By ; Siti Husni Binti Entoh

JT U32 (KUP)
Unit Kecemasan & Trauma
Hospital Kudat
 MYOCARDIAL INFARCTION

LEARNING OBJECTIVES :

Define myocardial infarction (MI)

List etiology of myocardial infarction
Name the clinical manifestation of myocardial
infarction.
Explain types of medication used in MI
Able to identify 2 nursing problems and plan
the nursing process for these problems.
Explain the preventive measure that should be
taken.
 MYOCARDIAL INFARCTION

Myocardial Infarction
Also known as heart attack

Definition :
Death of heart muscle (myocardium) from the
sudden blockage of a coronary artery by blood
clot.
Onset maybe sudden or gradual & progression
to completion takes 3 6 hours.
 MYOCARDIAL INFARCTION

PATHOPHYSIOLOGY :

The coronary arteries are responsible for the

delivery of oxygen-containing blood to the muscle.

When they become severely blocked, they

restrict the flow of oxygen to the heart causing
injury to the heart muscle. This results in MI
 ETIOLOGY

Atherosclerosis
Smoking
High BP
Elevated cholesterol
DM
Male
Family history of heart disease
 CLINICAL MANIFESTATIONS
Chest pain
Severe, diffuse substernal pain crushing &
squeezing.
Not relieved by rest / sublingual GTN, needs narcotics
eg Morphine.
May radiate to arms (common left), shoulder, neck,
back, jaw.
Continues > 15 mins.
Produce anxiety, fear HR, BP, RR.

Diaphoresis, cool clammy, pallor.

CLINICAL MANIFESTATION..(cont)

Hypertension / hypotension.
Bradycardia / tachycardia.
Palpitation, anxiety, dyspnea.
Disorientation, confusion, restlessness.
Fainting, weakness.
Nausea, vomiting.
Atypical symptoms epigastric / abdominal distress,
SOB, dull aching.
 DIAGNOSTIC EVALUATION
ECG CHANGES

Occur 2 12 hrs, but may take 72 96 hrs.

Necrotic, injured & ischemia alters ECG.
S-T segment depression & T inversion ischemia.
S-T elevation necrotic / infarction.
Q wave permanent tissue necrosis.
NORMAL ECG DOES NOT RULE OUT POSSIBILITY
MYOCARDIAL INFARCTION.
 ELEVATION OF SERUM ENZYMES & ISOENZYMES.

Enzymes drawn in serial pattern. Admission & every 6

to 24 hrs until 3 samples taken.
Enzyme activity correlated to extent of heart muscle
damage.
Commonly creatinine kinase (CK), lactic
dehydrogenase (LDH), aspartate aminotransferase
(AST).
Broken down more specific: CK-MB & LDH specific to
heart muscle.
Elevated cardiac troponins.
NORMAL ECG
NORMAL ECG
MYOCARDIAL INFARCTION
 MANAGEMENT
Aim of therapy :
Protection of ischemic & injured heart tissue to preserve
muscle function.
Reduce infarct size.
Prevent death.

Included :
O2 therapy.
Pain control.
Pharmacologic therapy.
Percutaneous Transluminal Coronary Angioplasty (PTCA).
Surgery.
 OXYGEN THERAPY
To improve oxygenation
to ischemic heart muscle.
 PAIN CONTROL

Pain increase catecholamine release increase

workload on heart muscle increase O2 demand.
Opiate (Morphine) to relieve pain, to improve cardiac
hemodynamics, to provide anxiety relief.
Vasodilator (Nitroglycerin / GTN) sublingual, IV,
paste. Promotes venous & arterial relaxation.
Myocardial O2 demand reduced with pain relief.
Persistent chest pain IV nitroglycerin.
PHARMACOLOGICAL THERAPY
Thrombolytic agents tissue plasminogen activator,
streptokinase, reteplase dissolve obstructing
thrombus reestablish blood flow to coronary vessels.
Aspirin to prevent platelet activation.
Anticoagulant therapy may combine with thrombolytic
therapy.
Beta-adrenergic blocking agents improve O2 supply &
demand by sympathetic stimulation to heart.
Calcium channel blockers HR, BP & dilating
coronary vessels O2 demand.
 LET MONA TREATS
ALL THE PATIENTS !

Morphine Oxygen Nitroglycerine Aspirin

 PTCA

Mechanical opening of coronary vessel.

Can be used - combine with thrombolytic therapy.
 SURGERY

Surgical revascularization.
Coronary artery bypass graft (CABG) performed within
6 hrs of infarction.
Benefit definite treatment of stenosis.
 COMPLICATION
Rhythm disturbances.
Heart failure congestive heart failure (CHF),
cardiogenic shock.
Cardiac rupture.
Ventricular thrombus.
Thromboemboli.
Ventricular aneurysm.
Cardiac temponade.
Psychiatric problems depression.
 NURSING ASSESSMENT
Information regarding chest pain :
Nature & intensity
Onset & duration
Location & radiation
Aggravating factors

Associated symptoms SOB, diaphoresis, vomiting etc.

Health status, current medication, allergies.

Information cardiac risk factors.

 NURSING DIAGNOSIS : PAIN RELATED TO
IMBALANCE IN O2 SUPPLY & DEMAND
NURSING RATIONALE
INTERVENTIONS
Position in semi-Fowlers Allow rest & adequate
position. chest expansion, to
available O2 & cardiac
work.
Administer O2 nasal To myocardial
cannula @ 4L/min. oxygenation.
Administer Nitroglycerin & To reduce pain by
Morphine. venous return to heart.
Morphine decrease pts
sensation of pain.
 NURSING DIAGNOSIS : PAIN RELATED TO
IMBALANCE IN O2 SUPPLY & DEMAND
NURSING RATIONALE
INTERVENTIONS
Monitor BP closely. GTN & Morphine may
venous return & BP.

Attach electrodes for HR may indicate heart

continuous cardiac monitor. block. Arrhythmias common
Monitor HR & rhythm in initial stage of MI.
frequently.
 NURSING DIAGNOSIS : PAIN RELATED TO
IMBALANCE IN O2 SUPPLY & DEMAND
NURSING RATIONALE
INTERVENTIONS
Administer & monitor To relieve the coronary
thrombolytic therapy. occlusion.

Monitor signs of bleeding; Thrombolytic cause clot

avoid unnecessary venous / lysis, may cause bleeding.
arterial punctures.
 NURSING DIAGNOSIS : CARDIAC OUTPUT
RELATED TO CARDIAC CONTRACTILITY &
ARRHYTHMIAS
NURSING RATIONALE
INTERVENTIONS
Administer IV fluid as IV fluid may be necessary
ordered. to compensate for venous
return caused by nitrates &
morphine.

Monitor closely for signs of LVF may develop due to

developing LVF. (crackles) myocardial contractility.
 NURSING DIAGNOSIS : CARDIAC OUTPUT
RELATED TO CARDIAC CONTRACTILITY &
ARRHYTHMIAS
NURSING RATIONALE
INTERVENTIONS
Monitor urine output hourly. in urine output may
indicate in renal blood flow.

Monitor mental status. Change in mental status

may indicate in cardiac
output.
Monitor hemodynamic-CVP, Help to guide fluid volume
pulmonary artery pressure. administration, assess
cardiac performance.
 NURSING DIAGNOSIS : CARDIAC OUTPUT
RELATED TO CARDIAC CONTRACTILITY &
ARRHYTHMIAS
NURSING RATIONALE
INTERVENTIONS
Interpret rhythm at least Arrhythmias can cause in
every 4 hours. Administer stroke volume. Close
antiarrhythmics if indicated. monitoring (1st few hrs of MI)
& during thrombolytic
therapy prevent lethal
arrhythmias.
Administer vasopressor; Controversial may
titrate to BP response. systemic vascular resistance
cardiac work.
NURSING DIAGNOSIS : ANXIETY RELATED TO CHEST
PAIN, FEAR OF DEATH, INVASIVE THERAPIES &
UNCERTAIN PROGNOSIS.

NURSING RATIONALE
INTERVENTIONS
Explain equipment, Help to anxiety due to
procedure & need for threatening environment.
frequent assessment.

Observe for autonomic Anxiety associated with

signs & symptoms of anxiety sympathetic activity
( HR, BP, RR) cardiac work.
NURSING DIAGNOSIS : ANXIETY RELATED TO CHEST
PAIN, FEAR OF DEATH, INVASIVE THERAPIES &
UNCERTAIN PROGNOSIS.

NURSING RATIONALE
INTERVENTIONS

Administer diazepam. May limits anxiety.

Maintain continuity of care. Consistency of routine &

staff promotes trust &
confidence.
PATIENT EDUCATION & HEALTH
MAINTENANCE
Inform pt & family about the illness:
Explain about angina & MI.
Describe that heart healing is not complete 6 - 8 weeks.

Instruct pt how to judge bodys response to activity:

Inform different activities requires varied expenditures
of O2.
Emphasize importance rest in between activities.
Review signs & symptoms poor response to activity;
chest pain, SOB, extreme fatigue.
 Design an individualized activity progression
program for pt as directed.
Determine activity levels appropriate for pt.
Encourage pt & family to list activities they like.
Instruct pt to move from one activity to another as
tolerated.

Give pt specific activities guidelines ;

Walk daily, gradually distance & time.
Avoid strenuous activities.
Avoid working with arm overhead.
Gradually return to work.
Avoid extreme temperature.
Do not rush, avoid tension.
 Sexual relations may be resumed after exercise
tolerance is assessed.
If pt can walk briskly / climb two stairs can resume
sexual activity.
Sex should be avoided after eating heavy meal, when
tired.

Advise eating 3 4 meals / day. Not large heavy meals.

Rest 1 hour after meal.
Limits caffeine & alcohol.
Driving car after cleared by health care provider.
Teach pt about medication & side effects.
 Instruct pt to report if the following symptoms
appear;
Chest pressure / pain not relieved in 15 mins by GTN /
rest.
SOB.
Unusual fatigue.
Swelling of feet / ankles.
Fainting / dizziness.
Very slow / rapid HR.

Assist pt to reduce risk of another MI by risk

modification;
Smoking, cholesterol, hypertension, obesity, DM,
stress, lack of exercise.
THANK YOU!