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Introduction
Your heart muscle, just like every muscle in your body needs oxygen to survive. When oxygen supply to the heart is reduced, or cut off completely, the heart muscle becomes ischemic. When damage or death of part of the heart muscle occurs as a result of ischemia, it is called a heart attack or myocardial infarction (MI) (American Heart Association (AHA), 2012).
According to the American Heart Association (AHA), approximately every 34 seconds a person suffers from a heart attack in the United States (AHA, 2012). The number one leading cause of death in the world in 2011 was ischemic heart disease, taking over 7 million lives (World Health Organization, 2013). Objective: We are going to explore the different treatment plans for MI as recommended by The Joint Commission and proven effective by evidence
Clinical Presentation
P a t h o p h y s i o l o g y
diaphoresis
shortness of breath
general weakness
Depending on extent of ischemia patient may also experience nausea, vomiting, dyspnea, fainting, or feeling of impending doom.
In women, pain is more generalized, and patients often complain of overwhelming fatigue, weakness, and sleep disturbances.
(Osborne, Wraa, Watson, & Hollerand, 2013)
Risk Factors
P a t h o p h y s i o l o g y
Modifiable Tobacco Obesity Sedentary lifestyle Diet Hostility/Stress Medications Substance abuse Anabolic steroids
Diagnosis
P a t h o p h y s i o l o g y
Laboratory tests
Triponin, Creatine kinase, and Myoglobin
Twelve-lead EKG
A 12 lead ECG is used to evaluate changes in electrical activity of the heart. While all components are important, the ST segment is the major focus when evaluating damage from MI. Diagnostic criteria call for a change in ST segment and T wave in at least 2 contiguous leads. For an inferior wall MI, an ECG would have to have at least a 1mm elevated ST segment in two of three specific leads (p. 951).
Treatment
P a t h o p h y s i o l o g y
Implementation of CORE measures for acute MI from the Joint Commission Angioplasty Coronary Artery Bypass Graft (CABG)
(Osborne, Wraa, Watson, & Hollerand, 2013)
Prognosis
P a t h o p h y s i o l o g y
About 50% of patients that have MI are admitted to the hospital within the following year.
(Zafari, 2014)
Case Study
HPI: 61 year-old male presented to the emergency room on 02/03/2014 complaining of chest pain. Patient reports that about one week prior (01/26/2014), he experienced six episodes of this feeling within an hour, and that the pain lessened with each episode. When it began occurring again 8 days later, he decided to come to the ER. Patient states the pain in his chest pain would come and go and he described it as an intense heaviness that was squeezing my heart -- a 10/10. He said that activities such as walking or eating would aggravated it, and that until it dissipated, not would ease it.
CORE MEASURES
Aspirin within 24 hours of arrival
Rationale:
According to the Joint Commission, Aspirin is estimated to prevent recurring myocardial infarction (MI) in up to 4% of patients previously treated for an acute MI. Current guidelines recommend that any person arriving to the emergency department with a suspected MI immediately receive aspirin and continue on therapy after discharge (Joint Commission, 2014).
Rationale:
Clinical trials have determined that beginning angiotensin converting enzyme inhibitor (ACEI) therapy after a patient has recovered from an Acute MI improves long-term survival (Joint Commission, 2014).
Rationale:
Smoking is known to trigger coronary spasms, reduce the anti-ischemic effects of beta blockers, and increases mortality after an Acute MI. Evidence indicates that within one year of quitting smoking, a patient's risk of acute myocardial reinfarction and AMI mortality is reduced (Joint Commission, 2014).
Rationale:
Evidence indicates that beta blocker therapy reduces both the degree of infarction and incidence of complications in patients not receiving concomitant thrombolytic therapy, and the incidence of reinfarction in patients who receive thrombolytic therapy. In addition, several placebo-controlled trials have shown that long-term beta blocker therapy decreases mortality by reducing the incidence of sudden and nonsudden cardiac death (Joint Commission, 2014).
Rationale:
Evidence indicates that the timing of reperfusion is critical to the effective management of AMI patients and the earlier therapy is initiated, the better the outcome. The greatest benefits of thrombolytic therapy are evident in the first 3 hours after the onset of symptoms, but there is proven benefit for up to 12 hours after the onset of symptoms (Joint Commission, 2014). Our Patient Medication Orders
Our patient was initiated on prasugrel (Effient) 10 mg by mouth daily. The therapeutic effects of this drug is to decrease thrombotic events including cardiovascular death, nonfatal MI and nonfatal stroke. He was prescribed this medication to be continued upon discharge home
Nursing Diagnosis
Altered tissue perfusion (myocardial) related to narrowing of the right coronary artery associated with atherosclerosis.
NCLEX
What is the primary reason for administering morphine to a client with MI?
A. To sedate the client B. To decrease the clients pain C. To decrease the clients anxiety D. To decrease oxygen demand on the clients heart
NCLEX
Which diagnostic tool is used to determine the location of myocardial damage for a patient with a myocardial infarction (MI)?
A. B. C. D. Cardiac catheterization Cardiac enzymes Echocardiogram Electrocardiogram
References
American Heart Association. (2013, January 23). About heart attacks. Retrieved from http://www.heart.org/HEARTORG/Conditions/HeartAttack/AboutHeartAttacks/About-HeartAttacks_UCM_002038_Article.jsp Held, C., Jernberg, T., Johanson, P., Lindback, J., Svennblad, & Wallentin, L. (2011, April 27). Association between adoption of evidence-based treatment and survival for patients with ST-elevation myocardial infarction. The Journal of the American Medical Association, 305(16). doi:10.1001/jama.2011.522 Joint Commission. (2014). A comprehensive review of development and testing for national implementation of hospital core measures. Retrieved from http://www.jointcommission.org/assets/1/18/A_Comprehensive_Review_of_Development_for_Core_ Measures.pdf Osborn, K. S., Wraa, C. E., Watson, A., & Hollerand, R. (2013). Medical-surgical nursing: Preparation for practice (2nd ed.). Upper Saddle River, NJ: Pearson-Prentice Hall. Sommors, M. S. (2013). Diseases and disorders (4th ed.). Retrieved from http://nursing.unboundmedicine.com/nursingcentral/ub/index/Diseases-and-Disorders/All_Entries/A
World Health Organization (WHO). (2013, July). The top 10 causes of death. Retrieved from http://who.int/mediacentre/factsheets/fs310/en/
Zafari, A. M.(2014). Myocardial Infarction. Medscape. Retrieved from http://emedicine.medscape.com/article/155919-overview#aw2aab6b2b8aa