NUR 213- perfusion MI
When are fibrinolytics indicated? What is the time from door to NEEDLE?
for patients unable to get to a hospital with PCI capabilities within 90 minutes. 30 minutes from door to needle.
Fibrnolytic therapy is Alteplase (tPA) followed by?
heparin infusion
What are the absolute contraindications of fibrinolyitcs?
if they are on blood thinners. no recent surgery. if they had a hemorrhagic stroke [intracranial bleeding] within 3 months. if had any head or facial trauma in the last 3 months. Active bleeding. Severe or uncontrolled hypertension. treatment with fibrinolytics in the past 6 months.
What is the LAD?
left anterior descending (coronary artery). Supplies blood to the left ventricle. when blocked, this is nick named the widow maker.
What is normal troponin?
less than 0.1 mcg/L
What are 2 types of stress test?
med induced [dobutamine] or exercise induced via treadmill. But if they know they have had an MI and the heart muscle is damaged, they will not do this test.
Post procedure care of cardiac cath is?
monitor incision site: -On wrist there will be TR (transradial) band holding pressure. -On the groin they may not have anything but will still monitor. Monitor VS: q 15 x 4, 30 x 2, 1 hr x 4. -Monitor for bleeding, swelling, numbness or tingling. Check pulse distal to site look for good perfusion. If notice bleeding from radial or femoral, put pressure on top of dressing. Must lay flat anywhere from 2 to 6 hours for femoral, no bedrest with radial.
What might a female experiencing a MI have for s/s?
nausea, heartburn, neck, jaw or shoulder pain, pain radiates to the back, pain in one or both arms.
If a PCI is tried but cannot be done, what will they need to have?
open heart surgery.
Myocardial infarction is a lack of...
perfusion to the muscles of the heart.
What is the RCA?
right coronary artery. The right coronary artery supplies blood to the right ventricle and the the right atrium.
why do we do a chest xray for chest pain and MI?
see size of heart, rule out clot or pneumonia
How can the patient tell if nitro is fresh?
should cause a tingling sensation under the tongue and then they'd have a headache.
If a person comes in with chest pain and MI, why do we do echocardiogram [uses sound waves to get images of heart]?
to see their ejection fraction, and to see if there is any valve abnormality
How is troponin drawn?
when they arrive to ED, draw 6 hours later, then another 6 hours later, can have a continued increase. But if the cause is fixed, we don't have to keep reporting it to the provider.
MI treatment options are?
#1 Cardiac Catheterization with Percutaneous Coronary Intervention [Cardiac Cath with a PCI]. Fibrinolytic Therapy [TPA] will break up the clot, also used for stroke. Coronary Artery Bypass Graft [CABG].
Pre procedure care of cardiac cath is?
-Contrast, ask if they are allergic to contrast or iodine. -NPO after midnight. -hold - Lasix, diuretics, ace inhibitors [prils] or arbs [sartans]. -Stop Metformin 24 hrs before and not restart for 72 hours because it will crystallizes in the blood when in contact with contrast. -Educate they are awake during, local so no pain, just pressure.
what is normal myoglobin?
0-85 ng/L
with myoglobin, what is the: Onset Peak return to normal
1-3 h. 4-8 h. 12-24 h.
ECG for chest pain and MI.
12 lead: for diagnostic ST elevation [STEMI st elevation myocardial infarction, shows a block in a coronary artery].
with troponin, what is the: Onset Peak return to normal?
2-4 h. 12-48 h. Days-weeks.
How do we administer morphine?
2-5mg slow IVP, over 2 minutes. Monitor VS closely for respiratory depression, and changes in HR and B/P. Can be given after all 3 nitro doses or after the second or third.
What is the time from door to needle with fibrinolytics?
30 Minutes.
Antiplatlet agent, aspirin: IF CAD is suspected, what mg? What mg is prophylactic ?
325mg chewed. 81 mg po every day.
What is the time from door to balloon with PCI?
90 minutes
Administering nitroglycerine SL rules are?
Assess BP, needs to be a minimum of 90/60 or above because it causes vasodilation which will drop the blood pressure. Give first pill, wait 5 min, if it didn't work, assess BP again, give second pill....repeat x 3 pills. Each pill is 0.4 mg. May need to give IV.
What labs do we take when someone comes in with Chest pain or an MI?
Cardiac Enzymes, CBC to rule out infection, Lipid Panels to see if they have hyperlipidemia, PT, PTT INR to look for increased clotting.
If the troponin is positive, they can't do a stress test, so what would they do?
Cardiac catheterization
Inclusion criteria for fibrinolytic therapy with a STEMI are?
Chest Pain typical of acute MI. 12 lead ECG findings consistent with STEMI. No absolute contraindications.
Clinical manifestations of an MI are?
Chest Pain. Dyspnea. Indigestion. Nausea. Anxiety. Cool, pale moist skin. Pain in left shoulder or arm.
What are some antiplatelet medicines and how often are they taken? do these have an antidote?
Clopidogrel [Plavix]-once a day and now generic. Prasugrel [Effient]-once a day. Ticagrelo [Brilinta]-twice a day. None of these have antidotes, up to the doctor which one they will choose.
What does the cardiac marker myoglobin show?
Damage to heart or skeletal muscle
History and physical for chest pain and MI are?
Do they have a history of HBP, diabetes, what were they doing when the pain started.
What does cardiac catheterization do?
Evaluates the heart function, PCI allows for re-perfusion of the coronary arteries. May go through femoral vein, or the radial artery. Inject contrast, if it flows through coronary arteries then it's not blocked, but if it narrows or blocks there is a blockage. May remove clot or put in stent.
Which is the gold standard and which is the least invasive diagnostic tests for MI?
Gold is cardiac catheterization. Least invasive is stress test.
Common side effect of nitroglycerine is? 3
Headache, dizzy, flushing of skin.
Diagnostic Tests for both chest pain and a MI are? [7]
History & Physical. ECG- 12 lead. CXR. Labs . Echocardiogram. Stress Test. Cardiac Catheterization aka Coronary Angiography.
Why is morphine sulfate used with a MI?
It's used if nitro does't work. It will decrease O2 consumption, it will relax the patient reducing anxiety and fear, it will also vasodilate to get O2 rich blood where it's needed in the heart.
What does the cardiac marker troponin show?
It's very specific to heart muscle damage.
How do we store nitroglycerine pills?
Keep it airtight, light resistant bottle. Inexpensive but needs to be replaced frequently, good for only 6-9 months.
Which leads show an injury to the circumflex coronary artery? 4
Leads 1, AvL, V5, and V6
Which leads show an injury to the right coronary artery? 3
Leads 2, 3 and AvF
Which leads show an injury to the LAD [left anterior descending coronary artery? 4
Leads V1, V2, V3 and V4
Assessing for a hematoma post cardiac cath.
Look for a hematoma [bulge or hard knot under skin] dressing could be dry but will still have blood under skin. For radial site, check entire arm. But they are more common in the femoral site, feel all around the leg.
MI with diabetes may present with?
More fatigue, they have more atherosclerotic plaques d/t the diabetes so are more prone to have MI.
Medication administration of STEMI & NSTEMI is?
Nitroglycerin [SL first d/t less invasive, if it doesn't work then IV] Morphine Sulfate if nitro doesn't work. Aspirin 325 mg, an antiplatelet. Heparin an anticoagulant that stops platelets from sticking together] ACE inhibitors. Beta- Adrenergic blockers.
When is it safe to do a stress test?
Only if triponin is negative, because if the heart muscle is injured, they don't want to injure it further.
Nursing intervention for STEMI & NSTEMI are?
Oxygen therapy First 2L NC. EKG monitoring to show where injury is. Establish IV access. Regular VS including Pain Assessment. Med management [more on other slide]. Bed Rest. Reassurance.
What is nursing care for MI?
Rest and de-stress! Cardiac monitor, vital signs. NTG PRN for angina. Oxygen. Teach s/s of angina, how to take NTG, lifestyle changes. Cardiac rehabilitation.
Where does the st changes occur on an EKG?
Right after the QR comes the ST.
What is a: STEMI NSTEMI
ST elevation myocardial infarction. Non ST elevation myocardial infarction [ST is not elevated but still had a heart attack].
What does ST elevation mean? What does ST depression mean?
ST-elevation: injury to myocardium ST-depression: ischemia to myocardium
What is the circumflex coronary artery?
The circumflex wraps around the heart and supplies blood to the left atrium, it comes off the LAD.
What is Percutaneous Coronary Intervention (PCI)?
When there is a blockage in the artery [when we see a STEMI], this is the fix to the blockage by opening the vessel. Could be a Balloon that pushes the blockage to the side of the artery and/or put in a stent to open the blockage
After the stent placement, what meds will the patient be prescribed?
antiplatelets [for about a year], aspirin and statins.
