NUR 155: Care of Clients with Problems in

Oxygenation, Fluid and Electrolyte,

Infectious, Inflammatory and Immunologic
Response, Cellular Aberrations, Acute and
Chronic Lecture
Prepared by: Krys Raymond B. Lopez, RN, MD
 CARE OF PATIENTS WITH MYOCARDIAL
INFARCTION
Learning Targets:
At the end of the module, students will be able to:
1. Discuss the pathophysiologic responses to alterations/problems in
oxygenation specifically with patient’s myocardial infarction;
2. Assess the at-risk and sick adult client’s one’s health status/competence;
3. Formulate with the client a plan of care to address needs /problems and based
on priority;
4. Implement safe and quality nursing interventions with client to address needs/
problems;
5. Institute appropriate corrective actions to prevent or minimize harm arising
from adverse effects; and,
6. Compare patients with myocardial infarction with regard to cause, incidence,
clinical manifestations, management, and the significance of preventive health
care.
 Myocardial Infarction (MI)
• is used synonymously with
coronary occlusion and heart
attack, yet MI is the most preferred
term as myocardial ischemia
causes acute coronary syndrome
(ACS) that can result in myocardial
death.
• In an MI, an area of the
myocardium is permanently
destroyed because plaque rupture
and subsequent thrombus
formation result in complete
occlusion of the artery.
• The spectrum of ACS includes
unstable angina, non-ST-segment
elevation MI, and ST-segment
elevation MI.
 Causes
The causes of MI primarily stem
from the vascular system.
• Vasospasm. This is the sudden
constriction or narrowing of the
coronary artery.
• Decreased oxygen supply. The
decrease in oxygen supply occurs
from acute blood loss, anemia, or
low blood pressure.
• Increased demand for oxygen. A
rapid heart rate, thyrotoxicosis, or
ingestion of cocaine causes an
increase in the demand for
oxygen.
 Location of obstruction in MI
• Left Anterior Descending
= anterior wall or septal,
or both
• Circumflex artery =
posterior wall MI, or
lateral wall MI
• Right Coronary artery =
Inferior wall MI
 RISK FACTORS
MODIFIABLE NON-MODIFIABLE
• Atherosclerosis
• Coronary Artery Disease
• Age (the older, the greater the
• Elevated Cholesterol Levels risk)
• Smoking • Sex (Men > Women) Women’s
• Hypertension risk starts going up at age 50 or
• Obesity after reaching menopause,
• Physical Inactivity whichever is first
• Impaired Glucose Tolerance
• Family History
• Stress
• Recreational Drug • Inherited or conditions present at
Use(Stimulants) birth (genetic or congenital)
 Clinical Manifestations
• Some of the patients have
prodromal symptoms or a
previous diagnosis of CAD, but
about half report no previous
symptoms.
• Chest pain. This is the cardinal
symptom of MI. Persistent and
crushing substernal pain that may
radiate to the left arm, jaw, neck,
or shoulder blades. Pain is
usually described as heavy,
squeezing, or crushing and may
persist for 12 hours or more.
 CLINICAL MANIFESTATIONS
• Shortness of Breath. Because of increased oxygen demand and a
decrease in the supply of oxygen, shortness of breath occurs.
• Indigestion. Indigestion is present as a result of the stimulation of
the sympathetic nervous system.
• Tachycardia and Tachypnea. To compensate for the decreased
oxygen supply, the heart rate and respiratory rate speed up.
• Catecholamine Responses. The patient may experience such as
coolness in extremities, perspiration, anxiety, and restlessness.
• Fever. Unusually occurs at the onset of MI, but a low-grade
temperature elevation may develop during the next few days.
 Pathophysiology
• In each case of MI, a profound imbalance exists between
myocardial oxygen supply and demand.
• Unstable angina. There is reduced blood flow in a coronary
artery, often due to rupture of an atherosclerotic plaque, but the
artery is not completely occluded. (no necrosis)
• Development of infarction. As the cells are deprived of oxygen,
ischemia develops, cellular injury occurs, and lack of oxygen
leads to infarction or death of the cells.
 Assessment and Diagnostic Findings
Pain Assessment
• The diagnosis of MI is generally O = Onset. When did it begin?
based on the presenting P = Provocation/Palliation. What
symptoms. were you doing when the pain
• Patient history. The patient started? ...
history includes the Q = Quality/Quantity. What does
it feel like? ...
description of the presenting
R = Region/Radiation. Where
symptoms, the history of does it spread
previous cardiac and other S = Severity Scale. 1/10
illnesses, and the family T = Timing/Treatment.
history of heart diseases.
 Assessment and Diagnostic Findings
• ECG. ST elevation
signifying
ischemia; peaked
upright or inverted
T wave indicating
injury;
development of Q
waves signifying
prolonged
ischemia or
necrosis.
 Assessment and Diagnostic Findings
• Cardiac enzymes and
isoenzymes. CPK-MB (isoenzyme
in cardiac muscle): Elevates within
4–8 hr, peaks in 12–20 hr, returns to
normal in 48–72 hr.
• Troponins. Troponin I (cTnI) and
troponin T (cTnT): Levels are
elevated at 4–6 hr, peak at 14–18
hr, and return to baseline over 6–7
days. These enzymes have
increased specificity for necrosis
and are therefore useful in
diagnosing postoperative MI when
MB-CPK may be elevated related
to skeletal trauma.
 Assessment and Diagnostic Findings
• LDH. Elevates within 8–24 hr,
peaks within 72–144 hr, and
may take as long as 14 days to
return to normal. An LDH1
greater than LDH2 (flipped
ratio) helps confirm/diagnose
MI if not detected in acute
phase.
• Myoglobin. A heme protein of
small molecular weight that is
more rapidly released from
damaged muscle tissue with
elevation within 2 hr after an
acute MI, and peak levels
occurring in 3–15 hr.
 Assessment and Diagnostic Findings
• Electrolytes. Imbalances
of sodium and potassium
can alter conduction and
compromise contractility.
• WBC. Leukocytosis
(10,000–20,000) usually
appears on the second day
after MI because of the
inflammatory process.
• ESR. Rises on second or
third day after MI,
indicating inflammatory
response.
 Assessment and Diagnostic Findings
• Chemistry profiles. May be abnormal, depending on
acute/chronic abnormal organ function/perfusion.
• ABGs/pulse oximetry. May indicate hypoxia or
acute/chronic lung disease processes.
• Lipids (total lipids, HDL, LDL, VLDL, total
cholesterol, triglycerides, phospholipids).
Elevations may reflect arteriosclerosis as a cause for
coronary narrowing or spasm.
 Assessment and Diagnostic Findings
• Chest x-ray. May be normal or show an
enlarged cardiac shadow suggestive of
HF or ventricular aneurysm.
• Two-dimensional echocardiogram.
May be done to determine dimensions
of chambers, septal/ventricular wall
motion, ejection fraction (blood flow),
and valve configuration/function.
• Nuclear imaging studies: Persantine
or Thallium. Evaluates myocardial
blood flow and status of myocardial
cells, e.g., location/extent of
acute/previous MI
 Assessment and Diagnostic Findings
• Cardiac blood imaging/MUGA.
Evaluates specific and general
ventricular performance, regional
wall motion, and ejection fraction.
• Technetium. Accumulates in
ischemic cells, outlining necrotic
area(s).
• Coronary angiography. Visualizes
narrowing/occlusion of coronary
arteries and is usually done in
conjunction with measurements of
chamber pressures and
assessment of left ventricular
function (ejection fraction).
Procedure is not usually done in
acute phase of MI unless
angioplasty or emergency heart
surgery is imminent.
 Assessment and Diagnostic Findings
• Digital subtraction angiography (DSA).
Technique used to visualize status of
arterial bypass grafts and to detect
peripheral artery disease.
• Magnetic resonance imaging (MRI).
Allows visualization of blood flow,
cardiac chambers or intraventricular
septum, valves, vascular lesions, plaque
formations, areas of necrosis/infarction,
and blood clots.
• Exercise stress test. Determines
cardiovascular response to activity
(often done in conjunction with thallium
imaging in the recovery phase).
 Medical Management
• The goals of medical management are to minimize myocardial damage,
preserve myocardial function, and prevent complications.

Pharmacologic Therapy
• Morphine administered in IV boluses is used for MI to reduce pain and
anxiety.
• ACE Inhibitors. ACE inhibitors prevent the conversion of angiotensin I to
angiotensin II to decrease blood pressure and for the kidneys to secrete
sodium and fluid, decreasing the oxygen demand of the heart.
 Medical Management
• Thrombolytics. Ex. Alteplase, Tenecteplase
Thrombolytics Used early in the course of myocardial infarction to restore
dissolve the blood flow, limit myocardial damage, and prevent death.
thrombus in
the coronary Contraindications: Active internal bleeding, history of
artery, allowing hemorrhagic stroke, hepatic or renal disease, allergy
blood to flow Side Effects: Bleeding, Dysrhythmias, allergic reactions
through the
coronary artery Interventions:
again, • Determine, apTT, PT, Fibrinogen, hematocrit, platelet
minimizing the • Monitor for bleeding, hypotension
size of the
infarction and • Instruct the client to use an electric razor for shaving
preserving
ventricular
function.
 Surgical Procedures
1. Percutaneous Coronary
Intervention
• The patient with STEMI may be taken
directly to the cardiac catheterization
laboratory for an immediate PCI. 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 use
of PCI compared to thrombolytics
2. Cardiac Rehabilitation
• The goals of rehabilitation for the patient
who has had an MI are to extend life
and improve the quality of life, targets
risk reduction by means of education,
individual and group support, and
physical activity.
 Surgical Procedures
3. Percutaneous Transluminal
Coronary Angioplasty
• A catheter with a balloon tip is
inserted usually via the
femoral artery and advanced
into the heart, once the
blocked coronary artery is
entered the balloon is inflated
and the atherosclerotic plaque
is compressed. This results in a
dilated vessel being able to
deliver more oxygen-rich blood
to the myocardium, the patency
of the vessel is restored.
 Surgical Procedures
4. Coronary Artery Stents
• Used to prevent closure of a
coronary artery from an
atherosclerotic lesion while
providing support to a coronary
artery wall at the area of
stenosis to keep blood flowing
through the artery, these
stents are put in place during
an angioplasty.
 Surgical Procedures
5. Myocardial
Revascularization – Coronary
Artery Bypass Graft
• A procedure used to increase
blood flow and oxygen to the
myocardium and alleviating
angina symptoms, during
bypass surgery, a blood
vessel is from the leg or chest
is used to reroute blood
around a segment of a coronary
artery that is narrowed by
atherosclerosis.
 Nursing Management
• The nursing management involved in MI is critical and
systematic, and efficiency is needed to implement the care for a
patient with MI.
• Diagnosis Based on the clinical manifestations, history, and
diagnostic assessment data, major nursing diagnoses may
include.
1. Ineffective cardiac tissue perfusion related to reduced coronary
blood flow.
2. Risk for ineffective peripheral tissue perfusion related to
decreased cardiac output from left ventricular dysfunction.
3. Deficient knowledge related to post-MI self-care.
 Nursing Priorities
1. Relieve pain, anxiety.
2. Reduce myocardial workload.
3. Prevent/detect and assist in treatment of
life-threatening dysrhythmias or
complications.
4. Promote cardiac health, self-care.
 Nursing Interventions
• Nursing interventions should be anchored on the goals in
the nursing care plan.
• Obtain a description of the chest discomfort.
• Administer oxygen along with medication
therapy(Morhpine, nitrates) to assist with relief of
symptoms.
• Encourage bed rest with the back rest elevated(Semi-
fowler’s position) to help decrease chest discomfort
and dyspnea.
• Encourage changing of positions frequently to help keep
fluid from pooling in the bases of the lungs.
 Nursing Interventions
• Establish an IV access route
• Obtain a 12-L ECG
• Monitor laboratory values
• Monitor for cardiac dysrhythmias
• Administer thrombolytic therapy as prescribed
within the first 6 hours of the coronary event if
cardiac catheterization is not to be done emergently.
Monitor for signs of bleeding.
 Nursing Interventions
• Check skin temperature and peripheral pulses
frequently to monitor tissue perfusion. Poor cardiac
output may be identified may be identified by cool
diaphoretic skin, and diminished or absent
pulses.
• Provide information in an honest and supportive
manner.
• Monitor the patient closely for changes in cardiac
rate and rhythm, heart sounds, blood pressure,
chest pain, respiratory status, urinary output,
changes in skin color, and laboratory values.
 NURSING INTERVENTIONS FOLLOWING
THE ACUTE EPISODE
• Maintain BED REST as prescribed.
• Allow the client to stand to void or use a bedside
commode as prescribed.
• Provide range-of-motion exercises to prevent
thrombus formation and maintain muscle strength.
• Monitor for complications.
• Encourage the client to verbalize feelings regarding the
MI.
 Complications of MI
• Dysrhythmias
• Heart Failure
• Pulmonary Edema
• Cardiogenic Shock
• Thrombophlebitis
• Pericarditis
END