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Nursing Management of Patients with Cardiovascular Disease
Part II: Acute Myocardial Infarction
Barbara Moloney DNPc, RN, CCRN
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Second Patient
52-year-old woman came to the hospital complaining of fatigue, nausea, and chest discomfort
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Assessment
BP 156/80 HR: 100 Rhythm : regular R-28 T-37oC SA2 96% room air
Respiratory tachypnea
Neurological Anxious, restless,
oriented Skin
Diaphoretic
Complains of Epigastric discomfort
6/10 Nausea Short of breath
WHAT ARE YOUR CONCERNS?
Is there anything that you want to do now?
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Focused history
Precipitation factor: preparing a meal
Quality of pain: pressure in chest and back
Radiating – “no”
Associated symptoms: Nausea, short of breath, diaphoretic
Onset of pain: 6 hours ago
Allergies: unknown
PMHx: hypertension
Meds at home: hydrochlorothiazide
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ECG
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Review: Coronary Arteries
Supply oxygen to the myocardium
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Formation of Plaque
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Coronary Artery Disease
Non-modifiable Risk Factors Age Gender Genetics
Contributing factors Diabetes Stress
Modifiable Risk Factors Smoking Hypertension Hyperlipidemia Physical Inactivity Obesity
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Blocked Coronary Artery
Myocardial ischemia
Anaerobic metabolism Lactic acid irritates
cardiac nerves
Angina Ischemia>20 min.
= acute myocardial infarction
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How it looks on ECG
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Different leads show different views of the heart
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What does this look like on the ECG?
Blue circles = ischemia, Red circles = injury
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STEMI: ECG changes = injury through the myocardium
Area of necrosis penetrates full myocardium = ST elevation usually followed by Q wave as MI evolves
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NSTEMI: no permanent ECG changes = injury does not go all the way through the myocardium
Small area of necrosis not penetrating full myocardium; may have some non-specific ST-T wave changes, but will not have ST elevation
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Blood tests
Marker Normal level
Time for Onset of increase
Peak concentration
Return to
normal CPK (total) 15-105 U/l men
10-80 U/l women
4-6 hours 12-14 hours 2-3 days
CK-MB 0-9 U/L 4-6 hours 12-24 hours 2-3 days
CK index <2.5%
Troponins T & I
0.0-0.4 ng/mL (tropI) Check lab
2-4 hours 8-12 5-14 days
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What happens to the heart?
Normal heart beat:
Heart during a myocardial infarction
http://www.youtube.com/watch?v=AOiyjNFB0as
http://www.youtube.com/watch?v=w8wXdtoW-HQ
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Analysis
Your analysis
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Review: Signs and symptoms
Pale, diaphoretic Chest discomfort
Epigastric Pressure Pain Arm, shoulder,
neck, jaw, back Restless,
apprehensive Dyspnea,
orthopnea
Palpitations Syncope confusion Cyanosis Nausea Fatigue
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Women, Diabetics, Elderly Symptoms may be more vague
Fatigue Short of breath Indigestion, nausea Anxiety Silent ischemia
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Vital signs Temperature elevation
Up to 38 o C due to tissue damage within first 24 hours
May last for as long as a week
Pulse may be rapid,
irregular, or slow
Respirations increases with pain
and anxiety may increase if in
heart failure decreases with
sedation
Blood pressure may fall below 90
immediately following an MI, returns to pre-infarction 2-4 days
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Other tests
WBC rise in early phase of infarction
Sed rate rises in early phase
Electrolytes PT/PTT/INR Platelets CBC Chest x-ray Echocardiogram
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Nursing Diagnoses
Problem List Myocardial Ischemia/Injury
Pain related to myocardial ischemia Nausea Short of Breath
Hemodynamic Stability Risk for dysrhythmias Risk for decreased cardiac output
Anxiety Knowledge Deficit
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Guidelines for management
Assess: Chest pain, Vital signs MONITOR
#1 cause of death is dysrhythmias
ECG IV access/blood draw Oxygen, medications Chest x-ray
American Heart Association Guidelines, 2011
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Medications
Aspirin Nitroglycerine Oxygen Morphine
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Aspirin
Action: Decrease platelet aggregation
Dose 162-325 mg chewed as soon as ACS is
suspected
Nursing considerations Allergy
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Nitroglycerine Action:
Vasodilates Dilates coronary arteries Increases collateral blood flow
Dose: 0.4 mg SL Give every 5 minutes for a total of 3 doses
if needed Nursing considerations
Assess pain and blood pressure after each dose
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Oxygen
Rationale: Reduces pain Reduces risk for dysrhythmias
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Morphine
Action: Reduces pre-load, afterload Reduces anxiety, pain, dyspnea, and Reduces myocardial oxygen demand
Dose 1-5 mg IV
Nursing considerations Monitor for effect, monitor BP, nausea,
respiratory depression
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Heparin
Action: Inhibits thrombus
Dose Monitor PTT
Nursing considerations: Bleeding precautions Monitor PTT Protamine sulfate
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Clopidogrel (Plavix)
Action Inhibits platelet aggregation May be given in place of ASA or in addition to
ASA
Dose May be given a loading dose (300mg or 600mg)
followed by 75mg daily for 3-12 months (maybe longer if client has stents)
Nursing considerations Allergy Bleeding Discontinue steroids & avoid NSAIDS
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Beta Blockers
Metoprolol Administered to acute MI usually
within 2 hours - may be given IV Action:
Slow heart rate Decrease oxygen consumption Decrease pain
Nursing considerations Monitor blood pressure, pulse
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ACE inhibitors (Lisinopril, Quinapril)
Decreases ventricular remodeling – helps the heart heal
Start slowly - usually within first 24 hours Action
Reduce afterload Reduce pre-load Decreases ventricular remodeling
Nursing considerations Orthostatic hypotension, monitor VS Dose – start low
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Plan: Nursing Care
Chest pain: Manage and alleviate Monitor
Dysrhythmias ST segment
Vital signs, including oxygen saturation
Anxiety: assess and reduce Monitor labs – esp. potassium and
magnesium
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Continuous assessment – lung sounds, heart sounds, head to toe
Activity Bed rest if unstable (having chest pain) Once hemodynamically stable should not be
in bed longer than 12 hours Monitor response of heart rate – remember
increased HR = increased oxygen consumption of myocardium
Prevent constipation Monitor effects of medications
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Now What????
Your patient is on the monitor
Her heart rhythm becomes irregular
She becomes unresponsive
Now what do you do?
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1. Establish unresponsiveness 2. Call for help
Defibrillator or DEA
3. Check for pulse 4. Start compressions – give 30 5. Open airway 6. Deliver 2 breaths with ambu bag 7. Continue CPR until defibrillator
arrives
Nursing management: CAB
American Heart Association (2011)
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New Guidelines
http://www.youtube.com/americanheartassoc#p/c/7A68846B17049716/9/O9T25SMyz3A
(3 minutes – in English; change to French version when available)
Key points: Know what to do if a patient becomes
unresponsive Know where the defibrillator or DEA is Code cart needs to be checked regularly,
Defibrillator must remain plugged in
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Teaching guidelines
Patient teaching Start as soon as patient is ready Diet and Activity Medications Smoking cessation – client and family How to take nitroglycerine, when to call the MD
or come to the ED Risk factors – modifiable Cardiac rehab
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Guidelines continued
Signs and symptoms of acute MI, angina and the reasons they occur
Healing after MI Risk factors Rationales for treatments Resumption of work, physical activity, sexual activity Measures to take to promote recovery ad health Importance of gradual, progressive resumption of
activity When to seek and how to seek help
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Teaching guidelines for HT
Explain what HT means – may include numeric value
Dietary recommendations Life-style recommendations Medications