANCE INSTITUTE OF NURSING 1

2. BIODATA OF THE PATIENT
INTRODUCTION:- My patient name is Ram bahadur basyal age 65 year he is
admited in male word of with the complan of central chest pain , shoulder pain ,vomiting ,
shortness .
Name : Ram Bahadur Basyal
father / hasband Name:
Age:65 years
Sex: Male
Adress :
IPD.NO: 170210
OOD.NO: 100357
Bed no. : 05
Word no. : Male word
Hospital :
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Edited by :- MR. ROMAN BAJRANG

3. Reliance institute of nursing
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occupation : farmer
Education: 8th
Religion: Hindu
Marital status: Married
Dr. consultant :
Dr. dignosed :
Date of admission:
Admission of time:
Discharge of date :
Diagnosis: Myocardial Infarction ( heart attacke )
Chief complain: My patient chief complail is central chest pain , shoulder pain ,vomiting ,
shortness .
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4. Present health history :-
Medical history :- My patient no any present medical
history .
Surgical history :- There is no any significant history
of present surgery.
4

5. Past health history:-
Medical history :- My patient no any past medical
history .
Surgical history :- There is no any significant history
of past surgery.
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6. OPD Notes:- My patient mr. Ram Bahadur Basyal from he is 65 year
admitted in male word he is complain in opd in the complain of central chest pain , shoulder pain
,vomiting , shortness .
Examination :-
Temprature :- 98 f
Pulse:- 70b/m
Respiration:-24b/m
Blood pressure:-120/80mm/hg
Highet:-45kg.
Wegh:- 5.1 inch
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7. Family history
Name Age / Sex Relation Education Occupation Marital
status
Health status
1 . Ram
Bahadur Basyal
65/m self 8th farmer yes unhealthy
2.Rukhmani 55 / f wife 5th House wife yes healthy
3. Ajay
4.rameshwar
35/m
30 /m
Son
Son
12th
BA
Selmen
Electricion
No
No
Healthy
healthy
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8. Family tree :-
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9. Socio economic history:-
 Type of house: Pakka type
 No. of rooms: 4 rooms
 Kitchen : separate
 Type of drainage: open drainage
 Type of toilet used: water seal
 Sources of water: Hand pump and tap
 Type of fuel: wood and gas
 Adequate lighting: present
 Facilities available in surrounding: medical shops, schools available
 Monthly income: Rs 37000
 Bread winner : Self, Son
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Edited by :- MR. ROMAN BAJRANG

10. Personal history :-
 Smoking : Smoker, smoke 12 sticks per day from 20 years
 Alcohol: Alcoholic
 Food habbit: Mixed diet , 2-3 times a day
 Food allergy : not known
 Drug allergy: Not Known
 Bowel and Bladder: Regular
 Sleeping pattern: Disturbed due to hospitalization
 Hobbies: He likes to watch TV, listen radio
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Editedby:-MR.ROMANBAJRANG

11. Education & occupation :-
My patient is pass he is farmer family he is well
maintain .
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Edited by :- MR. ROMAN BAJRANG

12. Enviroment:-
Physical :- my patient is family physical enviroment is good be cause her family
may good co – operation maintain .
Social:-
Interpersonal :-
Cultural:-
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13. Life style :-
Sleeping patten :- distered sleep pattern .
Elimination:- not good .
Any bad habbit:- no any bad habbit .
Diet:- non vegeterin .
Stress :- not
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14. Physical examination :-
General appearance :-
 nurishment :- well nourishment
Body bulid :- thin
Health :- unhealthy
Activity :-active
Skin condition :-
•Colour:- white
•Texture :- dryness
•Temerature :- warm
•Lesions :-no wound.
Hight :- 45kg
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15. Head & face :-
•Hade – normal
•Sculp- normal
•Face – normal
Eye:-
•Eye lashes – normal
•Eye brows –normal
•Eye bulls - normal
•Eye lids –normal
Ear:-
•Ear –normal
•Hearing- normal
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16. Nose:-
septum - normal
Mucosa – normal
Mouth & pharynx :- normal
Neck:- normal
Abdomen:- normal
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17. Investigation
S.N Name of
Investigation
Normal valve Patient value Remarks
1 Hemoglobin male – 14 to 17 gm /dl 10.2mg/dl
female -12 to 15 gm/dl
Anemia
2. Total RBC count male – 14 to 17 gm /dl 3.74 million/
female -12 to 15 gm/dl cu mm
Anemia
3. Neutrophils 1,5000-8,000 82%
(1.5-8.0 ) n/mcl
Neutrophilia
4. lymphocytes 1,000-4,800 15% leukopenia
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18. 5. Total bilirubin 0-1 mg/dl 0.69 g/dl Jaundice
6. Conjugated bilirubin 0-0.35 mg /dl 1.61mg/dl Indicate
hepatobiliary
7. Unconjug
ated
bilirubin
0.2- 0.65 mg/dl 2.0 mg/dl Indicate blood or
liver problem
8. SGPT/ALT 10-40 iu/l 85 iu/l Liver injury
9. Alkaline phosphate 40-112 u/l 3.4 u/l Problem with gall
bladder
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19. Medication
S.N Name of
Drug
Dose /Route Action Side effect Nursing
responsibility
1. Inj. Tazopip 4.5g
m I/V
It used to treat
varius types of
bacterial
infection .
Antibiotic To check the dose .
2. Inj. Luponex 40m g
Subcutaneous
This can help
reduce damage
caused by clots
in your blood
vessels .
Low molecular
weight heparin
group
to check the exper
date .
3. Tab. clonaz 0.25
Mg P/O
It is used to
prevent and
control seizures .
Benzodiazepine To check the
medicen
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20. 4. Tab.
Ecospirin
150mg It has antiplatelt action
and prevent the
formation of blood clots .
Antiplatelet agent To check the
medicen
5. Tab.
Clopidet
75mg Preventing platelets . NSAIDS To check the
medicen .
6.
7.
Tab.
Lipicure
Tab.
Pantocid
20m
g
40mg
Cholesterol preventing .
Stomach & esophagus
problems .
Lipid lowering
agent.
Diarrhea .
Stomach pain .
Nausea .
Headache .
To check the
medicen .
To check the
medicen .
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21. Diagnosis :- heart attack
DEFINATION
Antero septal myocardial infraction is a heart problem where part
of the heart muscle dies and scars due to poor blood supply. In
this case tissue damage is around the anteroseptal wall , the area
between the left and right ventricles.
- Wikipedia
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22. The death of heart muscle due to the loss of blood supply. The loss of
blood supply is usually caused by a complete blockage of a coronary
artery, one of the arteries that supplies blood to the heart muscle.
Death of the heart muscle, in turn, causes chest pain and electrical
instability of the heart muscle tissue.
- Medical net
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23. ETIOLOGY
S.N In book In my patient
1. Smoking Smoking habit present
2. Stress Stress
3. Exposure to air pollution Exposure to air pollution
4. Alcohol Consumption Alcohol consumption
5. Diabetes mellitus Diabetes mellitus type II
6. Coronary artery diseases,
High blood pressure
Absent
7. High level of blood
cholesterol
Absent
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24. 25

25. CLINICAL FEATURES
S.N Name of the book In my patient
1. Chest and shoulder pain present
2. Shortness of breathe present
3. Diaphoresis present
4. Decreased urinary output present
5. Weakness , fatigue present
6. Vomiting present
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26. 7. Lack of consciousness Absent
8. Sleep disturbance present
9. ECG elevation ECG elevation
( ST segment elevated)
10. Tachypnea present
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27. DIAGNOSTIC EVALUATION
S.N in book In my Patient’s
1. History collection present
2. Physical examination present
3. Electrocardiogram present
4. Lab test i.e Blood test,
Troponin I , II., HDL, LDL
present
5. Chest X-ray present
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28. MEDICAL MANAGMENT
 Open IV access
 High flow oxygen
 ECG monitoring
 IV analgesia: 5-10 mg morphine
 Thrombolytic therapy (streptokinase,alteplase)
 Antiplatelete therapy :- aspirin 75-300mg, clopidegrel 75 mg
 Anticoagulants ( heparin)
 Beta blockers ( propanolol , esmolol, labetolol)
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29. • M= morphine
• O = oxygen
• N = nitrates
• A = aspirin
• T = thrombolytic agent
• A = anti- coagulants
• S = stool softener
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Edited by :- MR. ROMAN BAJRANG

30. NURSING MANAGMENT
• Provide emotional support
• Balancing of myocardial oxygen supply as per demand
• Medication administration as per order
• Continuous monitoring of cardiac function
• Continuous ECG monitoring, hemodynamic monitoring
• Monitoring and recording input/ output.
• Nutritional support
• Bed rest for couple of days, reduce stress factors
• Provide heath education
• Asses the patient level of pain, location, duration.
• Prevention of the complication
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31. 32Reliance institute of nursing
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32. Nursing
Diagnosis
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33. 34

34. 35

35. 36
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36. 37

37. COMPLICATION
• Angina
• Re-infarction
• Infarct extension
• Heart failure
• Cardiogenic shock
• Mitral valave dysfunction
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38. 39
Edited by :- MR. ROMAN BAJRANG

39. Health Education
I. PERSONAL HYGIENE
II. DIET
III. MEDICATION
IV. FOLLOW UP
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40. Thank You!
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