Acute Myocardial Infarction

Assessment
1. clinical manifestations
  1. subjective
    1. Nausea - SNS Activation
    2. Anxiety
    3. SOB, Dyspnea or Orthopnea
    4. Chest pain - Crushing, heaviness, pressure
      1. Pain may radiate to neck, jaw, back and arms
  2. Objective
    1. Fever - inflammatory response
    2. Vitals
      1. High BP and High HR
        Last stages decrease BP d/t decrease CO
    3. Sweating - SNS activation
    4. Syncope / Presyncope
    5. Skin - cool clammy bc SNS
    6. Crackles in lungs left ventricular ischemia
    7. Jugular vein distention, peripheral edema right ventricular ischemia
    8. Abnormal Heart Sounds - S3 or S4 - indication of ventricular dysfunction
    9. Hyperkalemia - Acidosis - Necrosis
  3. S/S difference from Men and Women
2. risk factors
  1. non-modifiable
    1. African Amerian Decent
      1. Family History
        Age Men > 45 & Women > 55
        CAD - Coronary Artery Disease
  2. modifiable
    1. Smoking
      1. obesity
        stress
        high LDL & low HDL
        lack of physical activity
        hypertension
Treatment
1. pharmaceutticals
  1. Intravenous Nitroglycerin
    1. goals of therapy
      1. reduce angina pain
      2. improve coronary blood flow
    2. effects
      1. preload
      2. afterload
      3. oxygen supply
    3. adverse effects
      1. hypotension
        monitor BP
      2. tolerance
        administer a lower dose at night and a higher dose during the day
  2. Morphine Sulphate
    1. used for chest pain not relieved by nitroglycerin
    2. effects (vasodilator)
      1. Cardiac Workload by
        myocardial oxygen consumption
        contractility
        BP
        HR
    3. adverse effects
      1. respiratory depression
        monitor for signs of bradypnea and hypoxia
  3. B-Adrenergic Blockers
    1. NOT given by IV to patients with STEMI
      1. S-T Elevation Myocardial Infarction
    2. administered PO within 24 hours of STEMI
    3. effects
      1. myocardial oxygen demand
        HR
        BP
        Contractility
  4. Angiotensin-Converting Enzyme Inhibitors
    1. recommended
      1. Anterior wall MI
      2. Infarctions that cause decreased left ventricular function
      3. pulmonary congestion
  5. Antidysrhythmia Medications
  6. Cholesterol- Lowering Drugs
  7. Stool Softeners
    1. Post MI patients are on bedrest and are administered opioids
      1. increases risk of constipation
    2. Colace
      1. prevents straining and vagal stimulation
2. non-pharmeceuticals
  1. Nutritional
    1. NPO (pt may sip water) until stable
  2. Coronary Surgical Revascularization
    1. Coronary Artery Bypass Graft Surgery (CABG)
      1. Construction of new conduits between major arteries and the myocardium distal to the obstructed coronary arteries
      2. needs
        sternotomy
        opening of the chest cavity
        cardiopulmonary bypass (CPB)
        diverts patient's blood from the heart to the CPB machine
        the CPB machine oxygenates the blood
        blood is pumped back into patient
    2. Minimally Invasive Direct Coronary Artery Bypass
      1. for patients with single vessel disease
        left anterior descending
        Right sided Coronary Artery Disease
      2. does not involve a sternotomy and CPB
3. Emergent Care
  1. Administer Oxygen
  2. Nitrates for Chest Pain
    1. Opioid analgesic
  3. Vitals
  4. Telemetry
    1. White is Right, Black is Opposite, Snow(White) over Trees(Green), Smoke(Black) over Fire(Red)
  5. Heart Sounds
  6. Comfortable Positon
  7. PCI (percutaneous coronary intervention)
    1. catheter equipped with an inflatable balloon tip is inserted into a narrowed coronary artery and the balloon is inflated
Diagnosis
1. Diagnostic Testing
  1. ECG
    1. help identify areas of your heart that are dysfunctioning
    2. STEMI (ST elevation myocardial infarction) with pathological Q waves
  2. Bloodwork
    1. check for proteins that are associated with heart damage, such as serum cardiac markers
      1. Specific to MI
        Cardiac specific tropinin T (cTnT)
        Cardiac specific tropinin I (cTnI)
      2. Creatine Kinase muscle brain (CK-MB) levels rise 3 - 12 hrs after MI
        indication of myocardial damage
      3. Myoglobin is a small, oxygen-binding protein found in heart and skeletal muscle
        Early MI indication - it is release in the blood after heart injury
  3. Stress Test
    1. see how your heart responds to certain situations, such as exercise
  4. Angiogram
    1. coronary catheterization to look for areas of blockage in your arteries
      1. help indicate a need for PCI (percutaneous Coronary Intervention)
2. Special Consideration
  1. Women are often misdiagnosised
    1. MI’s in women are usually more fatal than in men because:
      1. symptoms in females are less typical (less severe chest pain, often reported as severe heartburn or pain in the breast)
      2. do not seek treatment early in attack or at all
      3. onset is later (>65 yrs) when other health conditions may contribute or complicate
      4. smaller coronary arteries
  2. Elderly are also misdiagnosis
    1. Decrease CO leads to decrease LOC
      1. decrease LOC is mistaken for delirium
Pathophysiology
1. Irreversible myocardial cell death due to lack of blood flow
2. Zones
  1. 1. Necrotic zone 2. Injured area: some cells may recover 3. Ischemic zone: cells will recover if perfusion is restored
3. Caused usually by thrombus leading to distal portions of the heart to necrosis
4. Heart is able to withstand 20 mins of ischemic condition then cell death begins
  1. Starting from the inner layer to the outer it takes about 5-6 hours to become full necrotic in an area
5. Necrosis can happen anywhere in the heart and it correlates to the circulation that is impaired
  1. For ex: Anterior wall infractions come from the right coronary artery occlusion
6. METAPHOR
  1. Think of a one way road and an accident stopping traffic
    1. Accident is Thrombus
      1. Cars are Blood flow
Complications
1. Dysrhythmias
  1. Most Common complication
  2. Ventricular fibrillation
    1. Occurs within 4 hours of onset of pain
  3. Premature Ventricular Contractions
    1. May precede ventricular tachycardia and fibrillation
2. Heart Failure
  1. Pumping power of heart has decreased
    1. Manifestations
      1. Dyspnea, restlessness, agitation, tacycardia
      2. S4 and S3 sounds, crackles, distended jugular veins
3. Cardiogenic Shock
  1. Inadequate oxygen and nutrient supply to tissues
4. Papillary Muscle dysfunction
  1. Occurs if infarcts area includes papillary muscles that attaches to mitral valve
    1. Causes mitral valve regurgitation
      1. Increases volume of blood in left atriu
        Decreases CO
        Can lead to papillary rupture (rare)
        Results in dyspnea, pulmonary edema, and decreased CO
        Patient’s condition decreases rapidly
5. Ventricular Aneurysm
  1. occurs when infarcted myocardial wall thins and bulges during contraction
    1. refractory heart failure, angina,
    2. dysrhythmias
    3. can lead to embolic stroke
    4. can lead to
6. Pericarditis
  1. inflammation
    1. visceral
    2. parietal pericardium
  2. chest pain (may be relived by sitting), coughing,
7. Dressler's Syndrome
  1. pericarditis + effusion and fever that develops 4-6 weeks after MI
    1. potentially occurs after open heart surgery
    2. manifestations
      1. pericardial pain
      2. fever
      3. friction rub
      4. plural effusion
      5. arthralgia
Nursing Process
1. Planning
  1. Care Goals
    1. relief of pain
    2. preservation of myocardium
    3. treatment of ischemia
    4. coping with anxiety
    5. patient participation in rehabilitation plan
    6. reduction of risk factors
2. Implementation
  1. Patient Education
    1. Physical Activity
      1. 5 or more times per week
        intensity is determined by HR
        HR during activity should not be more than 20 beats/min over resting HR
      2. type
        regular, rhythmic, and repetitive; large muscles should be used
        Walking
        cycling
        swimming
        rowing
      3. Gradual resumption of activities
        Activity should not be abruptly started or stopped
        stretch for 3-5 minutes before and after activity
    2. S/S of angina and Acute MI
      1. why angina and MI occur
        When and how to seek help
    3. Definition of terms
      1. CAD
      2. Acute MI
      3. HF
    4. Healing after an MI
      1. promote recovery
    5. decrease Risk Factors
    6. Sexual activity
      1. Wait 3-4 hours after a large meal before sexual activity
      2. Hot or cold showers should be avoided before and after
      3. Erectile agents are contradicted if patient is taking nitrates
      4. Prophylactic use of nitrates decreases angina during sexual activity
      5. Anal intercourse may cause cardiac stress
        Can Induce vasovagal response
  2. Nursing Diagnosis
    1. Acute Pain
      1. Evaluate PQRST and alleviating factors
      2. monitor
        cardiac rhythm and rate
        BP
        hemodynamic parameters
        effectiveness of O2 therapy
      3. administer pain medication
      4. Obtain 12-lead ECG during pain episode
    2. Decreased Cardiac Output
      1. monitor
        Vital signs
        dysrhythmias
        Respiratory
        watch for signs of HF
        Fluid balance
        observe for fluid retention
      2. Arrange exercise and periods of rest
    3. Anxiety
      1. observe for S/S
      2. Assess for changes in anxiety
        anxiety increases O2 needs
      3. teach relaxation techniques
        deep, relaxed breathing
      4. Encourage patient to voice fears and feelings
    4. Activity Intolerance
      1. monitor response to antidysrhythmic medications before activity
      2. arrange for exercise and rest periods
      3. teach patient about energy conservation
        teach patients pacing techniques for ADL's and to self monitor O2
3. Evaluation
  1. Expected Outcomes
    1. understands medication
      1. purpose
      2. action
      3. dosage
      4. route
      5. leads to compliance of medication
        pain relief and optimal conditions
    2. Health Teaching
      1. Understands the disease process
        able to explain acute MI in their own words
        anxiety relief
        lifestyle changes
        reducing risk factors
        Avaliblity to local community resources
    3. Reports Relief Of pain
    4. Stable signs of effective cardiac perfusion
    5. Able to tolerate activity
4. Nursing Assessment
  1. Refer to Red Assessment Bubble for S/S
  2. Head to Toe Assessment
    1. Priority
      1. Cardiac
      2. Respiratory
      3. Neurological
  3. Past Medical History
  4. Current Medical History
    1. Current Medication
Jaimee Plumley 215 149 784 & Vaanathy Sivanandan (214 237 929)

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Acute Myocardial Infarction

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	Created by Jaimee Plumley about 6 years ago