Myocardial Infarction

1. Myocardial Infarction Amanda Cooley, Sean McLean, Judy Wilkin

2. Mr. Miller 58 yrs old

3. Emergency Department • Mr. Miller presents in the ED with chest pain that he describes as an achiness/pressure. • Rates his pain 5/10 • Radiates to his left arm • Complains of shortness of breath but not diaphoretic • Last night the chest pain came on at rest and lasted throughout the night. • Decided to go to ED when pain did not reside.

4. Past Medical History • Diabetes II • HTN • Hyperlipidemia • Obesity: 320 lbs-BMI 35 • Obstructive Sleep Apnea

5. Initial Assessment Vital Signs: • Temp: 99.2 • Pulse: 108 • Respirations: 20 • BP: 164/86 • O2 Sats: 96% RA Nursing Assessment: • RESP: CTA Bilateral, non-labored • CARDIAC: pink, warm & dry, S1S2, no edema, pulses 3+ in all extremities • NEURO: alert & oriented x 4, anxious • GI/GU: active BS in all quads, soft/non-tender, voiding w/o difficulty, frequency, but no pain, urine clear • MISC: pale, beads of sweat on forehead

6. Lab/Diagnostic Results • CXR: clear with no infiltrates. Heart is moderately enlarged(most likely due to HTN & Obesity) • EKG: 2mm ST elevation across leads V1-V4 • Troponin: 1.6 (Normal: < 0.1) • CK: 588 (Normal: 55-170) • CK-MB: 85 (Normal: < 6.7)

7. STEMI

8. Physician Orders • NTG 0.4mg subl. Every 5 min x 3……..follow with NTG gtt. Titrate to pain relief and SBP >90 • ASA 325 mg PO • Plavix 600 mg PO • Heparin gtt IV and bolus per protocol • Metoprolol 5 mg IV every 5 min x 3 Hold if HR < 50 or SBP <90 • Transfer to Cath lab ASAP for coronary angiogram • ? No pain medication ordered. Pt rates 5/10 and is very anxious. Maybe Nitro will relieve pain.

9. Medications • Aspirin is the preferred antiplatelet agent for preventing platlet aggregation in patients having an MI. • Nitro is a vasodilator helping to dilate vessels and reperfuse the ischemic cardiac tissue and helps relieve coronary pain. • Metoprolol is a betablocker and acts as antagonists to -receptor–mediated functions of the sympathetic nervous system and thus decrease myocardial oxygen demand by reducing heart rate, cardiac contractility, and systemic arterial blood pressure. • Heparin in an anti-coagulant and assists in preventing more blockage and assisting in reperfusion. • Plavix also prevents platlet aggregation used sometimes instead of aspirin or along with.

10. STEMIST Elevation Myocardial Infarction • Also known as heart attack, is characterized by the ischemic death of myocardial tissue associated with atherosclerotic disease of the coronary arteries. The area of infarction is determined by the coronary artery that is affected an by its distribution of blood flow. The injured myocardial cells depolarize normally but repolarize more rapidly than normal cells, causing the ST segment to rise at least 1 mm. Elevation is in two leads is a key indicator of infarction. • According to Mr. Miller’s EKG ST elevation was seen in leads V1-V4 anterior so we expect the left anterior descending artery to be blocked.

11. What image looks like under Fluroscopy.

12. Primary Concerns • Get Mr. Miller to the Cath Lab as soon as possible • Make sure he has two IVs started. • Start Heparin and Nitro Drips • Administer oral medications and oxygen as while closely monitoring vital signs and ECG

13. PriorityPerfusion, Perfusion, Perfusion • The faster we get Mr. Miller to the Cath lab the more cardiac tissue we are saving from ischemia. • By administering the medications ordered we are already starting to help save cardiac tissue. • Perfusion to the cardiac tissue is key here. Getting as much blood flow past the blockage as possible without dropping Mr. Miller’s HR and BP to low. • Primarily focusing on perfusion to cardiac tissue as long as his airway and breathing are intact.

14. Worst Case Scenario Cardiac Arrest

15. Nursing Plan of Care Nursing Diagnoses Interventions Administer medications and get pt to cath lab as soon as possible. Assess peripheral perfusion often until care is transferred.. Teach patient to help ease his fears about his condition and the procedure. • Ineffective cardiac tissue perfusion related to reduced coronary blood flow. • Risk for ineffective peripheral tissue perfusion related to decreased cardiac output from left ventricular dysfunction • Death anxiety related to cardiac event.

16. Education Plan • What is a Cardiac Catheterization? • Why does Mr. Miller need it? • Help Mr. Miller develop questions to ask Cardiologist when he comes in. • Teach Mr. Miller about what we are doing to prepare him for this procedure and why these thing are necessary. • Teach Mr. Miller about what happens during procedure and after.

17. N-CLEX Questions

18. Nursing Care Question • If a client who was admitted for MI develops cardiogenic shock, which characteristic signs should the nurse expect to observe? 1) Oliguria 2) Bradycardia 3) Elevated blood pressure 4) Fever

19. Teaching Question • Sublingual nitroglycerin tablets begin to work within 1-2 minutes. How should the nurse instruct the client to use the drug when chest pain occurs? 1)Take one tablet every 2 to 5 minutes until the pain stops 2) Take one tablet and rest for 10 minutes. Call the physician if pain persists after 10 minutes. 3) Take one tablet, then an additional tablet every 5 minutes for a total of three tablets. 4) Take one tablet. If pain persists after 5 minutes take two tablets. If pain still persists 5 minutes later, call the physician.

20. Medical Care Question • A client with angina has been taking nifedipine(Procardia). The nurse should teach the client to: 1) Monitor blood pressure. 2) Perform daily weights. 3) Inspect gums daily. 4) Limit intake of green leafy vegetables.