Med Surg CH. 23 Acute Coronary Syndrome and Myocardial Infarction

Cardiac Rehabilitation

-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

pathophysiology- what happens when MI occurs

-Vasospasm (sudden constriction or narrowing) of a coronary artery, decreased oxygen supply (e.g., from acute blood loss, anemia, or low blood pressure), and increased demand for oxygen (e.g., from a rapid heart rate, thyrotoxicosis, or ingestion of cocaine) are other causes of MI

inpatient management

-after pci or thrombolytic therapy, continous cadiac monitoring in an ICU -continuing pharm management:aspirin, beta blocker,and an ace inhibitor Ace inhibitors prevent conversion of angiotensin I and 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. -monitor bp, urine output, and serum sodium, potassium, and creatinine levels. -angiotensin receptor blocker prescribed if ace inhibtor is not suitable.

Assessment and Diagnostic findings

-based on presenting symptoms. -ECG and LABS

CM of acute coronary syndome

-chest pain suddenly despite rest or medications -prodromal symptoms or previous diagnosis of CAD. -chest pai, shortness of breath, indigestion, nausea, anxiety, cool &pale& moist skin -HR and RR fast -s/s are hard to distinguish from unstable angina

what does morphine for patient?

-drug of choice to reduce pain and anxiety -reduces preload and afterload -monitor for hypotension, or decreased respiratory rate. -beta blocker if arrthymias occur -beta blocker is not apart of intial management ,should be introudced within 24 hours of admission, once hemodynamics have stabilized and it is confirmed the patient has no contraindicitions.

Phase 3: patient with acute coronary syndrome

-long -term outpatient program that focuses on maintaining cardiovascular stability and long-term conditioning.

Nursing Interventions/ improving respiratory function

-monitor fluid volume status to prevent fluid overload and encourage the patient to breathe deeply and change position frequently o maintain ffective ventilation throughtout the lungs.

ECG

-obtained within 10 minutes of time patient reports pain or arrives to ED -first signs are seen in T wave and ST segment -Q wave signs develop in 1-3 days

emergent percutanoues coronary intervention?

-pt with stemi is taken directly to cardiac catherization lab for PCI -procedure is used to open the occluded coronary artery and promote reperfusion to the area that has been deprived of oxygen -door-to-balloon time

Nursing Process/ assessment

-symptoms: chest pain, discomfort, dyspnea, palpitations, unsual fatigue, syncope, other possible indictators of myocardial ischemia. - time, duration, and factors that precipitate the symptom Two IV lines are placed for easy access is available for administering emergency medications

inital management

-the patient with suspected MI should be immediately recieve supplemental oxygen, aspirin, nitroglycern, and morphine

from ECG, how can you tell recovery is there?

ST segement returned to normal, Q wave are usually permanent -An old STEMI is usually indicated by an abnormal Q wave or decreased height of the R wave without ST-segment and T-wave changes.

Nursing Interventions:

Releieving pain and other signs and symptoms: -balance myocardial oxygen supply with demand -2-4 L of oxygen -head of bed elevated or chair -elevation of torso beneficial for tidal volume: improves because of reduced pressure from abdomnical contents on the diaphragm and better lung expansion drainage of the upper lung lobes improves venous return to the heart (preload decreases), reducing work of the heart.

physical assessment

may include S3 and S4 and a murmur - increased jugular venous distention -BP may be elevated -irregular pulse -irregular pulse indicate atrial fibrillation

Phase 2 cardiac rehab

after the patient has been discharged. attends sessions for 3 times a week for 4-6 weeks and may continue for 6 months. -he 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.

Lab Test

cardiac enzymes: troponin- protein found in myocardial cells, regulates the contractile process. - C,I,T -I,T are for cardiac muscle and these biomarkers are reliable and critical markers for myocardial injury - can be detected within a few hours during acute MI. It remains elevated for a long period as 2 weeks, can detect recent myocardial damage -should be noted these can rise during inflammation or other forms of stress on myocardium Creatine Kinase and Its isoenzymes-CK-MM (skeletal muscle), CK-MB (heart muscle), and CK-BB (brain tissue). CK-MB is the cardiac-specific isoenzyme; it is found mainly in cardiac cells and therefore increases when there has been damage to these cells. Elevated CK-MB is an indicator of acute MI; the level begins to increase within a few hours and peaks within 24 hours of an infarct. Myoglobin-heme protein that helps transport oxygen. Like the CK-MB enzyme, myoglobin is found in cardiac and skeletal muscle. The myoglobin level starts to increase within 1 to 3 hours and peaks within 12 hours after the onset of symptoms. An increase in myoglobin is not very specific in indicating an acute cardiac event; however, negative results can be used to rule out an acute MI.

patient history

description of symptom previous cardiac and other illness genetic patient risk factors

pathophysiology -acute coronary syndrome

in unstable angina, there is reduced blood flow in coronary artery, often due to a rupture of an atherosclerotic plaque. a clot forms on the top of coronary lesion, but artery is not completely occluded. -results in chest pain and symptoms that are preinfaarction angina because an MI may occur

Phases 1 of cardiac rehab

phase 1: -begins with diagnosis of atherosclerosis, mobilization occurs early and patient education focuses on the essentials of self care rather than instituting behavioral changes for risk reduction, s/s of when to call 911, medication regimen, rest-activity balance, and follow up appointments withthe primary provider -pt reassured that they can have normal life . -activity depends on age, condition, and extent, course of hospital stay and development of any complications.

thrombolytics

therapy initiated when primary PCI is not available or the transport time to PCI-capable hospital is too long. -agents: altepase, reteplase, and tenecteplase Its purpose is to dissolve the thrombus in cornary artery allowing blood blow but it does not affect the underlying atherosclerotic lesion . -patient may be taken for cardiac catherization following this therapy. -these should not be used if pt has bleeding or bleeding disorder. -should be given within 30 minutes of symptom -"door-to-needle" time.

unstable angina? STEMI? NSTEMI?

unstable: he patient has clinical manifestations of coronary ischemia, but ECG and cardiac biomarkers show no evidence of acute MI. STEMI:The patient has ECG evidence of acute MI with characteristic changes in two contiguous leads on a 12-lead ECG. In this type of MI, there is a significant damage to the myocardium. NSTEMI: The patient has elevated cardiac biomarkers (e.g., troponin) but no definite ECG evidence of acute MI. In this type of MI, there may be less damage to the myocardium.

Echocardiogram?

used to evalate ventricular function -used when ECG is nondiagnostic -can detect hypokinetic and akinetic wall motion and can determine the ejection fraction.