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Nursing 272: Final Semester > Unit 2: Myocardial Infarction (MI) > Flashcards

Unit 2: Myocardial Infarction (MI) Flashcards

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1
Q

Acute Myocardial Infarction

A

destruction of heart muscle from lack of oxygenated blood supply
-common cause of obstruction = atherosclerosis

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2
Q

Risk Factors for Heart Disease and MI

A

-cigarette smoking
-high LDLs
-type 2 diabetes
-elevated adrenaline (catecholamines)
-obesity
-inactivity
-hypertension
-male gender
-post menopausal female
-family hx
>can occur at any time
>most dangerous time = early morning hours; may be d/t higher levels of circulating adrenaline at this time

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3
Q

Atherosclerosis

A

gradual build up of plaque inside the wall of the artery

  • rupture of plaque = thrombus formation and obstruction of coronary artery flow = ischemia and death of heart muscle
  • heart muscle damaged by inadequate blood supply cannot maintain normal cardiac function = decrease in cardiac output (CO)
  • systemic symptoms associated w/ MI = chest pain and poor peripheral perfusion
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4
Q

Stable Angina

A

episodes of intermittent chest pain present when artery is narrowed 60 to 70%

  • associated w/ activity or exercise
  • relieved by rest
  • not associated w/ damage to heart muscle
  • warning sign for potential heart muscle damage
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5
Q

Acute Coronary Syndrome

A 
umbrella term
-used when there is concern for myocardial ischemia
>unstable angina (UA)
>non-ST elevation MI (NSTEMI)
>ST elevation MI (STEMI)
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6
Q

Unstable Angina

A

pain not associated w/ exercise

  • not relieved by rest
  • may present w/ ECG changes
  • no elevation in cardiac markers
  • may present w/ nonspecific or transient ST segment depressions or elevations
  • emergency = requires immediate tx
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7
Q

Non-ST elevation MI (NSTEMI)

A

partial occlusion of a major coronary vessel or complete occlusion of a minor coronary vessel

  • causes reversible partial thickness heart muscle damage
  • ST depressions (0.5 mm at least) or
  • T wave inversions (1.0 mm at least)
  • w/o q waves in 2 contiguous leads w/ prominent R waves or AR/S ratio > 1
  • elevated cardiac markers
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8
Q

ST Elevation MI (STEMI)

A

complete occlusion of a major coronary vessel

  • results in irreversible full thickness heart muscle damage
  • ST elevations
  • elevated cardiac markers
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9
Q

Clinical Manifestations

A

-Chest Pain (angina); from obstructed blood flow to the heart muscle
-Angina can be stable or unstable
>Stable (exertional) angina: occurs during activity, has predictable pattern, goes away w/ rest
>Unstable (rest) angina: more serious; can occur at rest w/ no specific pattern, not relieved by change in activity, medical emergency
-angina is a warning sign of impending MI

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10
Q

Symptoms in addition to Chest Pain when there is a complete occlusion of the vessel resulting in an MI and muscle damage

A
  • shoulder and arm pain (more on left)
  • jaw and tooth pain
  • shoulder blade pain
  • upper back pain
  • SOB
  • nausea and vomiting
  • sweating
  • generalized fatigue
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11
Q

Things to consider w/ person to person

A
  • symptoms can vary significally from person to person
  • women are more likely to have neck, shoulder blade, jaw, and abdominal pain
  • diabetes are more likely to have SOB and fatigue
  • geriatrics tend to have co-morbidities may mimic angina; may experience dyspnea, syncope, weakness, or confusion
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12
Q

Right MI

A

right coronary artery/ventricle

  • Jugular Vein Distention (JVD)
  • Hypotension
  • Bradycardia r/t damage to SA node
  • Nausea and vomiting
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13
Q

Left MI

A

left coronary artery/ventricle
-worse prognosis; high risk of sudden death and congestive heart failure
-dyspnea
-tachycardia
-hypertension
>tachycardia and hypertension result from the loss of CO b/c of damage to the left ventricle and subsequent stimulation of sympathetic compensatory mechanisms
-hypotension will quickly evolve

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14
Q

Laboratory Testing

A
  • Creatinine kinase (CK)
  • Creatinine Kinase Myocardial Bands (CK-MB)
  • Troponin (I and T)
  • CMP, CBC, Coagulation, and ABGs
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15
Q

Laboratory Testing: Creatinine Kinase (CK)

A

general marker of cellular injury

-released from cells in the brain, skeletal muscle, and cardiac tissue after muscle damage has occurred

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16
Q

Laboratory Testing: Creatinine Kinase Myocardial Bands (CK-MB)

A

0-3 mg/dl

  • CK isoenzyme marker specific to cardiac tissue
  • when myocardial damage occurs, CK-MB is released from the cells
  • can remain elevated for up to 36 hours before returning to normal
  • increased levels can be seen at 3 hours after injury
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17
Q

Laboratory Testing: Troponin (T and I)

A

proteins expressed almost exclusively in the heart; specific marker of cardiac muscle damage
-less than 0.4 mg/ml (<0.4 mg/ml)
-can elevate within 4 hours of injury
-levels can stay elevated for up to 10 days
(b/c it stays elevated longer than CK-MB, it is a valuable marker when attempting to diagnose injury in recent past
-blood test of choice

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18
Q

Laboratory Testing: CMP

A

complete metabolic profile (CMP)

  • electrolytes
  • tests of organ system functioning (eg. Renal values: BUN + Creatinine)
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19
Q

Laboratory Testing: CBC

A

complete blood count (CBC)

-tests hemoglobin, hematocrit, and WBC

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20
Q

Laboratory Tests: Coagulation

A
  • Prothrombin time (PT): 10-13 sec
  • Activated Partial Thromboplastin Time (aPTT): 25-35 sec
  • INR: <2.0
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21
Q

Diagnostic Tests for MI

A

Invasive + Noninvasive

  • ECG
  • Echocardiogram
  • Stress testing
  • Coronary Angiography
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22
Q

Electrocardiogram (ECG)

A

-gold standard for diagnosis of MI
-inexpensive, easy to perform, safe, painless
>ST depression = ischemia
>ST elevation = infarction
>Q wave = confirms MI (later on)

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23
Q

Echocardiography

A
  • used to evaluate the ventricular functions (ejection fraction [EF])
  • assists in diagnosing an MI by looking at specific areas of heart muscle that are not contracting (wall motion abnormalities)
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24
Q

Stress Testing

A
  • not done during time an MI is evolving
  • another way to evaluate heart function
  • types: exercise stress test, dobutamine/adenosine test, stress echo, nuclear stress test
  • dependent on pts needs and condition
  • looks at coronary blood flow
  • looks at left ventricular function and wall motion abnormalities
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25
Q

Nuclear Stress Test

A

best for diagnosing myocardial ischemia; reveals amount of viable heart muscle

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26
Q

Coronary Angiography

A

gold standard for the diagnosis of flow-limiting coronary artery disease
-allows visualization of any obstruction or narrowing of the coronary arteries
-involves catheter insertion into radial or femoral artery, and advanced up to the heart
-radiopaque dye injected through the catheter into the coronary artery while sequences of x-rays (fluoroscopy) are obtained
>a ventriculogram can also be performed; positioning the catheter to allow injected dye to enter the left ventricle; demonstrates how efficiently the left ventricle fills and pumps blood, how well blood flows through the aortic and mitral valves, and size of left ventricle

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27
Q

Treatment for MI

A
  • maximizing oxygenation
  • administering medications to control pain, dilate the coronaries, prevent clots, and decrease myocardial workload
  • then therapies to increase blood flow to cardiac tissue, or reperfusion therapy (within 90 minutes)
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28
Q

Immediately upon arrival to the hospital, what should the patient recieve?

A
  • Oxygen
  • Sublingual (SL) nitroglycerin
  • Aspirin
  • Pain medication (morphine sulfate) if pain is not relieved by the SL nitroglycerin
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29
Q

Supplemental Oxygen

A
  • recommended for all patients w/ a suspected MI
  • used if in respiratory distress, if arterial saturation is less than 90%
  • for patients w/ high risk of hypoxia
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30
Q

Nitroglycerin

A

dilates coronary arteries; increasing blood flow to the heart in an attempt to limit myocardial muscle damage and control pain

  • one tablet sublingual q 5 minutes for a max of 3 doses as long as the patient maintains adequate BP
  • if pain not controlled with 3 doses, IV nitroglycerin will be started
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31
Q

Aspirin

A

given to help prevent platelets from enlarging the existing clot or new clots from forming

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32
Q

Morphine Sulfate

A

can be given to control pain

  • relieves chest pain
  • masks pain symptoms; not improving coronary blood flow, potentially worsening MI
  • used only if pain is not relieved by Nitroglycerin
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33
Q

Beta Blockers

A

> Metoprolol (Lopressor)
Atenolol (Tenormin)
-to decrease sympathetic nervous system response
-decreases myocardial workload and myocardial oxygen consumption
-not used in right coronary artery MI experiencing bradycardia

34
Q

Heparin

A

heparin sodium infusion

  • helps prevent new clot formation
  • anticoagulant
35
Q

Commonly Prescribed Medications for MI

A
  • Antiplatelet: Aspirin, Clopidogrel (Plavix), Eptifibatide (integrilin)
  • Anticoagulants: Heparin, Enoxaparin (Lovenox), Factor XA inhibitors
  • Narcotics: Morphine Sulfate, Hydromorphone (Dilaudid)
  • Beta Blocker: Metoprolol (Lopressor), Atenolol (Tenormin)
  • Nitrates: (Nitroglycerin)
  • Thrombolytics: (Alteplase (Activase), Reteplase (Retavase)
36
Q

Thrombolytics

A

> Alteplase (Activase)
Reteplase (Retavase)
revascularization of the heart muscle by dissolving clots in arteries

37
Q

Reperfusion Therapy

A
  • Percutaneous Coronary Intervention (PCI)

- Fibrinolytic Therapy

38
Q

Percutaneous Coronary Intervention (PCI)

A

most preferred method for opening blocked vessels that cause MI

  • done within 90 minutes of arrival to hospital
  • catheter w/ small balloon on its tip is inserted into an artery (radial or femoral) and advanced under fluoroscopy up to the left side of the heart and coronary arteries
  • balloon is inflated and deflated to open the lumen of the blocked artery
  • lumen opened –> a stent may be advanced to the location to hold the artery open and maintain adequate blood flow
  • risk of bleeding
  • femoral approach: need to lie flat w/o bending leg for 2 to 6 hours to allow artery to heal
  • radial preferred; risk for internal bleeding eliminated; external bleeding easily compressed
  • radial artery catheter removal–> compression device placed; no requirement for pt to remain immobile
39
Q

Fibrinolytics

A

medications that accomplish revascularization through fibrinolysis of the existing clot

  • administered within 30 minutes of arrival to hospital
  • considered if not contraindicated and immediate PCI not available
40
Q

Contraindications for Fibrinolytics

A
  • recent surgery or bleeding
  • presence of peptic ulcer
  • uncontrolled hypertension
  • pregnancy
  • non-compressible vascular punctures
41
Q

Complications of Fibrinolytics

A
  • bleeding

- increased risk of intracranial hemorrhage

42
Q

Coronary Artery Bypass Grafting (CABG)

A

surgical revascularization intervention that bypass blockages in the coronary arteries causing the myocardial muscle damage
-not first line; PCI and Fibrinolytics much quicker and do not require a surgical procedure
>in CABG, a healthy artery or vein is grafted to the blocked coronary artery; one end attached to the aorta while the other end is attached to the blocked coronary distal to the occlusion; by passing the blocked portion of the artery allowing blood to flow to the cardiac tissue

43
Q

Indications for CABG

A
  • unsuccessful PCI or not a candidate for PCI
  • failure of medical management
  • critical left main or 3 vessel disease
44
Q

Complications of CABG

A
  • bleeding
  • dysrhythmias
  • MI
  • stroke
  • nonunion of sternum
  • sternal infection
  • renal failure b/c of decreased renal blood flow
  • heart failure
45
Q

Complications of Bypass

A
  • induction of a systemic inflammatory response resulting in vasodilatory shock
  • heparin-induced thrombocytopenia
  • activation of platelets
  • complications associated w/ cross clamping the aorta during the procedure
46
Q

Secondary Prevention

A
  • cardiac rehabilitation after acute cardiovascular event (MI), percutaneous intervention, or surgical revascularization
  • supervised exercise program
  • education regarding diet, weight management, medication purpose and side effects, psychosocial support
  • Goal: improve recovery from event; improve quality of life
  • evaluated by cardiac specialists
47
Q

Complications of MI

A
  • Heart Failure
  • Arrhythmias
  • Cardiogenic Shock
48
Q

Complication of MI: Heart Failure

A

when an MI causes a large amount of heart muscle to die, there is decreased left ventricular function
-inability to produce an adequate cardiac output (CO) to maintain body’s metabolic demands

49
Q

Complication of MI: Arrhythmias

A

> Asystole
Symptomatic bradycardia
Heart Block
Ventricular arrhythmias
-asystole, symptomatic bradycardia, and heart block are associated w/ sinoatrial (SA) node dysfunction; most common after an inferior wall MI b/c the right coronary artery supplies the SA node (located in R atrium)
-temporary pacemaker may be used to prevent asystole
-ventricular arrhythmias occur in first 48 hours of MI
-immediate defibrillation tx of choice for v-fib and pulseless ventricular tachycardia

50
Q

Nursing Management: Assessment + Analysis of MI

A

the clinical manifestations of MI is r/t lack of oxygen delivery to the heart and resulting decrease of cardiac output

  • chest pain
  • shortness of breath
  • nausea/vomiting
  • dizziness
  • diaphoresis and pallor
51
Q

Women may present w/ clinical manifestations of:

A
  • neck, shoulder blade, and jaw pain

- abdominal pain

52
Q

Older Adults/ Geriatrics may show clinical manifestations of:

A
  • dyspnea
  • syncope
  • weakness
  • confusion
  • pts can be tachycardic w/ borderline low BP
53
Q

Nursing Assessments for MI

A
  • Vital signs
  • Pulse Oximetry
  • Characteristics of Pain
  • Assess ECG changes
  • Assess for restlessness
  • Skin color and temperature, diaphoresis
  • Peripheral pulses
  • Urine output
  • Asses Troponin, CK, CK-MB Levels
54
Q

Assessments: Vital Signs + Pulse Oximetry

A

-tachycardia w/ a borderline low BP and decreased Sp02 = inadequate CO and oxygen delivery (DO2)

55
Q

Assessments: Characteristics of Pain

A

> location, radiation, duration, intensity, precipitating/alleviating factors
use 1 to 10 pain scale
-chest pain is an indication of MI
-continued or changing pain characteristics can be indicative of a worsening condition

56
Q

Assessments: ECG Changes

A
  • ST-segment depression = ischemia
  • ST segment elevation = injury
  • if present, Q wave is diagnostic for MI
57
Q

Assessment: Assess for Restlessness

A
  • may be found in early stages of MI

- progression to severe anxiety and sense of doom is a late-stage symptom

58
Q

Assessment: Skin color, Temperature, Peripheral pulses, Diaphoresis

A
  • decreased pulses and cold, clammy, pale skin
  • signs of inadequate tissue perfusion and inadequate CO
  • activation of the sympathetic nervous system w/ low BP will stimulate diaphoresis
59
Q

Assessment: Urine Output

A

decreased or absent urine output is a sign of decreased renal perfusion r/t decreased CO

60
Q

Assessment: Troponin, CK, CK-MB

A

> Troponin: protein released from damage cardiac muscle; elevates within 4 hours; can stay elevated for up to 10 days
CK-MB: the CK isoenzyme marker specific to cardiac tissue is released from cells w/ cardiac muscle damage; increased levels seen at 3 hours; remain elevated for 36 hours

61
Q

Post CABG Assessments

A
  • Monitor HR and BP continuously w/ an arterial catheter at least q 15 minutes initially, then q 4 hours when stable
  • Hemodynamic monitoring
  • Continuous cardiac monitoring
  • Assess heart tones
  • Monitor breath sounds and continuous Sp02
  • Monitor core temperature hourly
  • Assess LOC, pupils and responsiveness
  • Hourly intake and output
  • Skin color, temperature, pulses, edema, capillary refill
  • chest tube output, color, and volume hourly
  • hemoglobin, hematocrit, electrolytes, creatinine and BUN, glucose
  • incision for drainage, warmth, redness, or swelling
62
Q

Post CABG Assessment: Monitor HR and BP w/ an arterial catheter q 15 min initially, q 4 hours when stable

A

-tachycardia, bradycardia, hypotension, or hypertension may be signs of decreased CO or compensatory mechanisms

63
Q

Post CABG Assessment: Hemodynamic monitoring

A

-decreased preload (CVP, PAOP), Sv02 may indicate decreased CO; poor tissue perfusion

64
Q

Post CABG Assessment: Continuous cardiac monitoring

A

-dysrhythmias common after CABG

65
Q

Post CABG Assessment: Heart tones

A
  • muffled may = tamponade

- S3, S4 and crackles may = heart failure

66
Q

Post CABG Assessment: Breath sounds and continuous Sp02 monitoring

A
  • decreasing saturation may = pulmonary complications

- diminished or unilateral absent breath sounds may = atelectasis, pleural effusions, or pneumothorax

67
Q

Post CABG Assessment: Monitor core temperature hourly

A
  • hypothermia during surgery reduces metabolic rate and risk of organ ischemia
  • re-warming may produce hypotension from vasodilation
  • core temp most reliable
68
Q

Post CABG Assessment: Assess LOC, pupils and responsiveness

A
  • assess effectiveness of sedation

- evaluates neurological function

69
Q

Post CABG Assessment: Hourly intake and output

A
  • notify provider for output less than 30 ml/hr for 2 hours

- decreased urine output may be a sig of renal damage or decreased CO

70
Q

Post CABG Assessment: Assess skin color, temperature, pulses, edema, capillary refill

A
  • pale, cool skin w/ delayed capillary refill and weak pulses may = decreased CO
  • edema can be expected response after CABG r/t fluid resuscitation during surgery
71
Q

Post CABG Assessment: Monitor Chest tube output, color, and volume hourly

A

-sudden increases in output greater than 100 to 200 mL not associated w/ position changes or increased bright red drainage may = hemorrhage and the need to return to OR

72
Q

Post CABG Assessment: Assess Hemoglobin, hematocrit, electrolytes, creatinine and BUN, Glucose

A
  • changes may indicate bleeding, fluid shifts, and renal dysfunction
  • tight glucose control associated w/ improved outcomes
73
Q

Post CABG Assessment: Assess incision site for drainage, warmth, redness, swelling

A

may = infection

74
Q

Nursing Actions for an MI

A

-Administer oxygen
-Insert 2 large bore-IVs (medication delivery, fluid resuscitation)
-Administer medications:
>Aspirin and Heparin: prevent new clot formation
>Nitroglycerin SL: dilates coronary arteries; increasing blood flow and decreasing pain
>Morphine: narcotic given for pain relief if nitroglycerin not effective
>Beta Blockers: decrease sympathetic response to an MI, decreasing cardiac workload and oxygen consumption
>Fibrinolytics: work to dissolve clots
-Continuous ECG monitoring
-Bed Rest: to decrease oxygen and cardiac demands

75
Q

Nursing Actions Post CABG

A
  • Maintain tight BP control
  • Administer fluids + Meds as ordered (vasodilators, vasoconstrictors, inotropes, and diuretics)
  • Rewarm patients slowly w/ warm fluids, blankets, or airflow devices. Prevent shivering
  • Administer pain medication and continuous sedation medication
  • Pulmonary hygiene while intubated (reposition frequently, suction PRN, oral care q 4 hours)
  • Pulmonary hygiene after extubation (incentive spirometry, cough and deep breathe q 1 to 2 hours while awake; chest splinting when coughing)
  • Plan for and initiate early mobility or ambulation
  • Wound Care: initial dressing to be removed or changed by provider, then change daily or PRN
76
Q

Nurse Teaching for MI

A
  • immediately report s/s of MI: chest pain, chest discomfort, or increased SOB
  • purpose, dose, and side effects of meds
  • AHA “Life’s Simple 7”
77
Q

Nurse Teaching Post CABG

A
  • infection
  • sternal precautions
  • cardiac rehab
78
Q

Sternal Precautions for Post CABG

A
  • do not lift weight over 10 lbs
  • do not raise arms overhead
  • do not bend at waist
  • do not participate in vigorous activity until cleared
79
Q

Participate in Cardiac Rehab

A
  • medical evaluation
  • exercise training and physical activity counseling
  • coronary risk factor reduction/secondary prevention
  • nutritional counseling + weight management
  • purpose of medications
  • medication side effect
  • effects on exercise tolerance
  • reinforce medication adherence
80
Q

Evaluating Care Outcomes

A
  • free from pain
  • normal vital signs
  • improved Sp02
  • signs of decreased perfusion from inadequate CO (cool extremities, weak pulses, decreased urine output) are resolving
81
Q

AHA “Life’s Simple 7”

A
  1. No smoking of cigarettes or other tobacco products
  2. Maintain normal body weight
  3. Exercise for at least 150 minutes w/ moderate-intensity activity, or 75 minutes of vigorous-intensity or combo of both each week
  4. Eat a healthy diet
  5. Maintain total cholesterol less than 200 mg/dl
  6. Keep BP less than 120/79 mmHg
  7. Fasting glucose less than 100 mg/dl

Nursing 272: Final Semester (79 decks)

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