Alterations That Affect Ability To Meet A Need For Oxygen: Myocardial Infarction

Acute Coronary Syndrome

Includes 3 types of CAD associated with sudden rupture of plaque

Unstable

angina Non-ST segment elevation MI (NSTEMI) ST segment elevation MI (STEMI)

Myocardial Infarction

Ruptured atherosclerotic plaque platelet aggregation with thrombus formation blocking of blood flow Loss of blood flow anaerobic metabolism, cell dysfunction and death Ischemic necrosis begins in subendothelial layer, progresses through muscle wall

Inflammatory Response

Acute inflammatory response within first 3 days Macrophages remove necrotic tissue

Gradual replacement with granulation tissue

4-7 days, center of infarcted area is soft/weak-may rupture 7-8wks necrotic tissue replaced with scar tissue

Clinical Manifestations (Chart 28-6)

Chest pain (remember OLDCART) SOB Indigestion, nausea Tachycardia, tachypnea Cool, pale, moist skin Anxiety

Diagnostic Tests

Timing is important, as is:

correlation

with patient symptoms, electrocardiograms, and angiographic studies.

A number of laboratory tests are available.

Electrocardiogram

Up to 50% of people with MI have normal EKG Changes depend on extent of damage

Done within 10 min of complaints of chest pain

Monitor over time location, evolution and resolution of MI can be monitored

Ischemia, Injury, Infarction

EKG done w/i 10 minutes

InjuryST segment elevation, tall peaked T wave InfarctT wave inversion followed by development of Q wave from scar tissue (in transmural MI) 12 lead changes

Lab Test CPK or CK nl=12-80 M 10-70 u/L F CPK-MB nl=10-13 u/L

Begins to Rise 4-8 hours

Peaks In 12-24 hours

Returns to Normal 2-3 days

Found In , brain, skeletal muscle - very specific

4-8 hours

12-24 hours

2-3 days

Myoglobin nl < 100 ng/mL Troponin T Nl < 0.1 ng/L Troponin I Nl < 1.5 ng/L

1-2 hours

4-8 hours

24-36 hours

, skeletal muscle

2-6 hours

12-24 hours

Several weeks 7-10 days

- specific

2-6 hours

12-36 hours

-specific

Goals
The goals of treatment include:
Minimize myocardial damage Preserve myocardial function Prevent complications

3 scenarios for patients in whom fibrinolysis is indicated:

AND EMS has fibrinlytic capability and pt. qualifies: prehospital fibrinolysis started w/i 30 minutes of EMS arrival.

AND transported to nonPCI-capable hospital: hospital door-to-needle time should be w/i 30 min. AND transported to PCI-capable hospital: hospital door-to-balloon time should be w/i 90 min.

From ACC/AHA Pocket Guideline: Management of Patients With ST-Elevation Myocardial Infarction

Triage Nurse

Assesses for STEMI S/S Obtains 12-lead ECG (within 10 minutes of arrival in ED) Conducts brief, focused history

ED Nurse

Initiates emergency nursing care

Cardiac

monitor Biomarkers Morphine Oxygen Nitroglycerin Aspirin IV D5W

MONA; MOVE

ED Physician

Evaluates patient
History
Physical

examination Interpret ECG

Physical Assessment
1. Airway, Breathing, Circulation (ABC) 2. Vital signs, general observation 3. Presence or absence of jugular venous distension 4. Pulmonary auscultation for rales 5. Cardiac auscultation for murmurs and gallops 6. Presence or absence of stroke 7. Presence or absence of pulses 8. Presence or absence of systemic hypo-perfusion (cool, clammy, pale, ashen)

Physical Assessment

History Neurologic Psychological Cardiovascular Respiratory GI Skin GU

Targeted Outcomes

Decrease Cardiac Workload

Bedrest,

head of bed up Oxygen, 2-4 LPM per NC IV administration of vasodilators (nitroglycerine) Beta Blockers - propanolol (inderal), atenolol (tenormin) Ace Inhibitors

Targeted Outcomes

Reestablish myocardial perfusion

Antiplatelets:

ASA (chew 1 immediately EMS) Anticoagulants: IV heparin (5000 Unit bolus then 1000 Unit drip; coumadin Thrombolytic therapy: tissue plasminogen activator, streptokinase (p. 877)
started

soon after onset of pain (w/i 3-6) contraindicated in people at risk-who are these individuals? careful monitoring

Thrombolytic Therapy: Nursing Interventions

Minimize skin punctures (IV punctures, IM injections, blood draws) Start IV lines before beginning thrombolytic therapy Avoid continual use of noninvasive BP cuff Monitor for dysrhythmias, hypotension, and allergic reactions

Thrombolytic Therapy: Nursing Interventions

Assess for S/S of bleeding Treat major bleeding Treat minor bleeding

Thrombolytic Therapy

Successful reperfusion
ECG

returns to normal Chest pain gone Appearance of reperfusion dysrhythmias (PVCs) Early rapid peak of CPK-MB (washout)

If not a candidate or unsuccessful

PTCA

& stent

CABG

Nursing Interventions

Promote Tissue Perfusion

Reduce

the myocardial oxygen consumption by limiting activity Check skin temperature and peripheral pulses frequently Administer oxygen to enrich the supply of circulating oxygen to the heart muscle.

Reduce anxiety

Targeted Outcomes

Decrease pain
MS

IV bolus Psychological support Relieve anxiety, stay with patient

Control dysrhythmias

Nursing Interventions

Relieve chest pain by the demand for oxygen and perfusion

MS IV

administration of vasodilators (nitroglycerine) IV anticoagulation (heparin) IV thrombolytics Oxygen administration Rest

PTCA
May be used to open the occluded coronary artery and promote reperfusion to the area that has been deprived of oxygen

Potential Complications

Clinical complications of myocardial infarction will depend upon the size and location of the infarction, as well as pre-existing myocardial damage. Complications can include:
Arrhythmias

with possible sudden death cause 50% of deaths after MI Extension or re-infarction Congestive heart failure
Acute onset, freq progressing to pulmonary edema risk of chronic heart failure

Potential Complications (cont.)

Cardiogenic shock: not common, but lethal

Myocardial rupture: 5-7 days after MI Pericarditis: inflammation of the pericardium, 28% with transmural MI, pericardial friction rub, pain with resp; analgesics, NSAIDS

Priority Nursing Diagnoses

Altered cardiac tissue perfusion r/t reduced coronary blood flow 2 to anterior MI aeb . . . Pain RT myocardial ischemia or injury Activity intolerance r/t episode of interrupted coronary blood flow 2 to ant MI aeb . . . Impaired gas exchange RT fluid overload, decreased cardiac output Knowledge deficit r/t post-MI self-care

Priority Nursing Diagnoses

Altered tissue perfusion (peripheral) r/t decreased cardiac output Altered tissue perfusion (renal) r/t decreased cardiac output Anxiety r/t uncertainty Powerlessness r/t lack of control over situation, disease progression

Rehabilitation and Teaching

6-12 weeks for recovery Cardiac rehabilitation

Phase

1: inpatient
ambulation, low Na diet, stool softeners,

progressive

telemetry
Phase

2: outpatient

discharge

- 4 to 6wks, may last up to 6months continue progressive exercise resume sex ~ 4-8 weeks back to work in 8-9 weeks

Rehabilitation and Teaching

Cardiac Rehabilitation (cont.)

Phase Phase

3: intermediate outpatient 4-6 mos

monitoring exercise tolerance and endurance

continue

4: maintenance outpatient

client

maintains program of exercise, diet, lifestyle modifications

Instructions for the Patient on Coumadin

Always know what your current dose is and when you are to have your next blood test.

Keep a coumadin calendar.

Remind anyone who prescribes medicine for you that you are on coumadin (there are important interactions with a number of other medications).

Instructions for the Patient on Coumadin

Report any unusual bleeding (it doesn't need to be a lot . . . it is simply important that it is occurring "for no good reason"). Get your blood tested as directed! Realize that significant changes in your diet can cause changes in coumadin's potency. In general, aspirin should not be used unless specifically prescribed, and acetaminophen should be used in only modest quantities.

Instructions for the Patient on Coumadin

Discuss the use of herbal preparations with your doctor.

Call your physician with questions earlier rather than later.

Consider obtaining a "medic alert" or similar bracelet stating that you are on Coumadin.