Interventions in the Acute Phase of Myocardial Infarction

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This should be one of the first things given to the patient, if emergency personnel have not already given it or if the patient did not take it at home at the onset of chest pain. Sublingual nitroglycerin should be given for pain relief and coronary artery dilation. The recommended dose is 0. A translingual spray is available and is given as 1—2 sprays under the tongue q5 minutes three times, or until pain subsides.

Nitroglycerin should be given with caution if the patient is hemodynamically unstable. One major side effect of nitroglycerin is hypotension because of arterial vasodilatation. The patient may also complain of a severe headache as a side effect of nitroglycerin. A continuous nitroglycerin infusion is usually initiated in the cardiac intensive care unit. Chest pain which persists after three doses of sublingual nitroglycerin and administration of oxygen should be treated with an analgesic.

Morphine is the analgesic of choice because it also a coronary artery vasodilator. Prompt pain relief may reduce the incidence of heart failure, arrhythmias, and other complications. In the past, oxygen was often prescribed for patients presenting with chest pain, even in cases with normal oxygen saturation. Research has indicated that supplemental oxygen for patients with suspected MI can have harmful effects. The doctor may also order heparin or a low molecular weight heparin, such as enoxaparin sodium Lovenox to medically manage patients undergoing acute MI.

If your patient is scheduled for a heart catheterization, ask the physician if the dose should be held before the procedure to prevent complications of bleeding. Unfractionated heparin may be used until the thrombus is no longer occluding blood flow. Heparin can be administered IV or SC. When administering heparin, nurses need to monitor the patient for heparin-induced thrombocytopenia, a life-threatening complication of heparin administration. Nurses should monitor the patient's platelet count and watch for signs of bleeding for the duration of heparin administration.

In addition to administering medications, nurses also need to obtain IV access in at least two sites, initiate cardiac monitoring, and keep the patient's family updated on the patient's condition as the medical team determines the most suitable treatment for the patient. Treatment of acute MI involves reperfusion, either mechanically or pharmacologically. PCI, a mechanical reperfusion intervention, has emerged as the preferred reperfusion treatment for acute MI.

PCI is performed in the cardiac catheterization cath lab by the cardiologist and a cath lab team of nurses and technicians. In percutaneous coronary angioplasty PTCA , the cardiologist inserts a diagnostic catheter into the femoral artery and guides the catheter up to the vessels of the heart. Once the catheter is in place, dye is injected and x-rays taken that show the dye being pumped through the cardiac vessels.

Any occlusions will be seen as the dye fails to penetrate the blocked artery's lumen. If the doctor determines the blockage is treatable, a catheter with a balloon is guided to the affected vessel. The balloon is inflated, pushing the atherosclerotic plaque against the artery wall. The result is a smooth artery lining and patent vessel. The doctor may also opt to place a stent at the site of the lesion. A cardiac stent is a fine, wire-mesh tube placed in the artery to prevent vessel closure or restenosis. After the heart cath, the patient will be on bedrest for a prescribed amount of time.

Monitor the patient's cardiac status for signs and symptoms of vessel reocclusion and complications of reperfusion e. Bleeding is a main complication of a heart cath. During bedrest, do not allow the patient to bend the affected leg. Closely monitor the insertion site for signs of bleeding. If the patient's groin site starts to bleed, hold pressure for at least 15 minutes until bleeding stops. Redress the site, maintain bedrest, and closely monitor for additional bleeding. A sand bag can be applied to the site if it is oozing slightly.

The Early Phase of Acute Myocardial Infarction: Pharmacologic Aspects of Therapy

Minutes count during an acute MI. The AHA has set the door-to-balloon-inflation goal time at 90 minutes. Whether nurses work in a clinic, an emergency department, or on a med-surg floor, they work together with other members of the healthcare team to meet this goal time. Doing so can help save heart muscle and even save a patient's life. In some hospitals, such as at rural hospitals, a cath lab is not available; other times, mechanical reperfusion is delayed beyond the minute goal.

In these cases, the patient may be treated with fibronolytics, such as tenecteplase TNKASE , streptokinase, alteplase Activase , or reteplase Retavase. All of these drugs, which are administered intravenously, limit the progression of the MI by dissolving the thrombus in the coronary artery and restoring blood supply to the ischemic myocardium.

Each thrombolytic agent has a different dosing regimen. Streptokinase is infused as 1. Tenecteplase is given as a single bolus over 5 seconds. Reteplase is given as two unit boluses, 30 minutes apart. Each reteplase dose should be given over 2 minutes. Alteplase is given as a bolus dose of 15 mg over 2 minutes, then 0. Since thrombolytic agents have a profound effect on the clotting system, side effects include bleeding problems.

The most serious is intracranial hemorrhage or stroke. Others include gastrointestinal bleeding, genitourinary bleeding, gingival bleeding, and bleeding on the skin surface from cuts, scratches, and other IV sites. Not every patient is a candidate for thrombolytic therapy.

For example, the patient in the case scenario had knee surgery 48 hours prior to experiencing an MI. Because of an increased risk for bleeding, thrombolytics were withheld and angioplasty was performed instead. Healthcare professionals should follow facility guidelines to determine whether a patient is a candidate for thrombolysis.

Heparin is another important drug in treating an acute MI. Whereas a thrombolytic agent will cause the clot to dissolve, heparin will keep the blood from clotting again and reoccluding the coronary artery. Heparin is most often given as a continuous I. Other pharmacologic agents that have been shown to be effective in reducing mortality in patients experiencing an MI include beta blockers, angiotensin-converting-enzyme ACE inhibitors, calcium channel blockers, and, for people who cannot tolerate ACE inhibitors, angiotensin II receptor blockers.

The purpose of these drugs is vasodilatation of coronary and peripheral vessels, decreased heart rate, reduced myocardial oxygen consumption, and overall decrease the extent of myocardial damage. In some cases, such as if PCI is unsuccessful or if a patient has severe blockages in the large coronary vessels, coronary artery bypass CABG; pronounced "cabbage" surgery may be indicated. CABG surgery is the most common type of open-heart surgery in the United States and is performed by a cardiothoracic surgeon.

During CABG surgery vessels taken from other areas of a patient's body, typically the left internal mammary artery or the saphenous vein, and grafted onto the heart to reroute blood around occluded cardiac vessels. The outlook after CABG surgery is good for most patients, who can experience symptom relief for up to 15 years in some cases. The nurse plays an important role in determining if reperfusion of the coronary artery has occurred. The only way to verify reperfusion with certainty is the use cardiac catheterization to view the artery.

This requires an invasive procedure and may pose some risk to the patient. Other noninvasive markers of reperfusion may be used. Keep in mind that even if reperfusion occurs, the ST segment may not return to baseline due to myocardial damage. Another clinical reperfusion marker is the resolution of chest pain. When blood flow is restored to the myocardium after thrombolysis, relief from chest pain is usually rapid and occurs with 30 minutes of the first noted improvement of the pain level.

Interventions in the Acute Phase of Myocardial Infarction

It is important to objectively assess the patient's pain level using the pain scale before, during, and after administration of a thrombolytic agent. Amazing advances have been made in the treatment of acute MI over the past several years; however, it is still one of the leading causes of death. This is due to the serious complications usually associated with an infarction. These include coronary artery reocclusion, heart failure and cardiogenic shock, and arrhythmias. Nurses play an important role in assessing the patient for signs and symptoms of complications and assisting with early intervention.

A small number of patients will experience reocclusion of the artery after thrombolytic therapy even when preventative measures are taken. This happens because, although, the clot in the artery has been dissolved, the athersclerotic plaque is still present and if anticoagulation is inadequate, another thrombus may form. Symptoms such as chest pain, nausea, diaphoresis, and ST segment elevation will usually be similar to those experienced with the original MI.

With this in mind, it is crucial to monitor the patient closely and be aware of changes indicative of reocclusion. Since readministration of a thrombolytic agent is not recommended, the patient will need to have a PTCA or CABG if angioplasty is not an option or unsuccessful. Congestive heart failure following a myocardial infarction can range from mild to severe, depending on the extent of ventricular damage.

Heart failure occurs when myocardial tissue is damaged and the ventricle no longer works as an efficient pump. In right-sided failure, the compromised right ventricle causes fluid to back up in the peripheral circulation; in left-sided heart failure, fluid backs up in the pulmonary circulation. The nurse should monitor for signs of heart failure, including shortness of breath; hypoxia; production of pink, frothy sputum; hypotension; oliguria; confusion or changes in level of consciousness; and tachycardia. Treatment of heart failure depends on the severity.

Expect to administer supplemental oxygen, diuretics, a continuous nitroglycerin infusion, morphine, inotropic agents to improve cardiac contractility, and an angiotensin-converting enzyme ACE inhibitor. These patients will be quite ill and may require transfer to the critical care unit. Mechanical ventilation may also be required. Patients with heart failure can rapidly decline into cardiogenic shock. Because the heart is incapable of contracting with sufficient force to pump enough blood, the vital organs and peripheral tissues cease to function as a result of ischemia.

The patient may experience the following symptoms: pulmonary congestion, diaphoresis, cool extremities, and mental confusion. Treatment for cardiogenic shock is aggressive and can include fluid replacement, inotropic drugs, and an intra-aortic balloon pump an invasive device used to decrease ventricular workload and improve coronary artery perfusion. Therefore, a very important nursing intervention is helping the patient and family work through end of life issues.

Successful thrombolysis can cause a variety of cardiac arrhythmias, such as ventricular tachycardia, premature ventricular contractions, accelerated idioventricular rhythm, and sinus bradycardia. These are generally accepted as normal consequences of coronary reperfusion, and treatment is not necessary unless the patient becomes unstable.

Ventricular fibrillation. The majority of sudden cardiac deaths are because of ventricular fibrillation, or v fib. This arrhythmia results in an ineffective quivering of the ventricles and no cardiac output. Treatment includes basic life support airway, breathing, and circulation , defibrillation, and advanced cardiac life support. The sooner the ventricular fibrillation is treated, the greater the chance of survival for the patient. Nurses in all areas of health care should be able to recognize the signs of cardiac arrest and intervene appropriately.

Ventricular tachycardia. Patients who have suffered an acute MI may experience ventricular tachycardia, or v tach. This ventricular arrhythmia can be benign or it can be life threatening. Patients may be asymptomatic or they may experience shortness of breath, chest discomfort, palpitations, and syncope. Patients may be given an antiarrhythmic, such as lidocaine, procainamide, or amiodarone, to reestablish sinus rhythm.

If the patient is unstable, electrical cardioversion may be conducted in an attempt to convert the myocardium to a sinus rhythm. This arrhythmia is most common in patients who have experienced an anterior or anterolateral MI. Sinus bradycardia and heart block. Bradycardia is a slowing of the heart rhythm.

Noninvasive Testing

The patient may experience hypotension and syncope which usually responds to oxygen and atropine. Heart blocks occur as a result of problems in the atrioventricular AV node of the conduction system. Electrical impulses are not conducted from the atrium to the ventricles, which can cause a decrease in cardiac output. To correct the arrhythmia, patients may need transcutaneous external pacing or surgery to insert a transvenous internal, temporary pacemaker. When an individual experiences an acute MI, healthcare professionals focus most of their attention on meeting the eminent physical needs of the patient.

However, an acute MI usually occurs suddenly and without warning and can be an extremely stressful experience for the patient and family. Studies have shown that patients often ignore symptoms when they first begin or contribute them to heart burn or muscle pain. They may also delay seeking medical care because they are in denial, refusing to believe they could be having a heart attack.

When symptoms become more serious, patients often appear apprehensive and fearful. They may have a feeling of impending doom and ask questions such as "Am I going to die? The emotional stress can have a profound effect on physiological functions as well. During times of anxiety and apprehension, the sympathetic nervous system causes changes to occur the "fight or flight" response. The heart rate increases, cardiac contractility becomes stronger, blood vessels constrict, and, initially, cardiac output increases.

These responses in turn increase the myocardial oxygen demand in a compromised patient. As the heart demands more oxygen and the supply diminishes, the patient may experience more chest pain and other signs of hemodynamic instability.

These changes then create more fear and anxiety in the patient. In the hospital, the patient's anxiety may increase due to unfamiliarity of the surroundings and procedures. For this reason, attempt to make the environment less stressful. Prevent unnecessary intrusions, conversations, disturbances, and interruptions.

If possible, schedule lab tests, EKGs, x-rays, and other diagnostic tests to be done within the same time frame. Rest is an essential part of the recovery process and allowing for uninterrupted periods of rest and sleep is helpful.


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Reducing bright lights and noise is also important. During patient transfers from one unit to the next, avoid having large gatherings of nurses at the bedside. One or two nurses calmly and confidently admitting the patient usually helps immensely in decreasing anxiety. During the admission process, explain each procedure, treatment, and piece of equipment to the patient, offering reassurance that the patient is being closely monitored. With this in mind, the goal of the nurse is to attempt to relieve the patient's anxiety while performing all of the other interventions.

The first priority after assessing the patient is pain relief. Chest pain has often been described as unrelenting and distressful. The nurse should not only administer an analgesic as ordered but also communicate to the patient that every effort is being made to get the pain under control. Decline in rates of death and heart failure in acute coronary syndromes, — Association between hospital process performance and outcomes among patients with acute coronary syndromes.

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Acute Myocardial Infarction in patients presenting with ST-segment elevation (Ma

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Exercise-based rehabilitation for coronary heart disease. Use of cardiac rehabilitation by Medicare beneficiaries after myocardial infarction or coronary bypass surgery. This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference.

This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv aafp. Want to use this article elsewhere? Get Permissions. Read the Issue. Sign Up Now. Nov 1, Issue. Myocardial Infarction: Management of the Subacute Period. Author disclosure: No relevant financial affiliations. A 6 — 11 Clopidogrel Plavix , prasugrel Effient , and ticagrelor Brilinta are recommended in combination with aspirin for a minimum of 12 months in patients receiving drug-eluting stents, and for up to 12 months in patients receiving bare metal stents.

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Spara som favorit. Skickas inom vardagar. In the 's a primary focus for intense cardiovascular research is in the treatment of patients with acute myocardial infarction.