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Medsurg: Cardiovascular: Myocardial Infarction


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Risk factors of MI are the same as those for coronary artery disease, what are they? (10)
1. Age
2. Gender
3. Heredity
4. Race
5. Smoking
6. Hyperlipidemia
7. Hypertension
8. Diabetes
9. Diet
10. Sedentary lifestyle
MI Pathophysiology:
Atherosclerotic plaque may form two types of lesions, what are they?
1. Stable lesion
2. Unstable (complicated) lesion
MI Pathophysiology:
Describe stable lesions
Stable lesions progress by gradually occluding the vessel lumen and often causes angina.
MI Pathophysiology:
Describe unstable or complicated lesions
Unstable or complicated lesions are prone to rupture and thrombus formation. Unstable lesions often lead to acute coronary syndrome or acute ischemic heart disease.
MI Pathophysiology:
Acute coronary syndromes include: (3)
1. Unstable angina
2. MI
3. Sudden Cardiac Death
MI Pathophysiology:
How does MI occurs?
MI occurs when blood flow to cardiac muscle is blocked, resulting in prolong tissue ischemia and irreversible cell damage.
MI Pathophysiology:
Describe the cause of coronary occlusion.
Coronary occlusion is usually caused by ulceration or rupture of a complicated atherosclerotic lesion.
MI Pathophysiology:
Describe the chain reaction of a ruptured atherosclerotic lesion
Rupture lesion  Platelet aggregation
 Thrombin generation
 Local vasomotor tone
As a result  Clot formation  Vessel occlusion  ischemia to distal muscles
MI Pathophysiology:
How long will it takes for tissue ischemia becomes irreversible tissue damage?
20 to 45 minutes
MI Pathophysiology:
Which area of the heart is most susceptible to changes in coronary blood flow?
MI Pathophysiology:
What is a Q wave MI?
When all the layers of the myocardium are affected by occlusion of blood flow. With this a significant Q wave develops.
MI Pathophysiology:
MI usually affects which portion of the heart and why?
The Left ventricle because its muscle mass is greatest, as also its oxygen demand.
MI Pathophysiology:
Occlusion of the lateral anterior descending (LAD) artery will damage which area(s) of the heart?
1. Anterior wall of the left ventricle (an anterior MI)
2. Part of the interventricular septum
MI Pathophysiology:
Occlusion of the left circumflex artery (LCA) will damage which area(s) of the heart?
Lateral portion of the heart (lateral MI)
MI Pathophysiology:
Occlusion of the right coronary artery (RCA) and posterior descending artery (PDA) will damage which area(s) of the heart?
1. Right ventricle
2. Anterior portion of the heart (anterior infarct)
3. Posterior portion of the heart (posterior infarct)
MI Pathophysiology:
Occlusion of the left main coronary artery will damage which area(s) of the heart?
Entire left ventricle (grave prognosis)
MI Pathophysiology:
Patent with cocaine induced MI may present with: (7)
1. Altered LOC
2. Confusion and restlessness
3. Seizure activity
4. Tachycardia
5. Hypotension
6. Increase respiratory rate
7. Respiratory crackles
Manifestation of MI:
1. Chest pain
2. Tachycardia, tachypnea
3. Dyspnea, SOB
4. Nausea and vomiting
5. Anxiety, sense of impending doom
6. Diaphoresis
7. Cool, molted skin
8. Diminished peripheral pulse
9. Hypotension or hypertension
10. Palpitation, dysrhythmias
11. Signs of left heart failure
12. Decrease LOC
How is MI chest pain distinguished from angina chest pain? (4)
1. Longer duration, lasting for than 15 to 20 minutes
2. Pain is sudden and usually not associated with activity
3. Often occurs early in the morning
4. Pain not relieved by rest or nitroglycerine
Describe atypical MI pain in women and older adult (4)
1. Indigestion
2. Heart burn
3. Nausea
4. Vomiting
List the complications associate with AMI (5)
1. Dysrhythmias
2. Pump failure (Heart failure)
3. Infarct Extension
4. Structural defects
5. Pericarditis
List manifestations of left-sided heart failure: (4)
1. Dyspnea
2. Fatigue
3. Weakness
4. Respiratory crackles on auscultation
List manifestations of right-sided heart failure (2)
1. Peripheral edema
2. Neck vein distension
List the manifestations of infarction extension: (3)
1. Continuing chest pain
2. Hemodynamic compromise
3. Worsening heart failure
When is infarction extension most likely to occur?
10 to 14 days after MI
List possible structural defects as a result of AMI?
1. Ventricular aneurysm
2. Rupture of ventricular septum
3. Rupture of papillary muscle
4. Myocardial rupture
When is structural defects most likely to occurs in patient with AM I?
4 to 7 days after MI
What are the manifestations of Pericarditis? (3)
1. Chest pain that maybe sharp or stabbing
2. Pain is aggravated by movement or breathing
3. Pericarditis maybe heard on auscultation of heart sounds
When is Pericarditis most likely to occur?
2 to 3 days after AMI
What is Dressler’s syndrome and when is it likely to occur?
A hypersensitivity response to necrotic tissue or an autoimmune disorder, may develop days to weeks after AMI.
What are the symptoms of Dressler’s syndrome?
1. Fever
2. Chest pain
3. Dyspnea
What are the immediate goals for the MI client? (5)
1. Relieve chest pain
2. Reduce the extent of myocardial damage
3. Maintain cardiovascular stability
4. Decrease cardiac workload
5. Prevent complications
What are the 4 serum cardiac markers?
1. Creatinine phosphokinase (CK or CPK)
2. CK-MB
3. Cardiac-specific troponin T (cTnT)
4. Cardiac-specific troponin I (cTnI)
CK (CPK) normal level
Male: 12 to 80 U/L
Female: 10 to 70 U/L
CK (CPK) primary tissue location (3)
1. Cardiac muscle
2. Skeletal muscle
3. Brain
CK (CPK) significance of elevation
Injury to muscle cells
CK (CPK) level changes occurring with MI
Appears 3 to 6 hours
Peaks 12 to 24 hours
Duration 24 to 48 hours
CK-MB normal level
0% to 3% of total CK
CK-MB primary tissue location
Cardiac muscle
CK-MB significance of elevation (5)
1. MI
2. Cardiac ischemia
3. Myocarditis
4. Cardiac contusion
5. Defibrillation
CK-MB level changes occurring with MI
Appears 4 to 8 hours
Peaks 18 to 24 hours
Duration 72 hours
cTnT normal level
< 0.2 mcg/L
cTnT primary tissue location
Cardiac muscle
cTnT significance of elevation (2)
1. Acute MI
2. Unstable angina
cTnT level changes occurring with MI
Appears 2 to 4 hours
Peaks 24 to 36 hours
Duration 10 to 14 days
cTnI normal level
< 3.1 mcg/L
cTnI primary tissue location
Cardiac muscle
cTnI significance of elevation (2)
1. Acute MI
2. Unstable angina
cTnI level changes occurring with MI
Appears 2 to 4 hours
Peaks 24 to 36 hours
Duration 7 to 10 days
Aside from Serum Cardiac Markers what other laboratory tests maybe run for MI patient? (3)
1. Myoglobin
2. CBC
3. ABGs
What diagnostic tests are commonly performed when AMI is suspected?
1. Electrocardiogram (ECG)
2. Echocardiography
3. Radionuclide imaging
4. Hemodynamic monitoring
Medication management if AMI includes what class of drugs? (9)
1. Thrombolytic
2. Analgesia
3. Antidysrhythmics
4. Beta blockers
5. ACE inhibitors
6. Nitroglycerins
7. Anticoagulants
8. Heparin
9. Stool softener
What is the first line of drug used to treat AMI?
Thrombolytic agents
What are contraindications for Thrombolytic agents? (8)
1. Bleeding disorders or active bleeding
2. History of cerebrovascular disease
3. Uncontrolled hypertension
4. Pregnancy
5. Recent trauma or surgery to the head or spine
6. Prolonged CPR
7. Gastrointestinal ulcers
8. Diabetic hemorrhagic retinopathy
What are the four commonly used thrombolytic agents?
1. Streptokinase
2. Anisoylated plasminogen streptokinase activator complex (APSAC)
3. Tissue plasminogen activator (t-PA)
4. Reteplase
How would the nurse evaluate the effectiveness of thrombolytic therapy?
Look for signs that the clot has been dissolved and the myocardium is being reperfused
1. Normalization of ST segment
2. Relief of chest pain
3. Reperfusion dysrhythmias
4. Early peaking of the CK and CK-MB
What are the manifestations of reocclusion?
1. Changes in the ST segment
2. Chest pain
3. Dysrhythmias
Thrombolytic therapy: Pre-infusion care (5)
1. Obtain nursing history, and perform a physical assessment
2. Evaluate for contradictions to thrombolytic therapy
3. Inform client the purpose of therapy
4. Discuss the risk of bleeding
5. Tell client to keep extremity immobile during and after the infusion
Thrombolytic therapy: During the infusion (6)
1. Assess and record vital signs and the infusion site for hematoma or bleeding.
2. Assess pulses, color, sensation, and temperature of both extremities with each vital sign check.
3. Remind client to keep extremities still and straight.
4. Do not elevate the head of the bed above 15 degree.
5. Maintain continuous cardiac monitoring
6. Keep antidysrhythmic drugs and the emergency cart ready.
Thrombolytic therapy: Post-infusion care (10)
1. Assess vital signs, distal pulses, and infusion site frequently as needed.
2. Evaluate response to therapy
3. Maintain bed rest for 6 hours
4. Avoid injections for 24 hours after catheter removal
5. On catheter removal hold direct pressure for 30 minutes
6. Assess body fluids for evidence of bleeding
7. Assess for changes in LOC
8. Administered platelet-modifying drugs
9. Report manifestations of reocclusion
10. Monitor Hgb, Hct, PT, and PTT levels
During the infusion of thrombolytic agent, how often are vital signs assess and record?
Every 15 minutes for the first hour,
Every 30 minutes for the next two hours, then
Hourly until the IV catheter is discontinued.
What analgesic medications are used for acute MI? (2)
1. Sublingual Nitroglycerine
2. Morphine sulfate
What is the dose of Sublingual Nitroglycerine given for Pt. with AMI?
Up to three 0.4 mg doses at five minutes interval.
What is the dose of Morphine Sulfate given for Pt. with AMI?
Initial IV dose of 4 to 8 mg. Small doses of 2 to 4 mg may be repeated IV q 5 minutes until pain is relieved.
What medication maybe given to Pt. with AMI for anxiety?
diazepam (Valium)
What antidysrhythmics medications are used in AMI? (3)
1. Class I or class II
2. Verapamil
3. Short acting Beta-blockers
What are medical managements for AMI patients? (6)
1. Continuous monitoring
2. ICU for the first 24 to 48 hours
3. IV line established
4. Bed rest for 24 hours
5. Oxygen 2 to 5 L/min
6. Restricted diet
What diet restrictions are imposed on AMI patients? (5)
1. Liquid diet for the first 4 to 12 hours
2. Low fat, low-cholesterol, reduced-sodium diet for 2 to 3 days
3. Small, frequent feedings
4. No drinks containing caffeine
5. No very hot and cold foods
What revascularization procedures may be performed for AMI patient?
1. Percutaneous coronary revascularization (PCR)
stent placement
2. CABG surgery
When AMI is large and Pt. shows evident of pump failure, what invasive devices may be used to temporary take over the function of the heart? (2)
1. Intra-aortic balloon pump (IABP)
2. Ventricular assist devices (VADs)
Nursing care:
What should the nurse discuss in regarding to health promotions for AMI patient? (3)
1. Risk factor management
2. Use of prescribed medications
3. Cardiac Rehabilitation
Nursing care:
What are nursing diagnoses for AMI patient? (3)
1. Acute pain
2. Ineffective tissue perfusion
3. Ineffective coping
Nursing care: What are the main nursing interventions for pain due to AMI? (5)
1. Assess for pain
2. Administer oxygen 2 to 5 L/min per nasal cannula
3. Promote rest and provide support
4. Titrate IV nitroglycerine per order (systolic > 100)
5. Administer 2 to 4 mg morphine by IV push as ordered
Nursing care: What are the main nursing interventions for ineffective tissue perfusion due to AMI?
1. Assess and record vital signs, report changes
2. Assess for changes in LOC
3. Assess for signs of ineffective tissue perfusion
4. Auscultate heart and breath sounds
5. Monitor ECG continuously
6. Monitor oxygen saturation
7. Administer antiarrhythmic medications
8. Obtain serial CK, isoenzyme, and troponin level
9. Plan for invasive hemodynamic monitoring

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