Acute myocardial infarction (MI) refers to insufficient blood flow to the heart muscle causing death of myocardial tissue. Common symptoms include chest pain and shortness of breath. Diagnosis involves ECG changes, elevated cardiac markers, and echocardiogram findings. Treatment includes oxygen, pain medications, vasodilators, antiarrhythmics, and thrombolytics. Complications can include arrhythmias, heart failure, cardiogenic shock, and cardiac rupture. Hypertensive crisis is a severe increase in blood pressure that can damage organs if untreated. It may be caused by renal disease, preeclampsia, withdrawing antihypertensives, or untreated hypertension. Symptoms include headaches, blurred vision, and chest

1. Important nurse

2. Acute Myocardial Infarction

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. 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. 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. 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. 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. Other findings:
Abnormal coagulation studies PT , PTT.
Cardiac muscle dysfunction noted on echocardiography.

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. Complications
Rhythm disturbances
Sudden cardiac death due to ventricular arrhythmias
Heart failure
Cardiogenic shock
Reinfarction
Cardiac rupture
Cardiac taponade
Pericarditis
Psychiatric problems

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. 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. 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.

14. HYPRETENSIVE CRISIS

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. 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. 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. 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. 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. 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. 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. Complications
Numerous complications may occur, including stroke ,
subarachnoid hemorrhage , dissecting aortic
aneurysm ,MI , lethal arrhythmias , retinopathy ,renal
failure ,and sudden death.

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. 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. 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.

26. REFRENCES
MANAUAL NURSING PRACTIC 8TH EDITION
LIPPINCOTT CRITICAL NURSING CARE