Title: Acute Myocardial Infarction
1Acute Myocardial Infarction
2Cause of AMI
- Complete obstruction of coronary artery resulting
in decreased blood flow and necrosis to
myocardium - Infarction-prolonged ischemia
3Types of AMI
- Affects The Left Ventricle
- - inferior wall-Inferior MI
- - anterior and lateral walls-
- Anterolateral MI
- - septum and adjoining wall-
- Anteroseptal or Posteroseptal MI
4Clinical Manifestations of AMI
- Pain- acute, sudden, continuous,
crushing,heavy, constricting, tightness, - - may radiate to neck, jaw, left arm
or back - - prolonged and unrelieved by rest
- - occurs while at rest or active,
asleep, or in early a.m. - .
5Clinical Manifestations of AMI
- Vagal stimulation leads to epigastric
distress-indigestion often treated with
antacids - Shortness of Breath
- Clammy, diaphoretic skin
- Increased pulse
- Decreased blood pressure
- Dizziness/lightheadedness
6Pain associated with AMI
- Client with Diabetes Mellitus-may not experience
severe pain due to neuropathy - Geriatric client-may not experience severe pain
due to decreased neurotransmitters
7Diagnostic Evaluation
- Consider the total clinical picture including the
client health history, physical examination.and
results of laboratory data - Health History-organized method to elicit
pertinent information regarding health status - requires time and trust
8Diagnostic Evaluation
- Identify Client Risk Factors
- Physical Examination
- - Inspection
- - Palpation
- - Percussion
- - Auscultation
9Diagnostic Evaluation
- Chest X-Ray
- -size and shape of heart and aorta
- -calcification in heart muscle,valves,
- pericardium
- -lung congestion
- -placement of cardiac catheters
10Laboratory Studies
- CBC and Differential Count- provides information
about hematologic system and oxygenation - - assess hemoglobin and hematocrit
- - WBC-mildly elevated to 13,000 cm indicates
systemic response to necrosis - -elevated temperature -101 degrees F
11Laboratory Data
- Serum electrolytes
- Sodium and Potassium are essential for
conduction of impulses - CO2-acid base balance
- Glucose-Hyperglycemia is a risk factor
12Laboratory Data
- BUN, Creatinine- assess effects of CO on kidneys
- Sedimentation Rate- nonspecific test to detect
Inflammation/necrotic processes - - used to follow the course of disease
- - increased in Endocarditis, Pericarditis,
- and Rheumatic Fever
13Non-invasive Tests
- Echocardiogram-small transducer which emits
ultrasonic sound waves is moved across the
clients chest wall above the heart. The
transducer records sound waves bounced off the
heart. It detects pericardial fluid, ventricular
aneurysms, tumors, defects, chamber size,stroke
volume,thickness of valves,and CO.
14Noninvasive Tests
- Phonocardiogram-graphic reading of heart sounds
done by placing a microphone on surface of the
body. It provides information on murmurs and
timing of various heart sounds.
15Digoxin Levels
- Blood test to determine toxic versus therapeutic
levels in body - -therapeutic-1-2ng/ml.
- -toxic- above 3ng/ml.
16Stress Testing
- objective- evaluate cardiovascular response to a
progressively graduated workload - GEST-Graduated exercise stress test
- ETT-Exercise tolerance test
17Uses of Stress Test
- Diagnose chest pain
- Screen for Ischemic Heart Disease
- Determine functional capacity after MI or heart
surgery - Assess effectiveness of medications
- Identify dysrhythmias during stress
- Aid in development of exercise program
18PT and PTT
- Pt (Prothrombin Time)-monitors extrinsic clotting
system - PTT (Partial Thromboplastin Time)-monitors
intrinsic clotting system
19Serum Lipids
- Cholesterol- is a blood lipid . Elevated levels
are associated with ASHD. - normal 150-200 mg/dl.
- - LDL- elevated levels assocated with CAD
- -HDL- elevated levels protect client from
CAD - Readings above 200mg. considered abnormal
-
20Serum Enzymes
- rationale- intracellular enzymes in myocardial
cells are released when cells are damaged or
destroyed - Specific to cardiac tissue
- -Troponin
- - CK-MB- Creatine Kinase
- - LDH
- - AST-Serum Aspartate Amino
- Transferase (formerly SGOT)
-
21Serum EnzymesTroponin-proteins that are
released following an MI. Both troponin T and
troponin I are highly specific to cardiac
tissue.Troponin T
22Serum Enzymes
- CK-MB-most cardiospecific
- onset- 1-4 hrs.
- peak- 12-20 hrs.
- duration -48-72 hrs
- Concentrations above 7.5 are highly indicative
of MI
23Serum Enzymes
- LDH- Lactic Dehydrogenase
- onset-24 hrs.
- peak-48-72 hrs.
- duration-5-10 days
- Has five different iso-enzymes
- Normal
24Serum Enzymes - LDH1 and LDH 2 LDH
iso-enzyme subgroups are contained in
heart muscle. -Test determines LDH1/LDH2
ratio. - If LDH1 is greater than LDH2, it
is indicative of MI.
25Serum Enzymes
- AST-formerly Transaminase (not cardiospecific)
- onset-6hrs.
- peak-24-48 hrs.
- duration- 96 hrs.
- Normal 7-40U/ml.
26Medical Management of AMI
- Goal- minimize myocardial damage
- Most critical time- first hour, first day, first
2-3 days - CCU- monitor for dysrhythmias, the most common
complication
27Medical Management of AMI
- a) rest- decreases demands of body
- for oxygen
- - allows heart to rest, recuperate, and
- - prevent further complications
- - allow client to use cammode
- - progressive ambulation
28Medical Management
- b) Analgesia- access the venous system
- -analgesic of choice is Morphine Sulfate to
control the chest pain
29Medical Management of AMI
- Administer Morphine Sulfate to control
- chest pain.
- - It results in peripheral vasodilation,
leads to decreased cardiac workload, decreased
anxiety, and produces somnolence.
30Medical Management of AMI
- Oxygen- Administer 2-4 L./minute via nasal
cannula to relieve ischemia of myocardium by
increasing blood oxygen levels -
- Nitroglycerin Drips titrated to keep SBP above
90 mm/hg
31Medical Management of AMI
- Prevent Complications
- -Dysrhythmias-present in 80
- -Cardiogenic Shock-10-15
- -CHF
- -Ventricular Rupture
- -Pulmonary Embolism
32Thrombolytic Therapy
- aim- lyse clot in coronary artery and
- restore blood flow
- early administration of medication is crucial
- - ideal is within 6 hours of onset of pain
- Streptokinase-IV or directly into coronary
arteries where it converts plasminogen into
plasma and breaks up fibrin clots
33Thrombolytic Therapy
- Streptokinase-risk of hemorrhage and allergic
reactions may occur - t-PA (Activase)-Tissue type plasminogen activator
- -risk of systemic bleeding decreased
- -expensive
- - few allergic reactions
- IV and intracoronary injections equally
effective
34Thrombolytic Therapy
- Anistreplase (Eminase)
- - low cost
- -ease of administration-one time only
35Nursing Interventions-Acute Phase
- Coronary care Unit- (2-3days)
- Priorities
- -Pain assessment and relief
- -Physiological monitoring
- -Promote rest and comfort
- -Alleviate stress and anxiety
- -Understand emotional and behavioral
- reactions
-
36Nursing Interventions
- Pain- administer morphine sulfate or nitrates
- Monitoring- V.S., EKG,oxygenation
- Rest/comfort- BRP,chair,rest periods
- Anxiety- identify source of anxiety
- -Provide information, education
- -Administer antianxiety
medications - -Assess support systems
37Nursing Interventions
- Emotional and behavioral reactions
- -Support positive coping mechanisms
- -Open visitation encouraged
38Common Nursing Diagnoses
- Pain rel. to tissue ischemia
- Anxiety rel. to change in health status
- Decreased C.O. rel. to changes in HR,rhythm, or
electrical conduction - Altered health maintenance
- Ineffective coping
39Nursing Interventions-Pain
- Monitor type, amount, cause
- Provide calm, quiet, environment
- Teach client relaxation techniques
- Approach client with calm, confident manner
- Administer oxygen at 2-4 L./minute
40Nursing Intervention-Pain
- Assist client with ADLS as needed
- Instruct client on energy saving techniques
- Provide rest periods as needed
41Nursing Intervention-Anxiety
- Encourage expressions of fear,anger, grief
- Encourage questions
- Answer questions factually
- Accept use of denial-do not reinforce
- Encourage independence, self-care, and decision
making
42Nursing Intervention-Altered Health Maintenance
- Give instruction on risk factors,
cause,treatment,medications,diet, smoking,and
hypertension
43Purpose- restoration of person to optimal state
of function in six areas
- -physiologic
- -psychological
- -mental
- -spiritual
- -economic
- - vocational
44Cardiac Rehabilitation
- Aim- help person adjust to disability
- -teach integration of all resources and
- concentrate on existing abilities
45Phases of cardiac Rehabilitation
- Phase 1 -acute phase-CCU
- Phase 2 -transfer from CCU,PCU, remainder of
hospitalization - Phase 3 - discharge to home(convalescent
period)--Outpatient cardiac programs,walking
programs - Phase 4 - Long term conditioning and maintenance