Myocardial Infarction

1
MyocardialInfarction

• -Heart Attack-

Carina Amor Bernardo, RN OPD-IM Staff
2
demographic data

• Patient J
• Case 157
• Age 37 years old
• Sex Male
• Nationality Filipino
• Diagnosis Inferiorposterior
• Myocardial Infarction

3
physical assessment
GENERAL

• Conscious and coherent
• Slightly weak
• In pain presented by facial grimaced while
  clutching his chest.
• Vital signs
• BP 90/80mmHg
• Temp 37C
• PR 80 bpm
• RR 32 cpm
• SPO2 99
• GCS 15/15

4
INTEGUMENTARY

• Cold and clammy skin.
• Diaphoretic.
• HEAD AND NECK
• Hair are evenly distributed.
• Facial symmetry.
• No deformity noted.
• No lesions and masses palpated.
• Slightly sunken eyeballs, no redness, no
  discharges, pupils are reactive to light.

5

• No nasal congestion or drainages noted.
• Lips are dry and pale but no ulcers are noted.
• Also no palpable lymph nodes are noted.
• BODY AND EXTREMITIES
• No physical deformities are noted.
• Good range of motion.
• Thorax is symmetric, slight retraction of the
  intercostal muscles during inspiration.
• Bilateral chest movements present. No crackles,
  no wheezing are noted.
• Soft abdomen palpated. Positive bowel sound
  noted.

6
PAST MEDICAL HISTORY

• NO
• DM
• HTN
• IHD
• YES
• SMOKER FOR
• MORE THAN
• 10 YEARS

7
PRESENT MEDICAL HISTORY

• Patient J was brought to the hospital by a
  private car with the complaint of chest pain
  radiating to his left shoulder and arm, pain
  scale results 8-9/10 in severity with sweating
  and nausea but no vomiting. Pain started one hour
  before he came to our hospital. He denies
  dyspnea, cough, or other symptoms. Patient was
  diaphoretic in severe pain. ECG showed sinus
  rhythm (SR) and 3 mm ST elevation II, III, AVF
  and 2 mm ST depression in V2-V3 and I, AVL leads,
  heart rate 80bpm. Myocardial Infarction.

8
definition

• Myocardial Infarction (MI) or Acute Myocardial
  Infarction (AMI), commonly known as a Heart
  Attack, results from the partial interruption of
  blood supply to a part of the heart muscle
  causing the heart cell to be damaged or die.

9
Basic Anatomy of the Heart

• The heart is the hardest working muscle in the
  human body. Located almost in the center of the
  chest, the adult human heart is about the size of
  one fist.
• The cardiovascular system, composed of the heart
  and blood vessels, is responsible for circulating
  blood throughout our body to supply the tissues
  with oxygen and nutrients.

10

• The heart is the muscle that pumps blood filled
  with oxygen and nutrients through the blood
  vessels to the body tissues. It is made up of
• Four chambers (two atria and two ventricles) that
  receive blood from the body and pump out blood to
  it
• The atria receive blood coming back to the heart.
• The ventricles pump the blood out of the heart. 
• Blood vessels, which compose a network of
  arteries and veins that carry blood throughout
  the body
• Arteries transport blood from the heart to the
  body tissues.
• Veins carry blood back to the heart.
• Four valves to prevent backward flow of blood
• Each valve is designed to allow the forward flow
  of blood and prevent backward flow.
• An electrical system of the heart that stimulates
  contraction of the heart muscle.

11
STRUCTURE OF THE HEART

• Pericardium - it is a tough double layered
  membrane/sac which covers the heart.
• Myocardium - is the muscular tissue of the heart.
• Endocardium -  is the innermost layer of tissue
  that lines the chambers of the heart.

12
  BLOOD CIRCULATION
13
INFARCTED HEART
14
PATHOPHYSIOLOGY
Predisposing factors
Premature, Accelerated Atherosclerosis
Progressive narrowing of blood vessels
Risk for excessive blood clot formation
Ischemia of the muscle
Thromboembolism
Hypoxia
15
Necrosis
Release of Lysozomal Enzyme
Aerobic to Unaerobic metabolism
Myocardial Contractility
Altered Depolarization
Lactic Acid formation
Cardiac Output
Renal Ischemia, Oliguria
Altered Repolarization
Chest Pain/Muscle Spasm
Myocardial Infarction
16
IMPORTANT RISK FACTORS

• Previous cardiovascular disease
• Older age
• Tobacco smoking
• High levels of certain lipids and low levels of
  high density lipoprotein
• Excessive alcohol consumption and drug abuse
• Diabetes
• High blood pressure
• Obesity
• Chronic kidney disease
• Heart failure
• Chronic high stress levels

17
signs and symptoms
SUDDEN CHEST PAIN
SHORTNESS OF BREATH
ANXIETY
SEEK HELP
NAUSEA AND VOMITING
SWEATING
PALPITATIONS
18
SOME CASES . .
25 are silent
WITHOUT CHEST PAIN OR OTHER SYMPTOMS
19
CLASSIFICATIONS

• Transmural associated with atherosclerosis
  involving a major coronary artery. It can be
  subclassified into anterior, posterior, inferior,
  lateral or septal.
• Subendocardial involving a small area in the
  subendocardial wall of the left ventricle,
  ventricular septum, or papillary muscles.

20
PATIENT Js ECG
21
BLOOD CHEMISTRY
Test Result Adult Reference Range
SODIUM 138 135-150 mmol/l
POTASSIUM 3.8 3.5-5.0 mmol/l
CHLORIDE 106 98-111 mmol/l
CPK (CK) 275 26-308 u/l
CK-MB 64.4 7.0-25.0 u/l
AST (SGOT) 36 M 10-38 U/L
ALT (SGPT) 74 10-41 U/L
CHOLESTEROL 6.9 3.1-5.2 mmol/L
TRIGLYCERIDES 1.38 0.34-2.30 mmol/L
HDLc 1.14 M 0.9-1.87 mmol/L
LDLc 5.05 3.9-4.7 mmol/L
Troponin Quantitative 0.628 lt0.120 ng/ml
22
MEDICAL MANAGEMENT

• Oxygen administration is initiated at the onset
  of chest pain.
• Cardiac Monitoring (ECG/2D Echo)
• Emergent Percutaneous Transluminal Coronary
  Angioplasty (PTCA).
• Coronary Artery Bypass or Minimal Invasive Direct
  Coronary Artery Bypass (MIDCAB).
• Angiography
• DIET Low Salt, Low Fat.

23
PHARMACOLOGIC THERAPY
Drugs Dose/Route/Frequency Action
Aspirin 81mg tab., PO, OD Pain killer, it also thins the blood in order to lower the risk of blood clots in coronary artery.
Plavix 75mg tab., PO, OD Used to prevent blood clots after a recent heart attack or stroke, and in people with certain disorders of the heart or blood vessels.
Crestor 20mg tab., PO, OD Reduces levels of "bad" cholesterol (low-density lipoprotein, or LDL) and triglycerides in the blood, while increasing levels of "good" cholesterol (high-density lipoprotein, or HDL).
Morphine Sulfate 2mg/ml, I.V., PRN Pain killer.
Clexane 80mg/0.8ml, S.C., BID an anticoagulant (blood thinner) that prevents the formation of blood clots.
24
NURSING INTERVENTIONS

• Monitor and record the patients vital signs and
  ECG readings.
• Assess level of consciousness.
• Evaluate chest pain, give analgesics as ordered.
• Check the patients blood pressure before and
  after giving nitroglycerin, especially on the 1st
  dose.
• Observe urinary output and check for edema an
  early sign of cardiogenic shock is hypotension
  with oliguria.
• Assess bowel motility mesenteric artery
  thrombosis is a potential fatal complication.
• Provide emotional support, and help reduce stress
  and anxiety.
• Organize patient care and activity to minimize
  periods of uninterrupted rest.

25
NURSING DIAGNOSIS

• Acute pain related to myocardial infarction.
• Anxiety related to fear of death.
• Impaired gas exchange related to fluid overload
  due to left ventricular dysfunction.

26
POTENTIAL COMPLICATIONS

• Dysrhythmias and Cardiac Arrest.
• Acute Pulmonary Edema.
• Heart Failure.
• Thromboembolism.
• Myocardial Rupture.
• Pericardial Effusion and Cardiac Tampobade.

27
Nursing Care Plan
ASSESSMENT PLANNING IMPLEMENTATION EVALUATION
Cues/Evidence Nursing Diagnosis Goals and Desired Outcome Nursing Interventions Rationale Evaluation
SUBJECTIVE I feels like there is a heavy object over my chest, and it cause a lot of pain. OBJECTIVE Sweating, Cold and clammy skin. Clutching his chest. Facial grimaced, Pain Scale 8-9/10. Acute Pain related to Myocardial Infarction. After 6-8 hours of nursing interventions, patient will be relieve from pain. Monitor the vital signs. BP 90/80mmHg T 37C PR 80bpm RR 32cpm Administer oxygen in tandem with analgesia as ordered. Aspirin 81mg,OD Plavix 75mg, OD Assist patient in relaxation techniques. Provide baseline data regarding the patients condition. To ensure maximum relief of pain. Assist in the reduction in the perception / response to pain. Giving control of the situation, increase positive behavior. After 6-8 hours of nursing interventions the goals were partially met as evidenced by Less facial grimaced, Pain scale 4-5/10. Expresses less anxiety. Complies with self-care program.
28
NURSING HEALTH TEACHING

• Explained the importance of totally giving up
  smoking, because it is the single most effective
  way to reduce the risk of having a further MI. 
• Suggest some changes in diet can make a big
  difference. People who eat a healthy diet may
  halve their chance of a further heart attack
  compared to those who do not eat healthily.
• Advised to have normal physical activity and
  regular exercise.
• Emphasized the importance of take home
  medications prescribed by the physician.

29
CONCLUSION

• When someone is suffering from chest pain,
  an ECG should be run to assess electrical
  activity of the heart and initial treatment
  should be given. Then further tests, such as an
  angiography, should be run as quickly as possible
  to learn more about the prognosis and apply
  findings to distinguish a more appropriate
  treatment.
• For any health problems, early detection is
  very important, even with or without any signs
  and symptoms persist.
• The importance of healthy living,
  especially healthy diet is the most effective way
  to avoid such disease like myocardial infarction.

30
BIBLIOGRAPHY

• Brunner Suddarths Medical-Surgical Nursing
  Textbook 10th Edition.
• http//www.patient.co.uk/health/Myocardial-Infarct
  ion-After-the-MI.htm
• http//www.webmd.com/heart-disease/understanding-h
  eart-attack-basics

31
THANK YOU__