care of patient with myocardial infarction

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By: kenrjam (94 month(s) ago)

Very well done. Thank you.

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CARE OF PATIENT WITH MI:

CARE OF PATIENT WITH MI PRESENTED BY: KIRAN RANDHAWA

INTRODUCTION:

INTRODUCTION ACUTE MYOCARDIAL INFARCTION(AMI OR MI), COMMONLY KNOWN AS A HEART ATTACK, IS A DISEASE STATE THAT WHEN THE BLOOD SUPPLY TO THE PART OF THE HEART IS INTERRUPTED, RESULTS IN ISCHEMIA OR OXYGEN SHORTAGE LEADS TO DAMAGE AND POTENTIAL DEATH OF HEART TISSUE. THE TERM MYOCARDIAL INFARCTION IS DERIVED FROM MYOCARDIUM (HEART MUSCLE) AND INFARCTION (TISSUE DEATH DUE TO OXYGEN STARVATION).

DEFINITION:

DEFINITION MI MAY BE DEFINED AS A PROCESS BY WHICH THE BLOOD SUPPLY TO THE MYOCARDIAL CELLS IS INTERRUPTED DUE TO OCCLUSION OF AN CORONARY ARTERY BY ATHEROSCLEROTIC PLAQUE, EMBOLUS OR THROMBUS, LEADS TO ISCHEMIA OF THESE CELLS AND IF IT CONTINUED FOR A PROLONGED PERIOD THEN IT CAUSES PERMANENT INJURY TO THE CELLS(MYOCARDIUM), ULTIMATELY LEADS TO INFARCTION AND IS NOT ABLE TO MEET THE METABOLIC NEEDS OF THE CELLS. MYOCARDIAL INFARCTION IS IRREVERSIBLE PROCESS.

RISK FACTORS:

RISK FACTORS MODIFIABLE RISK FACTORS HYPERLIPIDEMIA HYPERTENSION CIGARETTE SMOKING DIABETES MELLITUS OBESITY PHYSICAL INACTIVITY USE OF ORAL CONTRACEPTIVES TYPE A PERSONALITY CHARACTERISTICS NON-MODIFIABLE RISK FACTORS INCREASING AGE GENDER FAMILY HISTORY RACE

PATHOPHYSIOLOGY:

PATHOPHYSIOLOGY OBSTRUCTION OF A CORONARY ARTERY DECREASED BLOOD SUPPLY(OTHER PATHOLOGICAL CONDITIONS) RESULT IN ISCHEMIA & OXYGEN SHORTAGE OF MYOCARDIAL CELLS RESULTS IN CELLULAR INJURY AND UNABLE TO MEET METABOLIC NEEDS OF CELLS

CONTD…:

CONTD… IF ISCHEMIA OCCURS FOR PROLONGED DURATION PERMANENT DEATH OF TISSUES(INFARCTION) OCCURS IRREVERSIBLE CHANGE

CLASSIFICATION:

CLASSIFICATION ACUTE CORONARY SYNDROME (BASED ON LOCATION OF INFARCTION & LAYERS OF HEART INVOLVED) ELECTROCARDIOGRAM ST- ELEVATION NON ST- ELEVATION CARDIAC MARKERS UNSTABLE - ANGINA NEGATIVE POSITIVE MYOCARDIAL INFARCTION

CONTD…:

CONTD… ST E MI N ST E MI Q-wave MI non Q-wave MI ( MI INVOLVE (MI INVOLVES ALL LAYERS SUBENDOCARDIAL OF THE LAYER OF THE HEART) HEART )

CONTD…..:

CONTD….. 2. ANTERIOR MYOCARDIAL INFARCTION It result from the occlusion of LAD. 3. INFERIOR & POSTERIOR MI It result from the occlusion of RCA & Left circumflex artery. 4. LATERAL MYOCARDIAL INFARCTION It result from the occlusion of coronary branches supplying the lateral wall of the left ventricle.

CONTD….:

CONTD…. 5. RIGHT VENTRICULAR MI RV MI RESULTS FROM AN OCCLUSION OF THE RCA. IT OCCURS CHIEFLY IN RELATION WITH AN INFERIOR MI.

CLINICAL MANIFESTATIONS:

CLINICAL MANIFESTATIONS CARDIOVASCULAR RESPIRATORY GENITOURINARY GASTROINTESTINAL SKIN NEUROLOGIC PSYCHOLOGIC

DIAGNOSTIC FINDINGS:

DIAGNOSTIC FINDINGS PATIENT HISTORY PRESENTING SYMPTOMS PREVIOUS ILLNESS FAMILY HISTORY IDENTIFY FOR RISK FACTORS PHYSICAL EXAMINATION CHANGE IN PHYSICAL APPEARANCE INCREASED RESPIRATORY RATE COOL AND PALE SKIN BP MAY BE ELEVATED OR DECREASED

CONTD….:

CONTD…. 5. PULSE MAY BE IRREGULAR(PARADOXICAL) 6. ELEVATED JUGULAR VENOUS PRESSURE HEPATOJUGULAR REFLUX SWELLING OF LEGS DUE TO PERIPHERAL EDEMA. ON AUSCULTATION SYSTOLIC MURMURS CAN BE HEARD .

ELECTROCARDIOGRAM:

ELECTROCARDIOGRAM ECG IS CENTRAL TO DIAGNOSIS OF ACUTE MI & SHOULD BE OBTAINED WITHIN 10min. OF PRESENTATION. THE CLASSIC ECG CHANGES ARE: T-wave INVERSION ST-segment ELEVATION ABNORMAL Q -wave EFFECTS OF ISCHEMIA,INJURY,INFARCTION ON ECG RECORDINGS:- ISCHEMIA CAUSES T-wave INVERSION . INJURY CAUSES ST-segment ELEVATION .

CONTD….:

CONTD…. INFARCTED TISSUE OF MYOCARDIAL WALL CAUSES DEVELOPMENT OF Q-wave THE PRESENCE OF ST-segment ELEVATION STEMI(“ST-ELEVATION MI”) NSTEMI(“Non ST-ELEVATION MI”) THE LEADS WITH ST-SEGMENT ELEVATION HELPS IN IDENTIFYING AREA OF INFARCTION

CONTD….:

CONTD…. Walls Affected Leads Showing ST Segment Elevation Leads Showing Reciprocal ST Segment Depression Suspected culprit Artery SEPTAL V 1 ,V 2 NONE LAD ANTERIOR V 3 ,V 4 NONE LAD ANTEROSEPTAL V 1 ,V 2 ,V 3 ,V 4 NONE LAD ANTEROLATERAL V 3 ,V 4 ,V 5 ,V 6 ,I,aVL II,III,aVF LAD,LCX INFERIOR II, III, aVF I, aVL RCA,LCX

CONTD…:

CONTD… LATERAL I, aVL, V 5 ,V 6 II,III,aVF LCX OR OBTUSE MARGINAL POSTERIO-R V 7 ,V 8 ,V 9 V 1 ,V 2 ,V 3 ,V 4 POSTERIOR DESCENDING RIGHT VENTRICUL-AR II,III,aVF, V 1 I,aVL RCA

CARDIAC MARKERS:

CARDIAC MARKERS CARDIAC MARKERS OR CARDIAC ENZYMES ARE PROTEINS FROM CARDIAC TISSUE FOUND IN THE BLOOD.IN CASE OF MI , THESE PROTEINS ARE RELEASED INTO THE BLOODSTREAM WHEN DAMAGE TO THE HEART OCCURS. CREATININE KINASE: CK-MB FOUND IN CARDIAC CELLS REACHES PEAK LEVEL WITHIN 24 hrs OF MI MYOGLOBIN: FOUND IN CARDIAC AND SKELETAL MUSCLE

CONTD…:

CONTD… MYOGLOBIN LEVEL STARTS TO INCREASE WITHIN 1hr TO 3hr AND PEAK WITHIN 12 hr AFTER ONSET OF SYMPTOMS. 3. TROPONIN:- A PROTEIN FOUND IN MYOCARDIUM, HELPS IN CONTRACTION PROCESS. TROPONIN SUBUNITS(I OR T) USED TO IDENTIFY MYOCARDIAL INJURY. IT REMAINS ELEVATED UPTO 3 WEEKS.

ECHOCARDIOGRAPHY:

ECHOCARDIOGRAPHY IT HELPS IN IDENTIFYING REGIONS OF ABNORMAL WALL MOTION AND ALSO USED FOR RULING OUT HEMODYNAMIC COMPROMISE SUCH AS PERICARDIAL EFFUSION AND MITRAL INSUFFICIENCY.

CARDIAC IMAGING:

CARDIAC IMAGING RADIONUCLIDE STUDIES IS PERFORMED TO VISUALIZE ARES OF REDUCED BLOOD FLOW AND TISSUE NECROSIS. TECHNITIUM-99 AND THALIUM-201 ARE USED.

ANGIOGRAPHY:

ANGIOGRAPHY IT REMAINS THE MOST ACCURATE IN DIAGNOSING THE PERCENTAGE OF BLOCKAGE IN CORONARY ARTERIES DUE TO ATHEROSCLEROSIS.

DIAGNOSTIC CRITERIA:

DIAGNOSTIC CRITERIA WHO CRITERIA HAVE CLASSIFICALLY BEEN USED TO DIAGNOSE MI; A PATIENT IS DIAGNOSED WITH MYOCARDIAL INFARCTION IF TWO OR THREE OF THE FOLLOWING CRITERIA ARE SATISFIED; CLINICAL HISTORY OF ISCHEMIC TYPE CHEST PAIN LASTING FOR MORE THAN 20 min. CHANGES IN SERIAL ECG TRACINGS. RISE & FALL OF SERUM CARDIAC ENZYMES SUCH AS CREATININE KINASE, TROPONIN I SPECIFIC FOR HEART.

COMPLICATIONS:

COMPLICATIONS DYSRHYTHMIAS ECTOPIC RHYTHMS ARISE FROM ISCHEMIC AND DAMAGED MYOCARDIAL TISSUES. HEART BLOCK : DAMAGED MYOCARDIUM INTERFERE WITH THE CONDUCTION SYSTEM, CAUSING DISSOCIATION OF ATRIA & VENTRICLE. VENTRICULAR TACHYARRHYTHMIAS

CONTD…:

CONTD… CARDIOGENIC SHOCK ACUTE MI DIASTOLIC DYSFUNCTION DECREASED SV DECREASED CO DECREASED TISSUE PERFUSION IMPAIRED IN TISSUE METABOLISM

CONTD….:

CONTD …. HEART FAILURE LV FAILURE IS MOST COMMON. DECREASED CONTRACTILITY DECREASED LV FUNCTION DECREASED CO DECREASED LV EJECTION FRACTION.

CONTD….:

CONTD…. MYOCARDIAL RUPTURE IT IS MOST COMMON 3-5 DAYS AFTER MI. OCCUR IN FREE WALLS OF VENTRICLE, THE SEPTUM BETWEEN THEM,OR THE PAPILLARY MUSCLES.

CONTD…:

CONTD… PERICARDITIS THE INFLAMED AREA OF INFARCTION RUBS AGAINST THE PERICARDIAL SURFACE & CAUSES IT TO LOSE ITS LUBRICATING FLUID.

MEDICAL MANAGEMENT:

MEDICAL MANAGEMENT GOALS FOR TREATMENT OF ACUTE MI:- INITIATING PROMPT CARE. REDUCING PAIN DELIVERING SUCCESSFUL TREATMENT FOR THE ACUTE PAIN & REPERFUSION OF THE MYOCARDIUM. PREVENTING COMPLICATIONS.

1. INITIATING PROMPT CARE :

1. INITIATING PROMPT CARE IMMEDIATE ASSESSMENT: ELEVATION OF BED. LOOSEN TIGHT CLOTHING AROUND NECK. MEASURE VITAL SIGNS. MEASURE OXYGEN SATURATION. OBTAIN IV ACCESS. 12-LEAD ECG PERFORM BRIEF HISTORY. OBTAIN INITIAL SERUM CARDIAC MARKERS LEVEL.

2. REDUCING PAIN:

2. REDUCING PAIN IMMEDIATE GENERAL TREATMENT OXYGEN AT 3-4L/min. ASPIRIN 160 to 325 mg. NITROGLYCERINE (SUBLINGUALLY) IV MORPHINE (if pain not relieved with NTG).

3.REPERFUSION OF MYOCARDIUM:

3. REPERFUSION OF MYOCARDIUM THROMBOLYTIC THERAPY PATIENT WITH (STEMI). BUNDLE BRANCH BLOCK ON 12 lead ECG. PATIENT WITH (NSTEMI) MANAGED WITH ANTIPLATELET DRUGS AND ANTICOAGULANTS.

CONTD…:

CONTD… THROMBOLYTIC THERAPY INCLUDES: STREPTOKINASE(1.5 million units) UROKINASE ALTEPLASE( 15mg BOLUS, 50mg OVER 30min 35mg OVER 60min FOR A TOTAL DOSE OF 100mg). ALONG WITH THIS CONTINOUS IV HEPARIN IS GIVEN TO MAINTAIN (aPTT). THROMBOLYTICS AGENTS SHOULD BE GIVEN WITHIN 30 min AFTER MI. ( DOOR TO NEEDLE TIME)

CONTD….:

CONTD…. PERCUTANEOUS CORONARY INTERVENTION(PCI) IT REFERS TO THE GROUP OF PROCEDURES PERFORMED THROUGH PERCUTANEOUSLY TO TREAT CORONARY LESIONS. IT INCLUDES:- ANGIOPLASTY ATHERECTOMY INTERCORONARY STENTING IT SHOULD BE DONE WITHIN 60 min AFTER A CARDIAC EVENT ( DOOR TO BALLOON TIME )

CABG:

CABG

3.PREVENTING COMPLICATIONS:

3. PREVENTING COMPLICATIONS ASSESSMENT PHYSICAL EXAMINATION 12-lead ECG HEMODYNAMIC MONITORING

PHARMOCOLOGICAL MANAGEMENT:

PHARMOCOLOGICAL MANAGEMENT ASPIRIN – ANTIPLATELET EFFECT HEPARIN – THROMBOLYTIC NITRATES BETA-BLOCKING AGENTS ACE-INHIBITORS GPIIb/IIIa ANTAGONIST

NURSING MANAGEMENT:

NURSING MANAGEMENT NURSING DIAGNOSE: ACUTE PAIN RELATED TO MYOCARDIAL ICHEMIA RESULTING FROM CORONARY ARTEY OCCLUSION, AN IMBALANCE BETWEEN MYOCARDIAL OXYGEN SUPPLY AND DEMAND. GOAL : TO REDUCE OR ELIMINATE CHEST DISCOMFORT. INTERVENTIONS: ASSESS PATIENT’S DESCRIPTION OF CHEST DISCOMFORT.

CONTD…:

CONTD… 2. ASSESS BP, HEART RATE & RHYTHM & RESPIRATORY RATE. 3. ASSESS THE SKIN FOR TEMPERATURE AND MOISTNESS. 4. OBTAIN A 12-LEAD ECG DURING CHEST DISCOMFORT. 5. ADMINISTER OXYGEN, NTG, IV MORHINE, OR OTHER MEDICATION AS ORDERED. 6. PROVIDE A RESTFUL ENVIRONMENT: BY ELEVATING HEAD OF BED. 7. PROVIDE CARE IN A CALM, QUIET ENVIRONMENT.

Contd…..:

Contd….. 2. INEFFECTIVE TISSUE PERFUSION RELATED TO AN IMBLANCE BETWEEN MYOCARDIAL OXYGEN SUPPLY AND DEMAND AND MANIFESTED BY CHEST DISCOMFORT, DYSRHYTHMIAS. GOAL :- TO REDUCE OR ELIMINATE MANIFESTATIONS OF DECREASED MYOCARDIAL TISSUE PERFUSION. INTERVENTIONS:-

CONTD:-:

CONTD:- KEEP THE CLIENT ON BED REST WITH A QUIET ENVIRONMENT. ADMINISTER OXYGEN AND ANTIRRHYTHMIC AND OTHER MEDICATIONS AS ORDERED AND CONTINOUSLY EVALUATING PATIENT CONDITION. ADMINISTER THROMBOLYTICS OR SEND THE CLIENT FOR ANGIOPLASTY AS ORDERED. MONITOR ST SEGMENTS.

CONTD….:

CONTD…. 3. DECREASED SYSTEMIC TISSUE PERFUSION RELATED TO A DECREASE IN CARDIAC OUTPUT FROM ARRHYTHMIAS AND CONDUCTIVE DISTURBANCES. GOAL:- 1. REDUCE OR ELIMINATE MANIFESTATIONS OF DECREASED SYSTEMIC TISSUE PERFUSION. 2. PREVENT MANIFESTATIONS OF DECREASED SYSTEMIC TISSUE PERFUSION. INTERVENTIONS:-

CONTD…:

CONTD… DECREASED PATIENT PHYSICAL ACTIVITY. ADMINISTER OXYGEN AND ANTIRRHYTHMIC AND OTHER MEDICATIONS. ASSESS FOR PERIPHERAL PERFUSION:- BY MONITORING SKIN FOR CYNOSIS, PALLOR, COOLNESS,DIAPHORESIS AND PERIPHERAL PULSES. CHECK FOR CEREBRAL PERFUSION:- BY CHECKING MENTAL STATUS( RESTLESSNESS, DECREASED RESPONSIVENESS).

CONTD….:

CONTD …. 5. AUSCULTATE FOR LUNG SOUNDS:- BY MONITORING FOR CRACKLES. 6. AUSCULTATE FOR HEART SOUNDS:- NOTE THE PRESENCE OF GALLOP, MURMUR, AND INCREASED OR DECREASED HEART RATE. 7. CHECK FOR RENAL PERFUSION:- DECREASED URINE OUTPUT. 8. MONITOR ARTERIAL BLOOD GAS LEVELS.

CONTD…:

CONTD… IMPAIRED GAS EXCHANGE RELATED TO DECREASED CARDIAC OUTPUT, AS EVIDENCED BY CYANOSIS, IMPAIRED CAPILLARY REFILL TIME, DYSPNEA. GOAL :- TO IMPROVE GAS EXCHANGE. INTERVENTIONS:-

CONTD…:

CONTD… ADMINISTER OXYGEN AS ORDERED MAINTAIN ABGs AS ORDERED. CONTINUE TO ASSESS THE CLIENT’S SKIN, CAPILLARY REFILL, AND LEVEL OF CONSCIOUSNESS EVERY 2 to 4 hrs. ASSESS RESPIRATORY STATUS FOR DYSPNEA AND CRACKLES. PREPARE FOR INTUBATION & MECHANICAL VENTILATION IF HYPOXIA INCREASES.

CONTD…:

CONTD… ANXIETY AND FEAR RELATED TO DIAGNOSIS, TREATMENT,AND PROGNOSIS OF ANGINA, MANIFESTED BY ABNORMAL RATE AND RHYTHM OF PULSE AND RESPIRATION, ELEVATED BP. GOAL :- TO ALLAY ANXIETY AND FEAR. INTERVENTIONS:-

CONTD…:

CONTD… ASSESS AND DOCUMENT THE PATIENT’S AND FAMILY’S LEVEL OF FEAR AND ANXIETY AND EFFECTIVENESS OF COPING MECHANISM. PROVIDE CONTINUITY OF CARE. ALLOW AND ENCOURAGE THE CLIENT AND FAMILY TO ASK QUESTIONS. ALLOW THE CLIENT AND FAMILY TO VERBALIZE FEARS. PROVIDE A COMFORTABLE, QUIET ENVIRONMENT FOR THE CLIENT & FAMILY.

CONTD….:

CONTD…. 6. KNOWLEDGE DEFICIT RELATED TO MI, TREATMENT, PROGNOSIS, AND RISK FACTORS. GOAL:- TO GIVE ADEQUATE KNOWLEDGE ABOUT HIS DISEASED PROCESS. INTERVENTIONS:

CONTD…:

CONTD… DEVELOPMENT OF A TEACHING PLAN ENABLES THE NURSE TO PROMOTE STANDARDIZED CONTENT TO EACH PATIENT. TEACH PATIENT TO DECREASE PHYSICAL ACTIVITY AND TAKE NTG AS PRESCRIBED DURING PERIODS OF ANGINA. TEACH PATIENT TO SEEK MEDICAL ATTENTION IMMEDIATELY IF RELIEF OF CHEST PAIN HAS NOT OCCURRED WITHIN 30 min.

CONTD…:

CONTD… PROVIDE CONCRETE INFORMATION ABOUT DIAGNOSTIC PROCEDURES PERFORMED ON PATIENT AND THE RATIONALE BEHIND IT. TEACH PATIENT AND RELATIVES ABOUT THE IMPORTANCE OF CHANGING LIFESTYLES.PROVIDE INFORMATION ABOUT MODIFICATION OF RISK FACTORS. TEACH PATIENT TO REDUCE PRECIPITATING FACTOR.

SUMMARISATION:

SUMMARISATION INTRODUCTION DEFINITION RISK FACTORS PATHOPHYSIOLOGY CLASSIFICATION CLINICAL MANIFESTATIONS ASSESSMENT & DIAGNOSIS DIAGNOSTIC CRITERIA COMPLICATIONS MEDICAL MANAGEMENT PHARMACOLOGICAL MANAGEMENT NURSING MANAGEMENT

REFERENCES:

REFERENCES WILKIN’S & WILLIAM’S, “CARDIAC NURSING”, 5 th EDITION,”WOLTER’S KLUWER COMPANY”,Pg no. 550-580. SMELTZER C. SUZZANE,”TEXTBOOK OF MEDICAL-SURGICAL NURSING”,10 th EDITION,”LIPPINCOTT WILLIAMS& WILKIN’S, PHILADELPHIA,Pg NO.725-738. BLACK M.JOYCEE,”MEDICAL-SURGICAL NURSING”,VOL-2,7 th EDITION,”ELSEVIER”, Pg No. 1701-1727. www.google.com

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