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CRITICAL CARE NURSING

PRESENTED BY:

ABDULLAH KHAMIS NGWALI

BSc.N ,STUDENT

SUPERVISED BY : MADAME RAHMA

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At the end of session each student should be able to:-Define Myocardial infarctionExplain causes of Myocardial infarctionList the Pre-disposing factors of Myocardial infarctionDescribe the pathophysiology of Myocardial infarctionMention sign and symptoms of Myocardial infarction

Identify the diagnostic measures of Myocardial infarctionExplain the medical treatment of Myocardial infarctionExplain general nursing management of Patient with Myocardial infarctionDescribe nursing care plan of patient with Myocardial infarction

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Normal Heart

Myocardial infarction is commonly known as a heart attack, “Myo” means muscle “cardial” pertains to the heart and “infarction” means death of tissue due to lack of blood supply.

The heart like any organ requires blood for oxygen and other nutrients, so it can do its work.

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The heart does not gather oxygen or nutrients from the blood flowing inside it. Instead, it receives blood from coronary arteries that eventually carry blood into the heart muscle.

A heart attack occurs when blood vessels that supply blood to the heart are blocked, preventing enough oxygen from getting to the heart. The heart muscle then dies or becomes permanently damaged.

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Coronary Arteries for the heartCoronary Arteries for the heart

Myocardial infarction (MI) or heart attack is a medical emergency condition in which the blood supply to the heart suddenly reduces or stop, causing the myocardium to die from lack of oxygen.

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Heart is the main organ in cardiovascular system, which includes different types of blood vessels.

Some of the most important vessels in your body are the Coronary arteries. They take blood, rich in oxygen, to every location in the body.

When arteries become blocked or restricted by buildup, they can cause blood flow to stop or decrease significantly.

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Several factors may cause a heart attack:Bad Cholesterol: - Also called low-density lipoprotein (LDL), is

one of the leading problems that cause blockage.

Cholesterol can stick to the walls of the arteries and produce plaque. Plaque is a hard matter that blocks blood flow in the arteries.

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Saturated Fats (found mostly in meat):- May contribute to the buildup of plaque in the

coronary arteries. Saturated fat may lead to acute myocardial

infarction by increasing the amount of bad cholesterol in the blood system and reducing the good HDL (high-density lipoprotein) cholesterol.

Certain risk factors may make to susceptible for

heart attack which includes:-

High Blood Pressure

Obesity

Diabetes or High Blood Sugar

Smoking

Overweight

Excessive alcohol intake

Stress

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The most common cause of an MI is a blood clot (thrombosis) that forms inside a coronary artery, or one of its branches.

This blocks the blood flow to a part of the heart.

Blood clots do not usually form in normal arteries. However, a clot may form if there is some atheroma within the lining of the artery.

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Atheroma is like fatty patches or plaques that develop within the inside lining of arteries. (This is similar to water pipes that get furred up.)

Plaques of atheroma may gradually form over a number of years in one or more places in the coronary arteries.

Each plaque has an outer firm shell with a soft inner fatty core.

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What happens is that a crack develops in the outer shell of the atheroma plaque. This is called plaque rupture.

This exposes the softer inner core of the plaque to blood.

This can trigger the clotting mechanism in the blood to form a blood clot. Therefore, a build-up of atheroma is the root problem that leads to most cases of Myocardial Infarction.

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The diagram below shows four patches of atheroma as an example. However, atheroma may develop in any section of the coronary arteries.

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SIGNS: Physical signs Signs of Sympathetic activation (e.g. pallor,

sweating tachycardia) Signs of vagal activation (e.g. nausea, vomiting,

bradycardia) Signs of impaired myocardial function (e.g.

hypotension, oligurea, cold peripheries) Signs of complication (mitral, regurgitation,

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SYMPTOMS Chest pain is a major symptom of heart attack.

Pain may be felt in only one part of your body, or it may move from your chest to your arms, shoulder, neck, teeth, jaw belly area or back. The pain can be severe or mild.

Other symptoms of a heart attack includes:-

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Anxiety Cough Fainting Light headedness Dizziness Nausea or vomiting

Shortness of breath Sweating which may be

extreme Palpitation (feeling like

your heart is beating too fast or irregularly.

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SYMPTOMS

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Some people (the elderly, people with diabetes and women) may have little or no chest pain, or they may experience unusual symptoms (shortness of breath, fatigue, weakness)

Note: - A silent heart attack is a heart attack with no symptoms (ischemia).

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Back viewDiagram of pain zones in myocardial infarction; dark red: most typical area, light red: other possible areas; view of the chest

Diagnostic measures based on:-

Medical history/symptoms

Physical examination

Test results

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The history includes a description of the pain with regard to location, type, duration, intensity, and whether it radiates to other areas, such as down the arm or to the jaw.

A medical history, including a drug history, also is important because other disorders, such as diabetes mellitus and hypertension, may alter or require additional treatment modalities.

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Medical history/symptoms

Monitor vital signs frequently. Acuscultate heart and lungs, and assess peripheral pulses with particular attention to their amplitude. Note pallor, diaphoresis, nausea, cyanosis, and apprehension.

Monitor cardiac output by assessing urine volume and color.

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Physical examination

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Test results

Electrocardiogram (ECG):- This is the recording of the electrical activity of the heart. Abnormalities in the electrical activity usually occur with

heart attacks and can identify the areas of the heart muscle that are deprived of oxygen and or areas of the muscle that have died.

Use 12 leads ECG in myocardial infarction ST-T wave elevated by greater than 1 mm or more in two continuous lead.

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Blood test (Cardiac enzymes) A blood test that measures a chemical called tropinin

is the usual test that confirms Myocardial Infarction. This chemical is present in heart muscles cells. Damage to heart muscles cells releases tropinin into

the blood stream. In MIs the blood level of tropinin increases 3-12hrs

from the onset of chest pain, peaks at 24-48hrs and returns to a normal level over 5-14days.

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Test results

Coronary angiography: A coronary angiogram is a procedure that uses

special dye (contrast material) and X-ray imaging to see your heart's blood vessels.

Coronary angiograms are part of a general group of procedures known as heart (cardiac) catheterization.

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Test results

During a coronary angiogram, a type of dye that's visible by an X-ray machine is injected into the blood vessels of your heart.

The X-ray machine rapidly takes a series of images (angiograms), offering a detailed look at the inside of your blood vessels.

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Test results- coronary angiogram

Another testing may include: -

Nuclear scan Exercise stress test. Echocardiogram Chest radiographs Cardiac computerized tomography (CT) or

magnetic resonance imaging (MRI).

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Initial management of the patient with Myocardial Infarction is best to accomplished in a cardiac care unit (CCU) or intensive care unit (ICU), where constant monitoring is available.

Treatment is directed toward reducing tissue hypoxia, relieving pain, treating shock (if present), and correcting arrhythmias if they occur.

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Drugs Used in the Treatment of Myocardial

Infarction includes:- Analgesics: - Therapy includes Morphine to relief

and control pain; improve cardiac hemodynamic by reducing preload and after load.

Dose:- 2- 4mg, IV in every 5 minute diluted in sodium chloride solution until pain relief

Note: - those who are allergic to morphine, meperdine may be giving to avoid respiratory depression.

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Acetylsalicylic acid soluble 300mg, oral immediately, followed by 150mg daily

Isosobide dinitrate 5mg,sublingual, immediately

Analgesics: Cont’

Nitrates or Nitroglycerin: - Therapy includes Relieves chest pain by dilating coronary arteries, Re-establishes blood flow around thrombi.

Diuretics Furosemide (Lasix):- Decreases work of the heart by promoting the excretion of sodium and water thus reducing circulating blood volume.

Dose:-20mg-40mg daily od PO or 80mg IV od

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Anticoagulants (Heparin sodium -Hepalean):- Therapy includes Inhibits thrombus and clot formation by blocking the conversion of prothrombin to thrombin and fibrinogen to fibrin.

Dose :-500Iu,8hly in the acute phase and then Wafarin 5-10mg oral, in 24hrs.

Sedatives (Benzodiazepine):- therapy includes promoting rest and reduces anxiety.

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Beta-adrenergic Blockers Propranolol (Inderal):- Therapy includes Prevents or inhibits sympathetic stimulation, decreasing myocardial oxygen demand. Used to prevent angina attacks. Dose 60-240mg three times a day

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Note: - Complete bed rest is prescribed but is not recommended for uncomplicated MIs after the first 24 hours.

Activity is adjusted according to the extent of the MI, the occurrence of complications, and the client’s response to therapy.

Smoking is forbidden during the acute phase and permanent cessation is advised. Intake of fat, sodium, and calories are restricted.

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Allow client to express fears and anxieties. Carry out procedures in a calm, relaxed manner. Promote uninterrupted time for clients to rest,

sleep, or visit with family members

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Check on client frequently and answer call promptly.

Acknowledge feelings of grief over perceived or actual lost lifestyles.

Administer sedatives and antianxiety medications as indicated.

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Diastolic dysfunction Systolic dysfunction Heart failure Cardiogenic

shock/hypotension Right ventricular

infarction Myocardial repture

Pericarditis Pericardial effusion Dressler’s syndrome

MYOCARDIAL COMPLICATION

PERICARDIAL COMPLICATION

Recurrent ischemia Recurrent infarction

Left ventricular free wall repture

Ventricular septal repture

Papillary muscle repture withacute mitral regurgitation

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VASCULAR COMPLICATION

MECHANICAL COMPLICATION

Ventricular tachycardia

Ventricular fibrillation

bradydysrhythmias

Mural thrombosis Systemic

thromboembolism Pulmonary

embolism

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ELECTRICAL COMPLICATION

THROMBOEMBOLIC COMPLICATION

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