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alteration in cardiac perfusion output part 2

Acute Myocardial Infarction (MI) ___________________________. Leading cause of death of men

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alteration in cardiac perfusion output part 2

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    1. Alteration in Cardiac Perfusion & Output – Part 2 Rose Bianchi, RN, DNSc. Copyright 2011 and 2008

    3. Types of MI ___________________________ Non-Q wave (subendocardial) Q-Wave (Transmural)

    4. Pathophysiology of MI ___________________________ Lack of Blood Supply & O2 to the Myocardium | Anaerobic Metabolism | Lactic Acid Production | Acidosis | Conduction System Disorders Dysrhythmias Reduced Cardiac Contractility& Cardiac Output

    5. Sites of MI ___________________________ Anterior Wall of Left Ventricle (L.V.) a. Thrombus in Descending Branch of Left Coronary Artery (C.A.) 2. Posterior Wall Of LV a. Thrombus in Right C.A. or b. Circumflex Branch of Left C.A. 3. Inferior (Diaphragmatic) Surface of the Heart a. Thrombus in Right C.A.

    6. Sites of MI ___________________________ 4. Lateral 5. Septal

    7. Clinical Manifestations of MI ___________________________ Chest Pain Unrelieved by NTG &/or Rest may radiate to neck, jaw , shoulder , back, or down left arm Women often present with just SOB, fatigue, dizziness , indigestion , &/or back pain Nausea, vomiting, indigestion, Sympathetic Nervous System Stimulation – diaphoresis, vasoconstriction Fever – up to 100.4 Elevated BP & HR first , later Decreased BP due to low C.O. Edema – peripheral &/or pulmonary Abnormal Heart Sounds – S3 or S4

    8. EKG Changes with MI ___________________________ Ischemia causes ST segment elevation Peaked or inverted T wave

    9. Lab Tests For a Client with a MI ___________________________ Elevated Lab Tests 1. Serum Creatine Kinase (CPK MB) Normal Value: 21 – 232 u/l Elevates in 3 – 6 hrs. After a MI, Peaks in 12 –18 hrs., Returns to normal in 3 – 4 days 2. Troponin I – Normal < 0.5 ng/ml Borderline Result – 0.5 – 1.99 ng/ml May Indicate MI - >2.00 Rises fast, Peaks in 24 – 48 hrs.

    10. Elevated Lab Tests in MI ___________________________ Serum Aspartate Aminotransferase (AST) Elevates several hours after MI, Peaks in 12 – 18 hrs. Returns to Normal in 3 – 4 days Serum Lactate Dehydrogenase (LDH) M1 Isoenzyme Elevates 14 – 24 hrs.after MI Peaks in 48 – 72 hrs. Returns to normal in 7 –14 days

    11. Elevated Lab Tests in MI ___________________________ C-Reactive Protein Normal Value < 1.0 mg/dl Leukocytosis – Elevated WBC 10,000 – 20,000 per mm3, Occurs Day 2 Serum Erythrocyte Sedimentation Rate

    12. Overhead Projector Slides of Examples of Client Lab Values _____________________________________

    13. Treatment for Unstable Angina/Non-ST-Segment MI (NSTEMI) __________________________________________ I. Acute Intensive Therapy a. Nitroglycerin b. Low Molecular Weight Heparin c. Clopidogrel (Plavix) d. Glycoprotein IIb Inhibitors- Eptifibatide (Integrellin) II. Coronary Angioplasty a. Percutaneous Coronary Intervention (PCI)

    14. ST- Segment – Elevation MI (STEMI) ___________________________________ Immediate Reperfusion Therapy a. Percutaneous Coronary Intervention (PCI) b. Fibrinolytic Therapy c. Emergent CABG Surgery

    15. DiagnosticTests and Procedures for the Client with MI _____________________________________ Radionuclide Imaging Magnetic Resonance Imaging (MRI) Echocardiography Cardiac Catheterization Angioplasty Coronary Artery Bypass Grafting (CABG)

    16. Goals of Care for the Client with an Acute MI _____________________________________ Treat MI & its symptoms Prevent Complications & Another MI Educate & Rehabilitate the Client

    17. ICU Interventions ___________________________ Arterial Lines Swan Ganz Catheter Monitoring Pain Management O2 Therapy EKG Monitoring

    18. Thrombolytic Therapy for the Client with MI __________________________________________1. Start within 3 – 6 hours of start of the chest pain 2. Drugs Used a. t-PA (Tissue –Plasmingen Activator) b. Streptokinase or c. Urokinase 3. Complications – bleeding, stroke, allergic reactions

    20. Drug Therapy for the Client with a MI _____________________________________ Nitroglycerin a. Sublingual Tablets b. IV NTG (Tridil) – reduces pain, preload & afterload, & increases O2 supply 1. Starting dose 0.25 – 0.5 ug/kg/min. 2. Usual Dose – 1 – 3 ug/kg/min. 3. Titrate to reduce pain & keep SBP >90 – 100 mm Hg

    21. Drug Therapy for the Client with a MI _____________________________________ 2. Morphine IVP a. Main Action: to reduce chest pain b. By reducing chest pain, get secondary effects – reduction in cardiac workload by lowering myocardial O2 consumption, & reducing contractility, BP, & HR 3. Beta – Adrenergic Blockers a. Action: increases O2 supply to the heart & reduces myocardial demand by decreasing HR

    22. Drug Therapy for the Client with MI _____________________________________ 5. Calcium Channel Blockers a. Action: diminish calcium influx into cells, cause dilation of coronary arteries & arterioles, inhibit coronary artery spasm 6. Stool Softeners ( Docusate Sodium, Colace) a. Action: prevent straining, which causes vagal stimulation ? bradycardia & dysrhythmias, Also, after straining there is increased venous return to the heart loading a weakened heart

    23. Drug Therapy for the Client with MI _____________________________________ 7. Heparin Therapy a. Action: enhances the inhibitory actions of antithrombin III on several factors essential to normal blood clotting, blocks conversion of prothrombin to thrombin & fibrinogen to fibrin, inhibits formation of new clots

    24. Cardiac Rehabilitation Goals ___________________________ 1. Develop progressive physical activity Educate about the cause, treatment, & prevention of CAD 3. Reduce risk factors 4. Accept limitations Make lifestyle changes Adjust to occupational changes

    25. Discussion of Cardiac Rehabilitation Process ____________________________________

    26. Complications of MI ___________________________ Dysrhythmias Cardiogenic Shock Left Sided Heart Failure & Pulmonary Edema Pulmonary Embolism Recurrent MI Myocardial Necrosis Pericarditis Papillary Muscle Dysfunction

    27. Cardiogenic Shock ___________________________ Causes: 1. Decreased myocardial contraction & diminished cardiac output (C. O.) 2. Undetected dysrhythmias 3. Sepsis Signs & Symptoms: low SBP, tachycardia, diaphoresis, restlessness, AMS, cold, clammy , gray skin Prevention: Relieve pain, IV fluids

    28. Treatment of Cardiogenic Shock ___________________________ 1. Vasopressors - to raise BP by increasing peripheral resistance a. Norepinephrine b. Dopamine 2 – 5 mcg/kg/min. IV Drip c. Dobutamine 2.5 – 10.0 mcg/kg/min. IV Drip d. Metaraminol

    29. Treatment of Cardiogenic Shock ___________________________ 2. Vasodilators – to promote better blood flow in the microcirculation of the heart, to decrease preload & afterload a. Nitroprusside 0.5 – 8.0 mcg/kg/min. IV Drip

    30. Treatment for Cardiogenic Shock ___________________________ 3. Positive Inotropic Agents To increase cardiac (ventricular) contractility & C.O. To improve tissue perfusion a. Dobutamine b. Epinephrine c. Isoproterenol 0.5 – 5.0 mcg/kg/min. IV Drip 4. O2 Therapy 5. Antiarrhythmic Agents prn 6. Continuous Arterial Monitoring

    31. Treatment of Cardiogenic Shock ___________________________ 7. Swan Ganz Monitoring 8. Diuretics for volume overload 9. Intra-aortic Balloon Pump 10. Emergency Surgery – Angioplasty or CABG

    32. Nursing Diagnoses for the Client with a MI _____________________________________ Alteration in Comfort (Chest Pain) R/T Myocardial Ischemia from Coronary Artery Occlusion & Myocardial Necrosis Dysrhythmias R/T Electrical Instability or Irritability 2ary to Ischemia or Infarcted Tissue Decreased Cardiac Output R/T Negative Inotropic Changes in the Myocardium 2ary to Myocardial Ischemia , Injury, or Infarction Impaired Gas Exchange R/T Decreased Cardiac Output Anxiety or Fear R/T Change in Health Status, Hospitalization & Life threatening Illness

    33. Nursing Diagnoses for the Client with a MI _____________________________________ 6. Alteration in Health Maintenance R/T MI and necessary Lifestyle Changes 7. Activity Intolerance R/T Imbalance of Oxygen Supply & Demand

    34. Invasive Procedures to Treat C.A. Occlusion _____________________________________ Percutaneuos Transluminal Coronary Angioplasty (PTCA) a. Complications: dissection of C.A., infarction, abrupt C.A. closure Atherectomy a. Complications: thrombosis, restenosis PTCA with Stent Placement a. Post Procedure Medications – Integrillin GTT first, then start ASA &Plavix b. Complications: hemorrhage, vascular injury, stent thrombosis, MI, coronary artery spasm

    35. Invasive Procedures to Treat C.A. Occlusion _____________________________________ 4. Laser Angioplasty a. Complications: C.A. dissection, acute occlusion, perforation, embolism

    36. Surgical Treatment of Ischemic Heart Disease _____________________________________ Minimally Invasive Coronary Artery Bypass Grafting (MIDCABG) CABG a. Vessels Used: Saphenous Vein, Left Internal Mammary Vein, or Radial Artery

    37. Heart Valve Replacement Surgery _____________________________________ a. Types of Valves 1. Artificial or Mechanical 2. Human Valve

    38. Preoperative Care for Cardiac Surgery _____________________________________ See Syllabus Unit

    39. Postoperative Care for the Client Undergoing Cardiac Surgery _____________________________________ Assessment BP via arterial line Radial & Apical Pulses Temperature Respiratory Rate & O2 Saturation Chest Tubes

    40. Cardiac Surgery Postoperative Nursing Problems _____________________________________ Fluid Overload Risk of Altered Renal Function Electrolyte Imbalance Altered LOC Risk for Decreased Cardiac Output Risk for Ineffective Airway Clearance Hemorrhage Alteration in Comfort

    41. Cardiac Surgery Postoperative Nursing Problems _____________________________________ 9. Risk for Paralytic Ileus 10. Impaired Physical Mobility 11. Risk for Infection

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