M2P9.pdf

1/16/24, 10:31 PM Realizeit for Student Medical Management The goals of medical management are to minimize myocardial damage, preserve myocardial function, and prevent complications. These goals are facilitated by the use of guidelines developed by the ACC and the AHA. The goal for treating patien...

1/16/24, 10:31 PM Realizeit for Student Medical Management The goals of medical management are to minimize myocardial damage, preserve myocardial function, and prevent complications. These goals are facilitated by the use of guidelines developed by the ACC and the AHA. The goal for treating patients with acute MI is to minimize myocardial damage by reducing myocardial oxygen demand and increasing oxygen supply with medications, oxygen administration, and bed rest. The resolution of pain and ECG changes indicate that demand and supply are in equilibrium; they may also indicate reperfusion. Visualization of blood flow through an open vessel in the catheterization laboratory is evidence of reperfusion. Initial Management The patient with suspected MI should immediately receive supplemental oxygen, aspirin, nitroglycerin, and morphine. Morphine is the drug of choice to reduce pain and anxiety. It also reduces preload and afterload, decreasing the work of the heart. The response to morphine is monitored carefully to assess for hypotension or decreased respiratory rate. Nurses should be aware that evolving research has suggested an association between morphine and potential adverse outcomes, including larger infarct size, increased length of hospital stay, and mortality, and should stay abreast of changes to clinical guidelines impacting its use (McCarthy, Bhambhani, Pomerantsev, et al., 2018; Neto, 2018). A beta-blocker may also be used if arrhythmias occur. If a beta-blocker is not needed in the initial management period, it should be introduced within 24 hours of admission, once hemodynamics have stabilized and it is confirmed that the patient has no contraindications (Ibanez et al., 2018). Unfractionated heparin or LMWH may also be prescribed along with platelet-inhibiting agents to prevent further clot formation. Emergent Percutaneous Coronary Intervention The patient with STEMI is taken directly to the cardiac catheterization laboratory for an immediate PCI (if a cardiac catheterization laboratory is on site). The procedure is used to open the occluded coronary artery and promote reperfusion to the area that has been deprived of oxygen. Superior outcomes have been reported with the use of PCI when compared to thrombolytic agents (Urden et al., 2019) (also called fibrinolytic agents; see the Thrombolytics section). Thus, PCI is preferred as the initial treatment method for acute MI in all age groups (Urden et al., 2019). The procedure treats the underlying atherosclerotic lesion. Because the duration of oxygen deprivation determines the https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=lqf9HhURQ5RqpgqAkzH2zbfuwFjUs0mdxkPeVey4KH2F7i%2fH0LC0NH7inQLoUzK%2fM… 1/3 1/16/24, 10:31 PM Realizeit for Student number of myocardial cells that die, the time from the patient’s arrival in the ED to the time PCI is performed should be less than 90 minutes. This is frequently referred to as door-to-balloon time. A cardiac catheterization laboratory and staff must be available if an emergent PCI is to be performed within this short time. Thrombolytics (Fibrinolytics) Thrombolytic therapy is initiated when primary PCI is not available or the transport time to a PCI-capable hospital is too long. These agents are administered IV according to a specific protocol. The thrombolytic agents used most often are alteplase, reteplase, and tenecteplase. The purpose of thrombolytics is to dissolve (i.e., lyse) the thrombus in a coronary artery (thrombolysis), allowing blood to flow through the coronary artery again (reperfusion), minimizing the size of the infarction and preserving ventricular function. However, although thrombolytics may dissolve the thrombus, they do not affect the underlying atherosclerotic lesion. The patient may be referred for a cardiac catheterization and other invasive procedures following the use of thrombolytic therapy. Thrombolytics should not be used if the patient is bleeding or has a bleeding disorder. They should be given within 30 minutes of symptom onset for best results (Norris, 2019). This is frequently referred to as door-to-needle time. Inpatient Management Following PCI or thrombolytic therapy, continuous cardiac monitoring is indicated, preferably in a cardiac intensive care unit (ICU). Continuing pharmacologic management includes aspirin, a beta-blocker, and an angiotensin-converting enzyme (ACE) inhibitor. ACE inhibitors prevent the conversion of angiotensin I to angiotensin II. In the absence of angiotensin II, the blood pressure decreases and the kidneys excrete sodium and fluid (diuresis), decreasing the oxygen demand of the heart. The use of ACE inhibitors in patients after MI decreases mortality rates and prevents remodeling of myocardial cells that is associated with the onset of heart failure. Blood pressure, urine output, and serum sodium, potassium, and creatinine levels need to be monitored closely. If an ACE inhibitor is not suitable, an angiotensin receptor blocker (ARB) should be prescribed (Ibanez et al., 2018). Nicotine replacement therapy and tobacco cessation counseling should also be initiated for all tobacco users. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=lqf9HhURQ5RqpgqAkzH2zbfuwFjUs0mdxkPeVey4KH2F7i%2fH0LC0NH7inQLoUzK%2fM… 2/3 1/16/24, 10:31 PM Realizeit for Student Cardiac Rehabilitation After the patient with an MI is in a stable condition, an active rehabilitation program is initiated. Cardiac rehabilitation is an important continuing care program for patients with CAD that targets risk reduction by providing patient and family education, offering individual and group support, and encouraging physical activity and physical conditioning. The goals of rehabilitation for the patient who has had an MI are to extend life and improve the quality of life. The immediate objectives are to limit the effects and progression of atherosclerosis, return the patient to work and a pre-illness lifestyle, enhance the patient’s psychosocial and vocational status, and prevent another cardiac event. Cardiac rehabilitation programs increase survival, reduce recurrent events and the need for interventional procedures, and improve quality of life (Dickins & Braun, 2017). Physical conditioning is achieved gradually over time. Many times, patients will “overdo it” in an attempt to achieve their goals too rapidly. Patients are observed for chest pain, dyspnea, weakness, fatigue, and palpitations and are instructed to stop exercise if any of these occur. Patients may also be monitored for an increase in heart rate above the target heart rate, an increase in systolic or diastolic blood pressure of more than 20 mm Hg, a decrease in systolic blood pressure, onset or worsening of arrhythmias, or ST-segment changes on the ECG. Cardiac rehabilitation programs are categorized into three phases (Dickins & Braun, 2017). Phase I begins with the diagnosis of atherosclerosis, which may occur when the patient is admitted to the hospital for ACS. Because of brief hospital lengths of stay, mobilization occurs early and patient education focuses on the essentials of self-care rather than instituting behavioral changes for risk reduction. Priorities for in-hospital education include the signs and symptoms that indicate the need to call 911 (seek emergency assistance), the medication regimen, rest–activity balance, and follow-up appointments with the primary provider. The patient is reassured that although CAD is a lifelong disease and must be treated as such, they can likely resume a normal life after an MI. The amount and type of activity recommended at discharge depend on the patient’s age, his or her condition before the cardiac event, the extent of the disease, the course of the hospital stay, and the development of any complications. Phase II occurs after the patient has been discharged. The patient attends sessions three times a week for 4 to 6 weeks but may continue for as long as 6 months. The outpatient program consists of supervised, often ECG-monitored, exercise training that is individualized. At each session, the patient is assessed for the effectiveness of and adherence to the treatment. To prevent complications and another hospitalization, the cardiac rehabilitation staff alerts the referring primary provider to any problems. Phase II cardiac rehabilitation also includes educational sessions for patients and families that are given by cardiologists, exercise physiologists, dietitians, nurses, and other health care professionals. These sessions may take place outside a traditional classroom setting. For instance, a dietitian may take a group of patients to a grocery store to examine labels and meat selections or to a restaurant to discuss menu offerings for a heart-healthy diet. Phase III is a long-term outpatient program that focuses on maintaining cardiovascular stability and long-term conditioning. The patient is usually self-directed during this phase and does not require a supervised program, although it may be offered. The goals of each phase build on the accomplishments of the previous phase. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=lqf9HhURQ5RqpgqAkzH2zbfuwFjUs0mdxkPeVey4KH2F7i%2fH0LC0NH7inQLoUzK%2fM… 3/3