MINUTES IS MUSCLE
Created by: Becky Fitzgerald 2018
Who is our patient
Case Study
52 year old male
252 lbs (114.5 kg)
Father of 4
Full time construction worker
Chest pain radiating to his left arm and jaw at 0200 hours
Went to a small rural hospital to be assessed first.
- 0800 hours: Arrived at large tertiary center.
- Severe sub-sternal chest pain that refers down both arm and into neck
- Shortness of breath
- Maalox at home with no relief
- ST segment elevations with a 12 lead EKG
What is his history
Episodic "chest tightness' for past 6 months
Smokes 1 pack/day for 35 years
Drinks 3-4 beers/day
Father died of a heart attack at 55
Total cholecystectomy 10 years ago
Elevated cholesterol
Gastroesophageal Reflux Disease
NIDDM (Type 2 diabetes)
No known drug allergies
History
Current Vital Signs
LABS
K 3.0 mmol/L
Sodium 142 mmol/L
Glucose 16.5
Creatinine 168 umol/L
Troponin 4.2 mcg/L
Current VS
NORMAL VALUES FOR CARDIAC MARKERS
Cardiac Markers
Marker Reference Range
Cardiac troponin < 0.1 ng/mL *
Creatine kinase MB (CKMB) <10 ng/mL
Myoglobin <170 ng/mL (>25% increase over 90 min. suggests AMI)
NORMAL VALUES FOR CARDIAC MARKERS
Nanograms per milliliter, abbreviated ng/mL, is the unit of measure most commonly used to express drug testing cut-off levels and quantitative test results in urine and oral fluid. A nanogram is 10-9 grams
TROPONIN & CK-MB
MYOGLOBIN
Will be elevated 2 hours after MI and remain elevated for 24 hours
Released when cardiac or skeletal muscle is damanged
What are the client's risk factors?
RISK FACTORS
RISK FACTORS
- Overweight
- smoker
- Drinking
- High Cholesterol
- NIDDM
- Male > 45
- Family History
RISK FACTORS
Is he a candidate for t-PA
NO
The best results from t-PA occur within the first hour after symptom onset, may be administered within 3 hours.
He suffered his first symptoms at 0200 hours.
Arrived at larger tertiary centre at 0800 hours
Is he a candidate for t-PA
WHAT ARE THE CONTRAINDICATIONS FOR t-PA
CONTRAINDICATIONS
- HTN >180/110•
- Ischemic CVA > 3 months ago•
- Dementia
- Other intracranial disease
- Traumatic or Prolonged CPR > 10 minutes
- Major surgery in the last 3 weeks•
- Internal bleeding in the last 2-
- 4 weeks or active peptic ulcer•
- Noncompressible vascular punctures•
- Pregnancy•
- Current anticoagulant therapy
- Prior exposure to streptokinase
- Best results within 1 hours of symptom onset.
NURSING PRIORITIES
PRIORITIES
NURSING PRIORITIES
NURSING PRIORITIES
- Ischemic Chest Pain
- Decrease workload of the heart
- Dilation of coronary vessels
- Anticoagulants to prevent futher blockage
- Fluid and Electrolyte imbalance
- Assess for reprerfusion therapy
NURSING ASSESSMENTS
NURSING ASSESSMENTS
NURSING ASSESSMENTS
NURSING ASSESSMENTS
CNS
- Assess for chest pain not relieved by rest or medications.
- LOC
CVS
- Monitor vital signs, especially the blood pressure and pulse rate.
- Assess IV sites frequently
- Monitor Labs
RESP
- Assess for presence of shortness of breath, dyspnea, tachypnea, and crackles.
GI
- Assess for nausea and vomiting.
GU
- Assess for decreased urinary output.
INTEG
- Diaphoresis, cool clammy skin, pallor
PSYCH/SAFETY
- Anxiety
- Coping
- Family
- Nicotine withdrawal
Perform a precise and complete physical assessment to detect complications and changes in the patient’s status.
NURSING ACTIONS
NURSING ACTIONS
NURSING ACTIONS
- IV fluids
- M - morphing
- O - oxygen
- N - nitroglycerine
- A - aspirin
- Position of comfort - HOB elevated to ensure lung expansion and prevent pooling of fluid in the lungs.
- Minimize patient exertion - Bedrest
- Promote rest with early gradual increase in mobilization once out of ICU
- Maintain NPO
- Manage symptoms
- Prepare for ICU admission
- Check skin temperature and peripheral pulses frequently to monitor tissue perfusion.
- Provide information in an honest and supportive manner.
- Monitor the patient closely for changes in cardiac rate and rhythm, heart sounds, blood pressure, chest pain, respiratory status, urinary output, changes in skin color, and laboratory values
EVALUATION
EVALUATION
- There is an absence of pain or ischemic signs and symptoms.
- Myocardial damage is prevented.
- Absence of respiratory dysfunction.
- Adequate tissue perfusion maintained.
- Anxiety is reduced
DISCHARGE TEACHING
DISCHARGE TEACHING
HOME CARE
HOME CARE
Medication Teaching
Recovery after a heart attack takes time. Plan to rest for at least 4 to 8 weeks. Check with physician on return to work
Cardiac rehabilitation programs
Signs & symptoms of depression.
When to call 911
Ask your family members to learn CPR. This is an important skill that can save lives when it's needed.
Monitor BP and HR at home - talk about monitoring equipment
Keep follow-up appointments
LIFESTYLE CHANGES
LIFESTYLE CHANGES
DIET
- Consult a dietician
- Cut back on fats
- Low cholesterol diet
- Eat fresh fruit and vegetables
- Lean proteins - fish, poultry, beans - less red meat
- Low fat dairy
- Cut back on fast foods and sugars
EXERCISE
- Each individual is assessed for exercise tolerance.
- Recommendations are moderate to vigorous physical activity for at least 40 minutes each day, and for at least 3 to 4 days each week.
SEXUAL ACTIVITY
Sexual activity is reasonable if the patient can exert enough energy to ride a stationary bicycle or walk at a comfortable pace without experiencing angina, excessive breathlessness, ECG changes signifying lack of oxygen to the heart muscle, arrhythmias, or a rise in blood pressure.
SEXUAL ACTIVITY
As well it should take place in a familiar environment where the patient feels comfortable and safe.
Erectile dysfunction drugs interact dangerously with nitrates, which are given for chest pain.These two drugs should never be taken together!
OTHER POINTS
OTHER POINTS
Lose weight
Stop smoking
Drink in moderation
Learn to manage stress