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Acute Myocardial Infarction

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Title: Acute Myocardial Infarction


1
Acute Myocardial Infarction
  • Nursing 212

2
Cause of AMI
  • Complete obstruction of coronary artery resulting
    in decreased blood flow and necrosis to
    myocardium
  • Infarction-prolonged ischemia

3
Types of AMI
  • Affects The Left Ventricle
  • - inferior wall-Inferior MI
  • - anterior and lateral walls-
  • Anterolateral MI
  • - septum and adjoining wall-
  • Anteroseptal or Posteroseptal MI

4
Clinical 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.
  • .

5
Clinical 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

6
Pain 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

7
Diagnostic 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

8
Diagnostic Evaluation
  • Identify Client Risk Factors
  • Physical Examination
  • - Inspection
  • - Palpation
  • - Percussion
  • - Auscultation

9
Diagnostic Evaluation
  • Chest X-Ray
  • -size and shape of heart and aorta
  • -calcification in heart muscle,valves,
  • pericardium
  • -lung congestion
  • -placement of cardiac catheters

10
Laboratory 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

11
Laboratory Data
  • Serum electrolytes
  • Sodium and Potassium are essential for
    conduction of impulses
  • CO2-acid base balance
  • Glucose-Hyperglycemia is a risk factor

12
Laboratory 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

13
Non-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.

14
Noninvasive 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.

15
Digoxin Levels
  • Blood test to determine toxic versus therapeutic
    levels in body
  • -therapeutic-1-2ng/ml.
  • -toxic- above 3ng/ml.

16
Stress Testing
  • objective- evaluate cardiovascular response to a
    progressively graduated workload
  • GEST-Graduated exercise stress test
  • ETT-Exercise tolerance test

17
Uses 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

18
PT and PTT
  • Pt (Prothrombin Time)-monitors extrinsic clotting
    system
  • PTT (Partial Thromboplastin Time)-monitors
    intrinsic clotting system

19
Serum 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

20
Serum 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)

21
Serum EnzymesTroponin-proteins that are
released following an MI. Both troponin T and
troponin I are highly specific to cardiac
tissue.Troponin T 22
Serum 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

23
Serum Enzymes
  • LDH- Lactic Dehydrogenase
  • onset-24 hrs.
  • peak-48-72 hrs.
  • duration-5-10 days
  • Has five different iso-enzymes
  • Normal

24
Serum 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.
25
Serum Enzymes
  • AST-formerly Transaminase (not cardiospecific)
  • onset-6hrs.
  • peak-24-48 hrs.
  • duration- 96 hrs.
  • Normal 7-40U/ml.

26
Medical 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

27
Medical 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

28
Medical Management
  • b) Analgesia- access the venous system
  • -analgesic of choice is Morphine Sulfate to
    control the chest pain

29
Medical 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.

30
Medical 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

31
Medical Management of AMI
  • Prevent Complications
  • -Dysrhythmias-present in 80
  • -Cardiogenic Shock-10-15
  • -CHF
  • -Ventricular Rupture
  • -Pulmonary Embolism

32
Thrombolytic 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

33
Thrombolytic 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

34
Thrombolytic Therapy
  • Anistreplase (Eminase)
  • - low cost
  • -ease of administration-one time only

35
Nursing 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

36
Nursing 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

37
Nursing Interventions
  • Emotional and behavioral reactions
  • -Support positive coping mechanisms
  • -Open visitation encouraged

38
Common 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

39
Nursing 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

40
Nursing Intervention-Pain
  • Assist client with ADLS as needed
  • Instruct client on energy saving techniques
  • Provide rest periods as needed

41
Nursing 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

42
Nursing Intervention-Altered Health Maintenance
  • Give instruction on risk factors,
    cause,treatment,medications,diet, smoking,and
    hypertension

43
Purpose- restoration of person to optimal state
of function in six areas
  • -physiologic
  • -psychological
  • -mental
  • -spiritual
  • -economic
  • - vocational

44
Cardiac Rehabilitation
  • Aim- help person adjust to disability
  • -teach integration of all resources and
  • concentrate on existing abilities

45
Phases 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
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