Acute Myocardial

Infarction

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

Types of AMI
Affects The Left Ventricle
- inferior wall-Inferior MI
- anterior and lateral wallsAnterolateral MI
- septum and adjoining wallAnteroseptal or
Posteroseptal MI

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.
.

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

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

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

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

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

Laboratory Studies
CBC and Differential Countprovides 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

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

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

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.

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.

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

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

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

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

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

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)

Serum Enzymes
Troponin-proteins that are
released following an MI. Both
troponin T and troponin I are highly
specific to cardiac tissue.
Troponin T <0.1 ng/ml
Troponin I <0.1-3.1 ng/ml

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

Serum Enzymes
LDH- Lactic Dehydrogenase
onset-24 hrs.
peak-48-72 hrs.
duration-5-10 days
Has five different iso-enzymes
Normal: < 100U/L.

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.

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

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

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

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

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.

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

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

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

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

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

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

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

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

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

Nursing InterventionsPain
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

Nursing InterventionPain
Assist client with ADLS as needed
Instruct client on energy saving
techniques
Provide rest periods as needed

Nursing InterventionAnxiety
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

Nursing InterventionAltered Health

Maintenance
Give instruction on risk factors,
cause,treatment,medications,diet,
smoking,and hypertension

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

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

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