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  1. 1. Important nurse
  2. 2. Acute Myocardial Infarction
  3. 3. MI MI refers to a dynamic process by which one or more regions of the heart experience a sever and prolonged decrease oxygen supply because of insufficient coronary blood flow; subsequently, necroses or death to myocardial tissue occurs. Left ventricle is a common and dangeourus location for an MI because is the main pumping champer for the heart.
  4. 4. Clinical manifestation 1-Chest pain severe diffuse steady substernal pain of crushing and squeezing nature, not relieved by rest or sublingual vasodialator therapy but require opioids, may radiate to arms, shoulders, neck, back, and jaw, continuous for more than 15minutes, may produce anxiety or fear resulting in increase HR, BP, and RR.
  5. 5. 2-Diaphorsis, cool clammy skin, facial pallor. 3-Hypertension or hypotension. 4-Bradycardia or tachycardia. 5-premature ventricular and/or atrial beats. 7-Disorientation, confusion, restlessness. 8-Faintaing, marked weakness. 9-Nausea,vomiting, hiccups. 10-Atypical symptoms: epigastric or abdominal distress, dull aching or tingling sensations, shortness of breath, extreme fatigue.
  6. 6. Diagnostic Evaluation ECG changes: 1-ST segment depression and T wave invertion indicates pattern of ischemia. 2-ST elevation indicates an injury pattern. 3-Q wave indicate tissue necrosis and are permanent.
  7. 7. Cardiac markers: Troponin I and T are cardiac specific.Troponin I is assessed more commonly because the test is readily available. CK-MB is the CK isoenzyme found in the heart, drawbacks to use this marker include false positive result due to muscle injury or chronic muscle disease. Markers are usually drawn on admission and every 6 to 24 hrs until 3 samples obtained. Characteristic elevation over several days confirms an MI.
  8. 8. Other findings: Abnormal coagulation studies PT , PTT. Cardiac muscle dysfunction noted on echocardiography.
  9. 9. Management 1- oxygen therapy usually by nasal canulla. 2-Pain control: morphine is used to relieve pain. 3-Vasodailator therapy consist of nitrogelcerin 3-Thromblytic agents such as streptokinase 4-Antiarrhythmics such as lidocaine to decrease ventricular irritability that occurs after MI. CABG surgery can be Performed within 6 hrs of evolving infarction.
  10. 10. Complications Rhythm disturbances Sudden cardiac death due to ventricular arrhythmias Heart failure Cardiogenic shock Reinfarction Cardiac rupture Cardiac taponade Pericarditis Psychiatric problems
  11. 11. Nursing Diagnosis Acute pain related to O2 supply and demand imbalance 1-Handle pt carefully when providing initial care 2-Maintain O2 saturation greater than 92%. 3-Administer O2 by nasal canula if prescribed. 4-Offer support and reassurance to pt that relief pain is apriority. 5-Administer nirtoglycerin as directed recheck BP,HR, RR before administrating . 6-Administer opioids as prescribed .
  12. 12. Decrease Cardiac Output related to impaired contractility . 1-Monitor BP every 2 hrs or as directed. 2-Monitor Respiration and lungs field every 2-4 hrs or as prescribed. 3-Ascultate for normal and abnormal lung sound. 4-Evluate heart rate and heart sounds every 2-4 hrs or as directed . 5-Note presence of jugular vein distention. 6-Evaluate the major arterial pulses. 7-Monitore skin color and temperature. 8-Be alert for changes in mental status. 9-Evalute urine output . 10-Monitor for life-threatening dysrhythmais
  13. 13. Ineffective tissue perfusion related to coronary restenosis , extension of infarction. 1-Observe for persistent or recurrence of S&S of ischemia , including chest pain diaphoresis,hypotension 2-Adminster O2 as directed 3-Record ECG. 4-Prepaire pt for emergency procedure cardiac catheterization , bypass surgery.
  15. 15. Definition Hypertensive crisis is a severe rise in arterial blood pressure caused by a disturbance in one or more of regulating mechanisms. If untreated, hypertensive crisis may result in renal, cardiac, or cerebral complications, and possibly, death.
  16. 16. CAUSES OF HYPERTENSIVE CRISIS 1-Abnormal renal function 2-Eclampsia 3-Intracerbral hemorrhage 4-Withdrawal of antihypertensive drugs(abrupt) 5-Myocardial ischemia. 6-Untreated hypertension
  17. 17. Assessment Findings 1-Most common complain severe throbbing headache in the back of head. 2-Nausea, vomiting, or anorexia. 3-Irritabilaty, dizziness, confusion, somnolence, stupor. 4-Vision loss, blurred vision, or diplopia. 5-Dyspnea on exertion, orthopnea , paroxysmal nocturnal dyspnea , and edema secondary to heart failure. 6-Angina secondary to coronary artery disease. 7-In hypertensive encephalopathy : decreased level of consciousness , disorientation , seizures , focal neurologic deficits, such as hemiparesis , and unilateral sensory deficits.
  18. 18. Assessment Findings 8-If hypertensive crisis affects the kidney: reduced urine output, elevated blood urea nitrogen and creatinine levels. 9-Examination of the eye may reveal acute retinopathy and hemorrhage , retinal exudates , papilledema , and arterial venous nicking . 10-Blood pressure measurement , obtained several times at an interval of at least 2 minutes , reveals an elevated diastolic pressure above 120 mm Hg .
  19. 19. TEST RESULTS 1-blood pressure measurement confirms diagnosis of hypertensive crisis . 2-ECG reveals ischemic changes or left ventricular hypertrophy ; ST-segment depression and T-wave inversion suggest repolarization problems from endocardial fibrosis associated with left ventricular hypertrophy . 3-Echocardiography may reveal increased wall thickness with or without an increase in left ventricular size.
  20. 20. TEST RESULTS 4-Chest X-ray may reveal enlargement of the cardiac silhoutette with left ventricular dilation ;pulmonary congestion and pleural effusion with heart failure. 5- Urinanalysis may be normal unless renal impairment present ;then specific gravity will be low (less than 1.010) ; hematuria , casts ,proteinuria may also be found.
  21. 21. Treatment: 1-I.V antihypertensive therapy with sodium nitroprusside ,carefully titared not to reduce the patient's blood pressure too rapidly because patient auroregulatory controle is impaird (The current recommendation is to reduce blood pressure by no more than 25% of the mean arterial pressure [MAP] over the first 2 hours .further reduction should occur over the next several days.) 2-Other agents include labetalol , nitroglycrine ( the drug of choice for treating hypertensive crisis when myocardial infarction ischemia , acute myocardial infarction[MI], or pulmonary edema are present) , and hydralazine (specificall indicated for treating hypertension in pregnant women with preeclmpsia) 3-Life style changes , such as weight reduction , smoking cessation , and dietary changes.
  22. 22. Complications Numerous complications may occur, including stroke , subarachnoid hemorrhage , dissecting aortic aneurysm ,MI , lethal arrhythmias , retinopathy ,renal failure ,and sudden death.
  23. 23. Nursing Intervention 1-immediately obtain the patient blood pressure to confirm your suspicions, and ensure that patient's airway is patent. 2-If not already in place, institute continuous cardiac and arterial pressure monitoring to assess BP directly; determine patient MAP. 3-assess arterial blood gas levels and monitor the patient O2 saturation levels via pulse oximetry ; if patient is hemodynamically monitored , assess the patient mixed venous O2 saturation ; administer supplemental O2 as ordered based on findings. 4-Administer I.V. antihypertensive therapy as ordered.
  24. 24. Nursing Intervention 5-Monitore BP every 1-5 minutes while titrating drug therapy, then every 15 minutes to 1 hour as patient condition stabilizes. 6-Coninuously monitor ECG and institute treatment as indicated should arrhythmias occur; auscultate heart, noting signs of heart failure such as presence of a third or fourth heart sound. 7-Assess the patient neurologic status every hour initially and then every 4 hours as the patient condition stabilizes.
  25. 25. Nursing Intervention 8-Monitor urine output every hour and notify physician if urine output less than 0.5ml/kg/hour. Evaluate BUN and serum creatinine levels for changes. And monitor daily weight. 9-Administer antihypertensive as ordered. If patient experiencing fluid overload administer diuretics as ordered. 10-Assess patient visual ability and report such changes as increased blurred vision, diplopia, or loss of vision. 11-Amdinister analgesic as ordered for headache; keep environment quiet. with low light.