Medsurg Cardiac - MI PDF

Medsurg cardiac - MI Study online at https://quizlet.com/_gfbrr2 1. Acute coronary -umbrella term that includes both unstable angina and acute myocardial infarction syndrome (STEMI or NSTEMI) -ACS inv...

Medsurg cardiac - MI Study online at https://quizlet.com/_gfbrr2 1. Acute coronary -umbrella term that includes both unstable angina and acute myocardial infarction syndrome (STEMI or NSTEMI) -ACS involves ruptured plaque leading to platelet aggregation making a blockage of blood flow...if it is a complete blockage, it is an STEMI, if it is partial, it is NSTEMI (if tissue necrosis) or unstable angina if no tissue necrosis yet 2. Modifiable risk -Hyperlipidemia factors of heart -Cig smoking disease -HTN -Diabetes -Metabolic syndrome: combination of someone with abdominal obesity, high BP, and high triglycerides -Obesity -Physical inactivity -Chronic inflammatory conditions: can be a risk factor because when the coronary arteries have more inflammation, they are more likely to become atherosclerotic! 3. Non-modifiable -family history/genetic profile risk factors of -age heart disease -gender -race 4. The coronary ar- AORTA! teries come off the ___________ 5. Where is it re- in the upper part of the coronary artery, proximal to the aorta, meaning that blood ally bad to get can't get supply a great deal of tissues in the heart. an occlusion in the coronary ar- teries? 1 / 21  Medsurg cardiac - MI Study online at https://quizlet.com/_gfbrr2 6. MI definition acute onset of myocardial ischemia that results in myocardial cell death...infarction is the tissue death! *it is important to note that athersclerotic disease does not cause an MI...but, if the plaque ruptures, it can cause an MI! 7. Pathophysiology 1. Plaque ruptures in the coronary arteries. of MI 2. When the plaque ruptures, the body looks at it and interprets it like we are bleeding 3. The body sends platelets to that area to stop the bleeding, so we get platelet aggregation 4. The platelets aggregate and occlude the vessel. If it is just partial, the patient will have unstable angina. If it is complete, the patient will have MI *all of the tissue downstream of the coronary artery that is blocked is not getting enough oxygen, the cells become necrotic, die or "infarct" *once necrosis happens, it is irreversible! Infarcted area can no longer act as a pump or conduct electricity! 8. What is typically ASPIRIN!!!!! Aspirin is an anti-platelet agent that can help prevent those platelets given right away from being so sticky...it makes them more slippery so they won't adhere + aggre- if MI is suspect- gate, helps diminish the blood clot! ed (like if patient is having chest pain)? 9. STEMI vs NSTEMI -if the thrombus completely occludes the vessel, this will likely cause a STEMI vs unstable angi- na -if the clot partially occludes the vessel, this is manifestated as unstable angi- na/NSTEMI. NSTEMI would be elevated serum markers of MI present. 10. 2 / 21  Medsurg cardiac - MI Study online at https://quizlet.com/_gfbrr2 When does my- After about 20 minutes! The tissue death spreads out in a circle...starts out in a ocardial cellular smaller area and then grows death start once there is a block- age (prolonged ischemia)? 11. What are the -heart doesn't pump as well effects of IS- -may not have normal contractility, resulting in HYPOTENSION, HEART FAILURE, and CHEMIC myocar- ACUTE PULMONARY EDEMA! dial tissue? *also, increased risk of DYSRYTHMIAS!!! 12. What happens to -myocardial cell membrane ruptures, releasing all its enzymes into the blood- ENZYMES when stream! These are: there is the death *Troponin of myocardial tis- *Creatine Phosphokinase sue? *Myoglobin *Lactic Dehydrogenase 13. What are the 1. Type: based on EKG changes, like if it's a NSTEMI or a STEMI ways an MI can be described? 2. Location: which part of the heart has been damaged, like was it anterior, lateral, inferior, posterior point? 2. Point in time: was it acute, was it slowly building up, has it already resolved? 14. Let's say a patient GI bleed would be the primary thing to take care of! You need to stabilize the has some degree bleed, and then work on the heart (because the NSTEMI is not as severe in the of CAD, they are short-term). You would want to stabilize the bleed and then work on the heart. taking an antico- agulant for a past blood clot, and they get a se- 3 / 21  Medsurg cardiac - MI Study online at https://quizlet.com/_gfbrr2 vere GI bleed and start losing lots of blood. When they are bleed- ing, they are los- ing blood, he- moglobin, oxy- gen that the cells need. Some- times, in con- junction with the bleed, the pa- tient will have a NSTEMI. What would be PRIORI- TY treatment? 15. Acute MI mani- -CHEST PAIN: described as elephant sitting on chest, crushing, burning...there is no festations correlation to severity of infarction based on report of pain! Take all CP seriously!! -Chest pain is unrelieved by nitroglycerin or rest (vasodilating or resting won't do anything if there is thrombus completely occluding the vessel) -chest pain often radiates to one or both arms, jaws, neck, back -NEW MURMUR develops, S3 or S4 heart sounds -JVD and SOB if heart failure is present -dysrythmias -increased or decreased BP: may have increased BP because of the pain and increased sympathetic stimulation, but if the patient is having an infarction and 4 / 21  Medsurg cardiac - MI Study online at https://quizlet.com/_gfbrr2 there is a large amount of myocardium impacted, BP might go low - just keep checking BP! -EKG changes: may see ST segment elevation if it's a STEMI 16. Clinical presenta- -Shortness of breath/pulmonary edema: if the heart cannot pump blood forward, tion of someone blood will back up into the lungs, and that's when you get crackles and poor gas having an acute exchange MI -Diaphoresis -Heart palpatations -N/V - sometimes projectile vomit -Anxiety, feelings of impending doom -skin is cool + clammy -Cardiac arrest may occur - do CPR -Cardiogenic shock -dysrythmias -a LATE SIGN would be fever - may see this 24-48 hrs later due to dead tissue...im- mune system revved up to help clean it -cardiac enzyme elevation due to ruptured cells that die -EKG changes - ST semgent elevation in STEMI -VS - check frequently because pt may be stable one minute and then crash the next 5 / 21  Medsurg cardiac - MI Study online at https://quizlet.com/_gfbrr2 17. Physical assess- -Airway, breathing, circulation = priority...get frequent VS ment for some- one suspected of -NEURO: there is a slight increase in the risk of stroke with MI, so observe swallow, having an acute speech etc. Patient may end up restless, may have subtle changes you pick up, MI like mild dec in LOC - THIS IS SUPER DUPER IMPORTANT, COULD INDICATE NOT ENOUGH PERFUSION TO THE BRIAN, TAKE CARE OF THIS RIGHT AWAY!!!!!!! -CARDIAC: mention chest pain, dysrhythmias in EKG, JVD, listen for any S3 and S4 heart sounds -PULMONARY: crackles, respiratory distress, tachypnea, pulmonary edema (be- cause of backup of fluid + blood -GI: nausea + vomiting, may be projectile -Urination: decreased urination may be preset if kidney affected by certain treat- ments. The kidneys are a very vascular and a good indicator of the heart is pumping to perfuse them or not deoending on if cffe comds -Skin: cool, clammy, diaphoresis -psychosocial: feeling of impending doom, fear, denial! 18. Causes of chest EMERGENT PROBS: pain that are -aortic dissection not related to -pulmonary embolism acute coronary -esophageal rupture syndrome -pneumothorax Less emergent: -pleurisy -pneumonia -pericarditis 6 / 21  Medsurg cardiac - MI Study online at https://quizlet.com/_gfbrr2 -musculoskeletal problems -esophageal reflux -costochondritis -panic disorder -acute cholecystitis 19. Special consider- -Women: may come in, say they feel tired, weak, nauseated, etc...people often ations with acute dismiss these! MI -Elderly: there blunting of nerve fibers, so may not feel it as much...less pain possible -Diabetics: blunting of nerve fibers, may not feel it as much -Heart transplant patients: the nerves to the heart are cut, so they NEVER have angina or chest pain, so they need to get heart catheterization every year to see how they are doing (SO THEY WOULDN'T EVEN FEEL CHEST PAIN IF MYOCARDIAL TISSUE WAS DYING! 20. How is an acute 1. History and physical: ask about risk factors (ex: smoking, lack of exercise), MI diagnosed? 2. 12 lead EKG: helps us see if they are having the STEMI 3. Serum enzymes: blood test 21. EKG changes that -Ischemia: ST segment will drop below baseline in STEMI, T wave inversion (this indicate MI specifiically can be a sign of ischemia, but it is fairly non-specific - can happen for other reasons, like there are anti-dysrhythmic drugs that can cause this...often, would need to see this with acute chest pain for concern) -Injury: this is essentially the beginning of the MI...don't call it infarction because the tissue is still viable! If we can get there and get out this thrombus, we may not lose tissue! The tissue is not dead yet, but it will be soon! Myocardial injury is shown by ST segment elevations!!! 7 / 21  Medsurg cardiac - MI Study online at https://quizlet.com/_gfbrr2 -Infarction: pathologic q waves develop permanently with a STEMI, tissue is dead, irreversible damage, tissue is dead *Q WAVE NEVER GOES AWAY...however, eventually, ST segment eventually goes back to normal...silent MI may have occurred if see q wave on EKG with nothing else abnormal 22. MI diagnosis: en- -if enzymes are present, you know there has been myocardial infarction!!! zymes -TROPONIN IS VERY SPECIFIC INDICATOR OF CARDIAC CELLULAR DEATH! -Troponin rises fairly early, rises 3-6 hours after injury, peaks at 12-18 hours, stays elevated for 1-2 weeks...it is a good specific test for cardiac MI!! 23. What are the -relieve symptoms goals for treat- -prevent or minimize myocardial tissue death ment of an MI? -prevent complications 24. What are some 1. Do a 12-lead-EKG to be read in 10 minutes initial interven- 2. Get blood to look for Troponin biomarker tions you can do 3. Do routine medical interventions (like MONA!!) for someone with an MI? 25. MONA for MI (+ 1. Morphine: helps with vasodilation, pain relief! other INITIAL in- terventions) 2. Oxygen: Only recommended if oxygen saturation is under 94 percent 3. Nitroglycerin 4. Aspirin (chewable 162 mg-325 mg - chewable is absorbed into the bloodstream better) - this is an antiplatelet agent, stops platelets from sticking together. 8 / 21  Medsurg cardiac - MI Study online at https://quizlet.com/_gfbrr2 5. Beta blockers! - these slow the HR...if the heart is beating fast, you want to slow the HR because we don't want it to work as hard! Beta blockers block the effect of the SNS - will drop BP + HR. The SA node is under the influence of the SNS, so if we block the SNS, SA node will not fire as rapidly, slows down the HR. Slower HR means more time spent in diastole, and we want the HR to be slower to spend more time in diastole so it can rest. Also, during diastole, the coronary arteries fill with blood, which gives the arteries more time to fill and deliver O2 to the heart! 6. Anticoagulation: Plavix, Clopidogrel, Glycoproteins, try to minimize the blood clot 26. is MONA the de- NO NO NO!!!! Do this initially, but you would be grossly negligent if this is all you finitive treatment do. for MI 27. What are the -PCI reperfusion ther- apies that are -Thrombolytics more DEFINITIVE for treatment of an MI? 28. What patients are -patients who have had symptoms of an MI within the past 12 hours eligible for reper- fusion therapy? 29. by the time that door to balloon time = 90 minutes or less! EMS gets the per- son to the hos- pital with cath lab available, how much time do they have to get 9 / 21  Medsurg cardiac - MI Study online at https://quizlet.com/_gfbrr2 to have a balloon catheter placed? 30. if patient is in 120 minutes (2 hours) - if this cannot be done in less than 120 minutes, fibrolytic a facility with- therapy needs to be administered! out PCI available, how much time do they have to transport to a fa- cility with a cath lab for PCI avail- able? 31. fibrolytic drugs vs our anticoagulants don't break up the blood clot...they just stop it from getting anticoagulants bigger. Fibrinolytic drugs actually break up the blood clot 32. door to needle 30 minutes! Give 30 mins from within the hospital time for fibri- nolytics 33. What are some -the patient needs IV access - we need to do this so we can give them the meds nursing consider- they need for pain, anticoagulants, antidysrhythmics ations right when someone with -Monitor VS suspected MI en- -look for hemodynamic instability: this is essentially watching to see if heart is ters the hospital? pumping enough to still meet the metabolic demands of the body, like to the kidneys (urine output), brain, skin temperature, etc. -Put patient on continuous cardiac monitoring -LABS: Troponin, lytes like BUN, Mg, glucose, aPTT, etc. CBC baseline because of administration of anticoagulants 10 / 21  Medsurg cardiac - MI Study online at https://quizlet.com/_gfbrr2 -support and educate the patient...may not have a lot of support and it is pretty scary! 34. Percutaneous -Could be done electively or emergently - elective would be if you were walking up coronary a hill and get chest pain both times, want to look at how well the coronary arteries intervention are perfusing. Emergent would be if someone who is having a STEMI, everyone (PCI) procedure else gets bumped -the FEMORAL artery is cannulated because it is big. The catheter is put in this artery and snaked up to the aorta, and then dye is shot into the coronary arteries! -when the dye is shot in, there are pictures taken. If there is a blockage, it will show up like a bottleneck on the image. If there is a complete blockage, no dye will go beyond that...need to put a stent in the blockage area, open up the artery! 35. Diffuse coronary -this would be someone who has multiple blockages...you can try to put stents in artery disease all those places, but may need cardiac bypass (CABG) procedure if you can't do this. MORE COMMON IN PEOPLE WITH DIABETES! 36. Post-procedure -Monitor for dysrythmias - catheters can make the heart irritable care for PCI -Watch for any further chest pain -there is a slight increased risk of stroke, so watch for neuro symptoms! (slurred speech, droop, drool, etc.) -Patient needs to be on bedrest for at least 4 HOURS! - this is an arterial stick, so they need to lay FLAT to not put pressure on the puncture because increased risk of bleeding -HOB can be NO HIGHER than 30 degrees for same reasons above - don't want to bend and open up -Frequent VS checks...every 15 minutes 4x, every 30 minutes 4x, and then every 11 / 21  Medsurg cardiac - MI Study online at https://quizlet.com/_gfbrr2 hour 4x! -Assess the distal pulses with each VS - check pedal pulse on side of femoral artery enterance! At risk for vascular complications -Assess for bleeding or hematoma with each VS check - is site dry + intact? If site gets hard, could indicate bleeding. BACK PAIN could mean retroperitoneal internal bleeding!! REMEMBER...HR won't necessarily go up to indicate bleeding because patient on betablocker - do not rely on tachycardia to determine bleeding! -MONITOR INTAKE + OUTPUT!! - whenever the patient goes in for a cath, they shoot dye in, and we worry about the KIDNEYS! Could lead to contrast-induced nephropathy (CIN) - we want to be watching patients to make sure they are still urinating, we don't want an acute kidney injury!! You would need to increase fluid intake or give IV fluids to prevcent contrast-induced nephropathy *may give acetylcysteine to someone who already has kidney dysfunction or can't tolerate IV - some people can't tolerate getting extra volume on board! 37. What are the -Hematoma complications of a PCI? -Vascular complications -Embolism -Hypersensitivity to contrast dye - if this is the case, we want to premedicate them with an antihistamine, typically STEROIDS!!! (best option -dysrythmias 12 / 21  Medsurg cardiac - MI Study online at https://quizlet.com/_gfbrr2 -bleeding -restenosis: narrowing of blood vessel when stent abruptly malfunctions or closes - if this happens, the patient will have chest pain that comes back! -stroke: PCI slightly increases risk of stroke, keep a close eye on neuro function, like decreased LOC, etc. -contrast-induced nephropathy! 38. Fibrinolytics -Active the body's own fibrolytic system in order to break down blood clots -diagnosis of STEMI MUST BE CONFIRMED!!! -this is done if a PCI cannot be done within 120 minutes!! (2 hrs) 39. How fibrinolytics -When plaque ruptures, platelets become activated, aggregate in the area of the work rupture, form platelet plug around the plaque rupture. Also, some vasoconstriction occurs -initially, just the platelets aggregate, then fibrin surrounds those to actually form the blood clot -the fibrinolytics bust that annoying fibrin up! -essentially, activates plasminogen to plasmin, and the plasmin dissolves the clot!!! (tPA) 13 / 21  Medsurg cardiac - MI Study online at https://quizlet.com/_gfbrr2 40. ABSOLUTE -Prior intracranial hemorrhage or hemorrhagic stroke CONTRAINDICA- TIONS for -Known cerebral vascular lesion or neoplasm fibrinolytics? -Ischemic stroke that happened within the last 3 months -Suspected aortic dissection -Active bleeding happening -recent major surgery or trauma -severe uncontrolled hypertension that DOES NOT RESPOND TO MEDS! -Known bleeding disorder -PREGNANCY!! 41. What is the most INTRACRANIAL HEMORRHAGE!! feared complica- tion of fibrinolyt- -it is fatal in 80% of cases tics -usually happens within the first 24 hours of giving fibrinolytics 42. risk factors for -age over 65 getting intracra- nial hemorrhage -weight >70 kg 14 / 21  Medsurg cardiac - MI Study online at https://quizlet.com/_gfbrr2 when giving fibri- -Females nolytics -Hypertension present on admission 43. Evidence of -reperfusion dysrhythmias present: if the heart is not getting enough oxygen then reperfusion after all the sudden blood rushes to the tissue, it makes it irritable, but we like to see getting therapy this because it lets us know that reperfusion has ocurred! -Abrupt stop of chest pain (but, may not be reliable if morphine is used, and pain is subjective! -THE BEST PREDICTOR OF REPERFUSION IS THE STOPPING OF CHEST PAIN COU- PLED WITH ST SEGMENT THAT RETURNS TO BASELINE!! 44. What do you do -may need to get PCI if develop cardiogenic shock or urgent transfer for failed after fibrinolytic reperfusion therapy? -if the patient is stable, transfer between 3 and 24 hours after successful fibrinol- ysis -it is important to note that fibrinolytics have no effect on the underlying athersclo- erotic lesion! Just dissolve the fibrin 45. Nursing care -Frequently assess vital signs post-infusion of fibrinolytics -do continuous EKG monitoring -Observe for evidence of bleeding - decreased BP + increased heart rate, BUT...pa- tients on beta blockers may just have decreased BP and normal HR! -Assess any body fluids (like urine, feces) for evidence of bleeding - maybe even nose bleeds 15 / 21  Medsurg cardiac - MI Study online at https://quizlet.com/_gfbrr2 -flank/back pain - may indicate retroperitoneal bleeding -assess LOC - decreased could be evidence of intracranial bleed -assess puncture sites for bleeding -anticipate the need to apply additional pressure at puncture sites -Manifestations of re-occlusions: chest pain returns, will do 12-lead EKG to see what is happening with the ST segments -Minimally handle the patient - need to be on bedrest for 6 hours -AVOID injections - get 2 IVs in before we get started -Give prophylactic H-2 Blockers - do this if worried about a GI bleed! -Anticoagulation therapy may be recommended after fibrin therapy to improve vessel patency + prevent re-occlusion - IV heparin, Enoxaparin! 46. Echocardiogram -ultrasound of the heart that is usually done after an MI to see how bad it is, was it big was -gives ejection fraction (how well the heart is pumping) -gives indication of valvular function (shows valves opening + closing) -Shows any fluid around the heart -if there was an infarction, shows parts of the heart that died by showing that they are not moving 47. Thallium testing can let us know how much tissue was damaged - often, this is a resting thallium test! 16 / 21  Medsurg cardiac - MI Study online at https://quizlet.com/_gfbrr2 48. What are the -Cardiogenic shock complications of an acute MI? -Heart failure - like SOB, pulm edema, etc. -dysrhythmias: when someone is having an MI, they often become tachycardic, but they may have a slow HR...the right coronary supplies the SA node, so if not enough, slower HR, also heart block may cause a slower HR - usually ventricular arythmias -pericarditis: inflammation around the heart, can cause chest pain -Papillary muscle rupture - help control opening and closing of the valves, so if these rupture, valves not working as well -Cardiac wall rupture - if it happens on the ventricular wall, can lead to lots of issues! scar tissue will form in the infarcted area after about 6 weeks, but between that time, the cardiac wall is at risk if activity is increased too fast -Left ventricular aneurysm: the infarcted area is weak, so it may bulge out and form an aneurysm, and blood will pool there, doesn't move well, worry about blood clots -AKI - usually due to the dye from the PCI, but also there is decreased perfusion when the heart is not pumping as well -Anoxic brain injuries if there was a cardiac arrest 49. Complications of -happens when the infarcted tissue does not pump MI: Heart failure/pul- -may need vasopressor support and intubation if it is an accute problem!! monary edema + -TREATMENT: tx *ACE inhibitors to help decrease the BP 17 / 21  Medsurg cardiac - MI Study online at https://quizlet.com/_gfbrr2 *beta blockers to slow HR + lower BP *Diuretics to decrease fluid *aldosterone antagonists to decrease BP 50. Complications of -for ventricular dysrythmias, could to implantable cardioverter/defibrillator, MI: dysrhythmias anti-dysrythmic drugs -for slow HR, may require a pacemaker! 51. How do you eval- -LOC: any mental status changes? Are they restless? uate for ade- quate perfusion? -adequate urine output (indicates kidneys are being perfused) -GI symptoms: if the gut is not perfused, may get pain, nausea -skin temperature: warm -capillary refill: less than 2 secs 52. What is the best URINE OUTPUT (known as poor man's cardiac output!) indicator for car- diac output and adequate perfu- sion? 53. Nursing care for -assess + documnt the chest pain patients with chest pain -get vital signs including heart rhythm -assess the skin temperature -do a 12-lead EKG with a provider's order 18 / 21  Medsurg cardiac - MI Study online at https://quizlet.com/_gfbrr2 -decrease physical activity!! GET THE PATIENT TO SIT DOWN! -Give oxygen if needed, nitroglycerin, morphine, ASA (MONA!!) -Give the patient small meals -Assist with ADLs (to allow for rest) -Avoid straining (give stool softeners!) -Help the patient to relax -teach the patient to recognize symptoms! 54. What is the DECREASE ACTIVITY!!! (but, if pt needs oxygen, do that first!!). Immediately, de- PRIORITY INTER- creasing physical activity will decrease myocardial O2 demands! VENTION to do if the patient reports having chest pain? 55. inter-profession- -dietician al care to consult for MI -cardiac rehabilitation -physical and occupational therapy! 56. Discharge med- -Statin therapy ications after MI -Angiotensinogen converting enzyme inhibitors (ACE inhibitors) -Aldosterone antagonists -Dual Antiplatelet therapy (DAPT) 19 / 21  Medsurg cardiac - MI Study online at https://quizlet.com/_gfbrr2 57. Statin therapy -helps to lower LDL cholesterol -even if you do not have high LDL cholesterol, it provides plaque stabilization, making it less liley to rupture -Check liver enzymes and monitor for muscle pain (rhabdomyolysis possible!) 58. ACE inhibitors -prils -inhibit ace, which stops conversion of angiotensinogen to angeotensin - an- giotensin narrows blood vessels, increasing bp, so this helps to lower bp by stopping that! -give if the MI was on the anterior wall -give if there is heart failure and the ejection fraction is less than 40 percent! 59. Aldosterone an- -Spironolactone! (potassium spairing) tagonists -block the action of aldosterone. Aldosterone usually raises bp, so this blocks that, so blood pressure is lowered! -give if ejection fraction