PRESENTED BY:

Meljyn Gomez Cuyos

Dy,Arvie Jane
Ederango,Nemia Bless
Marjory,Epe
Aizyl,Flores
Objectives:
• Define and understand the epidemiology of MI’s and how
they are classified
• Will be able to identify the risk factors associated with
MI’s
• Will be able to recognize signs and symptoms of MI and
what the appropriate interventions are.
• Understand the treatment options available to treat MI.
• Nursing responsibilities
• Follow up care
• (Case study )Session #13
DEFINITION :
Myocardial infarction is
a disease condition
which is caused by
reduced blood flow in a
coronary artery due to
atherosclerosis and
occlusion of an artery by
an embolus or thrombus .
 Epidemiology
• MI’s are the leading cause of death in the
United States, affecting one in five men
and one in six women. 
• 450,000 people in the US die from
coronary disease each year.
 MI Classifications
•  MI’s can be subcategorized by anatomy and clinical diagnostic
information.
Anatomic
• Transmural - atherosclerosis involving a major coronary artery, it is
usually as a result of complete occlusion of the artery in addition on ECG
ST elevation and q waves are seen(STEMI)
(epicardium,myo,endocardium)
• Subendocardial - small area in the subendocardial wall of the left
ventricle, ventricular septum, or papillary muscles. It is particularly
susceptible to ischemia,in addition to ST depression is seen on
ecg(NSTEMI)
Diagnostic
• ST elevations (STEMI)-ECG must show new ST elevation in two or
more adjacent ECG leads or new LBBB , it must be greater than 2 mm in
leads V2 and V3 or greater than 1 mm in all other leads.
• Non ST elevations (NSTEMI)-ST segment depression ≥0.5mm or
dynamic T- wave inversion with pain or discomfort , and cardio specific
proteinstroponin are rises in blood in NSTEMI.
CAUSES:

• Coronary artery disease (atherosclerosis).

• Blood clot
• Coronary artery spasm
Pathophysiology
 MODIFIABLE RISK NONMODIFIABLE RISK
• . FACTORS:
•Tobacco use
FACTORS:
•Family history of heart
•High blood cholesterol disease
or triglyceride levels •Older age
•Lack of exercise •Sex
•Obesity
•Stress
•High blood pressure
•Diabetes

Atherosclerosis

Coronary Artery Disease(CAD) Hypoxemia

ANGINA

HEART ATTACK
(MYOCARDIAL INFARCTION)
 • Aute pain related to tissue ischemia (coronary
• . •
artey occlusion)
Activity intolerance related to imbalance
between myocardial oxygen supply and
demand
• Risk for excess fluid volume

• Aspirin
• thrombolytics
• anti platelet agent
• pain relievers
• nitroglycerin
• Beta blockers
• ACE inhinitors
• Statin

• Pressure or • Sudden death Electrocardiogram

• Disturbance of
tighness in the (ECG)
chest rate,rhythm and
 Blood test
• pain in the conduction
• Cardiogenic shock  chest x-ray
chest,back,jaw
• Cardiac rupture  Echocardiogram
and other
upper areas of • Heart failure
your body
• .

• shortness of • Angina  coronary

breath pectoris
• •
catherization
sweating Thromboembol
• nausea and ism (angiogram)
vomiting • Pericarditis  MRI
• anxiety • Ventricular
• cough septal defect
• dizziness
• Tachycardia

PATHOPHYSIOLOGY
MECHANISM
NURSING DIAGNOSIS
TREATMENT
SYMPTOMS
COMPLICATIONS
DIAGNOSTIC TEST
SYMPTOMS:
CARDIOVASCULAR
• Ischemia
• Low cardiac output
• Chest pain –chest pain occurs suddenly , severe immobilizing
chest pain that not relieved by rest , position change and
medications.
 Severity – more than angina pectoris
Duration –more than 15 minutes and not relieved by
nitroglycerine
Radiation - pain radiated to nose, jaw, shoulder and upper left
arm and downward 4th and 5th fingers
• Bradycardia (Decrease pulse rate)
• Hypertension
• Diaphoresis –excessive sweating
• ECG changes – ST segment and T wave changes, also show
tachycardia, bradcardia, or dysrhythimas.
SYMPTOMS:
RESPIRATORY
• Shortness of breath.
• Pulmonary edema
• Chest heaviness
• Dyspnea- difficulity of brathing
• Fatigue
Genitourinary-Decreased Urinary Output May Indicate
Cardiogenic Shock.
Gastrointestinal- Nausea And Vomiting
Skin- Cool, Clammy ,Diaphoretic , And Pale Appearance On
Skin
MANAGEMENT
• GOALS
 Restoration of the balance between the
oxygen supply and demand to prevent
further ischemia
 Pain relief
 Prevention and treatment of any
complications that may arise
MEDICAL MANAGEMENT
 DRUG THERAPY

ANTIPLATELET DRUG
 (Decrease platelet aggregation and inhibit thrombus formation)
• Aspirin(160 to 325mg) slows the blood's clotting action by
reducing the clumping of platelets
• Clopidogrel(300mg) -works by blocking platelets from sticking
together and prevents them from forming harmful
ANALGESIC
 NITRATES
• Sublingual Nitroglycerine- Nitrates act as a vasodilator and relief
pain,Total 3 doses (can repeat 3-5mts if no contraindication)
• Morphine Sulphate.
 produces central nervous system analgesia.
 Produce venodilation(it helps to reduce left ventricular preload
and oxygen demand)
BETA ADRENERGIC BLOCKERS
• (Propanolol) it inhibit SNS stimulation of heart.
 reduces both heart rate & contractility
CALCIUM CHANNEL BLOCKERS
• (Verapamil, Nifedipine)
 It causes coronary artery vasodilatation & decreases
myocardial contractility.
 Increases blood supply to myocardium & decreases
O2 demand of myocardium.
ANTI COAGULATION THERAPY (prevent the
formation of blood clots)
• Enoxeparin(Lovenox)
• Heparin
ACE Inhibitors
 These medicines lower bloodpressure and
reduce the strain on your heart. They also
help slow down further weakening of the
heart muscle.
 Eg:enalapril, captopril
CASE STUDY
(Session #13)
• Case Study
Mrs. Sims, aged 43, is admitted to the intensive care unit
with a diagnosis of atypical chest pain. She has a history of
midsternal chest cramping. The pain is radiating to her left
and right shoulders and down her left arm. Her pain
increases with activity and decreases with rest. She
smokes one and a half packs of cigarettes per day and is
50 pounds overweight. The cardiac monitor shows normal
sinus rhythm without dysrhythmias. She has an NTG
sublingual order PRN for chest pain. One hour after
admission, Mrs. Sims reports midsternal pain radiating to
the left neck and jaw. The cardiac monitor shows sinus
tachycardia with occasional premature ventricular
contractions (PVC’s) her blood pressure is 100/70,
respirations are 20 and unlabored and skin is warm and
dry.
NURSING CARE PLAN
ASSESSMEN NURSINGDIA INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION
T GNOSIS

Acute pain Angina can After 8 hours Independent: Evaluation:

SUBJECTIVE: related to result from any of nursing • Assess pain, *Helps After 8 hour of
Chest pain or decrease condition in intervention, noting evaluate nursing
pressure that myocardial which there’s a the pt. location, degree of intervention, pt
is radiating to flow decrease in verbalize characteristi discomfort and was able to

.
her left and
right shoulders
oxygen delivery
by the coronary
relief or
control of
c intensity
(0- 10)
may reveal
developing
verbalize relief
or control of
down to her arteries, an pain. And • Obtain complications pain and
left arm. increased maintain history of .*This provides relaxed body
Objective:Tach cardiac relaxed body previous information posture.
ycardiaElevate workload or an posture cardiac pain that may help
d blood increase in the and familial to differentiate
pressureJugul myocardium’s history of current pain
ar vein oxygen cardiac from previous
distention V/S requirements.T problems problems and
taken: BP: he most cause • Encourage complications.
100/70 is pt to *Reduction of
mmHgRR: 20 atherosclerosis verbalize anxiety, fears
but angina can concerns. that can
result from Actively promote
aortic stenosis, listen to relaxation and
mitral stenosis, these comfort.
or insufficiency, concerns
hypotension, and provide
hyperthyroidis support by
m, anemia, acceptance,
ventricular remaining
arrythmias or with pt and
hypertension. giving
appropriate
information.
ASSESSM NURSING INFERENCE PLANNING INTERVENTION RATIONALE EVALUATIO
ENT DIAGNOSI N
S

In an MI, an area of After 8 hours ●Provide comfort *Respirations may Evaluation:

the myocardium is of nursing measures such as be increased as a After 8 hour
permanently intervention, back rub or deep result of pain and of nursing
destroyed because the pt. breathing associated anxiety. intervention,
verbalize exercises. pt was able
relief or ●Assess *Reduces muscle to verbalize
control of respirations, BP joints or muscle relief or
pain. And and heart rate with stiffness. control of
maintain each episode of Ambulation returns pain and
relaxed body chest pain. the organ to normal relaxed body
posture ●Assist with range position and posture.
motion exercise promotes feeling
and encourage well being.

. ambulation.
●Investigate and
report abdominal
muscle rigidity,
*Requiring prompt
medical
intervention.
involuntary
guarding and * To provide optimal
rebound oxygenation to the
tenderness. myocardium.
ASSESSMENT NURSINGDIAG INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION
NOSIS

After 8 hours of ●Obtain a 12-lead *Relieves pain, Evaluation: After

nursing ECG immediately enhances 8 hour of
intervention, the during acute comfort and nursing
pt. verbalize chest pain. promote rest. intervention, pt
relief or control was able to
of pain. And COLLABORATIV verbalize relief
maintain relaxed E or control of
body posture ●Administer pain and
medications as relaxed body
indicated e.g posture.
analgesics and
antibiotics

.
DRUG STUDY
. DRUG NAME MECHANISM OF
ACTION
INDICATION SIDE/ADVERSE
EFFECTS
NURSING
RESPONSIBILITIES
Generic Interferes with Venous thrombosis; GI: nausea, Watch for signs and
Name:Warfarin synthesis of vitamin pulmonary vomiting, diarrhea, symptoms of bleeding
sodium Brand K-dependent clotting embolism; atrial abdominal cramps, and hepatitis.Instruct
Name:Coumadin factors (2, 7, 9, and fibrillation; stomatitis, patient to promptly report
10) and myocardial infarction anorexiaGU: unusual bleeding or
Classification:A anticoagulant (MI); hematuriaHematolog bruising. Caution patient
nticoagulant proteins C and S in thromboembolic ic: eosinophilia, to consult prescriber
liver. complications of bleeding, before taking over-the-
cardiac valve hemorrhage, counter preparations or
placement. agranulocytosis, herbs.Caution patient to
leukopeniaHepatic: avoid alcohol during
CONTRAINDICATION hepatitisSkin: rash, therapy.Stress
dermatitis, urticaria, importance of avoiding
Hypersensitivity to pruritus, alopecia, contact sports and other
drugUncontrolled dermal activities that could
bleedingOpen necrosisOther: fever, cause injury and
woundsSevere “purple toes” bleeding.
hepatic syndrome (bilateral
diseaseBacterial painful, purple
endocarditisMaligna lesions on toes and
nt side of feet),
hypertensionCerebr hypersensitivity
ovascular reaction
hemorrhage
 DRUG NAME MECHANISM OF INDICATION SIDE/ADVERSE NURSING
ACTION EFFECTS RESPONSIBILITIES
Generic Name:
Morphine
Sulfate
As a potent opioid,
morphine has
seemed
Morphine is.
Indications:

indicated for
Nausea, vomiting,
constipation,
lightheadedness,
Check prescribed
dosage and measure
carefully. Solution is
Brand Name: to be the ideal the relief of severedizziness, highly concentrated
Roxanol analgesic. It has acute drowsiness,
Drug innate and severe chronic increased Doses may be
Classification : hemodynamic pain. sweating, administered with food
Analgesics effects or dry mouth may or milk
(opoids) that are beneficial Contraindication : occur. Pain, to minimize GI irritation.
Route: PO during MI. It Contraindicated redness,
Dosage: Oral decreases with or swelling at the Swallow extended-
solution heart rate, blood conditions of injection site may release tablets whole;
starting pressure, and systemic occur if this do
dose: 10 to 15 venous mastocytosis,untrea medication is given not break, crush,
mg every 4 return, and it may ted into a muscle or dissolve, or chew (could
hours. also decreased level of under the skin. If result in rapid release
Each mL of stimulate local thyroid any and absorption of a
Roxanol histamine-mediated hormones, of these effects potentially toxic dose).
contains processes. decreased persist or worsen,
20 mg Theoretically, function of the tell Assess level of
this reduces adrenal your doctor or consciousness, BP,
myocardial gland, alcohol pharmacist pulse, and
oxygen demand. intoxication, drug promptly. respirations before and
abuse periodically during
and with asthma administration.
attack.
DRUG NAME MECHANISM OF INDICATION SIDE/ADVERSE NURSING
ACTION EFFECTS RESPONSIBILITIES
Roxanol Assess geriatric
(morphine patients frequently;
sulfate) is a highly older
concentrated adults are more
solution of sensitive to the effects
the narcotic of
analgesic opioid analgesics and
morphine sulfate may experience side
for effects and respiratory
oral administration complications more
used frequently. Pedi:
for the treatment Assess pediatric

.
of patient
severe, chronic frequently; children are
pain. more sensitive to the
effects of opioid
analgesics and may
experience respiratory
complications,
excitability, and
restlessness more
frequently.
 Patient/Family Teaching
Instruct patient how and when to ask for pain medication. Do not stop taking without
discussing with health care professional; may cause withdrawal symptoms if discontinued
abruptly after prolonged use.Discuss safe use, risks, and proper storage and disposal of
opioid analgesics with
patients and caregivers .Caution patient to avoid concurrent use of alcohol or other CNS
depressants with this medication.

Home Care Issues:

Explain to patient and family how and when to administer morphine and how to care for
infusion equipment properly. Pedi: Teach parents or
caregivers how to accurately measure liquid medication and to use only the measuring
device dispensed with the medication
What actions should you take?
Place on bedrest, administer O2 at 2 l nasal
cannula, assess BP and pulse, administer
nitroglycerin sublingual as ordered, obtain
ECG, and notify physician

What is happening to Mrs. Sims?

She may be having an anginal attack versus
acute MI.
How is angina different from an MI?
Nitroglycerin usually stops chest pain associated with
angina. Rest may also alleviate chest pain. Neither
nitroglycerin or rest will relieve the pain of an acute
MI
What are the four indicators of an MI?
Pt hx, ECG changes with ST segment elevation,
elevated troponin 1, and CK-MB elevation
What medical interventions can be used for an MI?
Nitroglycerin drip, morphine, or anticoagulant therapy
(heparin), and thrombolytic agents to dissolve the
clot. A cardiac catheter can determine which
coronary arty is blocked. PCI or a coronary artery
bypass graft may be done to reroute blood.
What education is indicated for Mrs. Sims?
Remind patient to follow the lifestyle modification
that can help prevent worsening of CAD which is
likely the cause of the patient’s angina (e.g. diet,
physical activities, weight management). Remind
patient to intake the pharmacological
interventions prescribed by the physician. Advise
to contact physician if any symptoms are
unmanageable.
Yours truly,
Future Nurses