The document provides information about myocardial infarction (MI), also known as a heart attack. It defines MI as the death of heart muscle caused by a blockage of blood flow through the coronary arteries. It discusses the causes, symptoms, diagnosis, and treatment of MI. The main symptoms of MI are chest pain and shortness of breath. Diagnosis involves electrocardiograms, cardiac enzyme levels, and other cardiac tests. Treatment focuses on restoring blood flow, reducing myocardial workload, and preventing complications through medications, procedures like angioplasty, and lifestyle changes.

1. MYOCARDIAL INFARCTION
PREPARED BY :
MR .SANJEEV KUMAR VISHWAKARMA
MSC NURSING .
NURSING SUPERINTENDENT
NARMADA APNA HOSPITAL
CHHATARPUR M.P.

3. MYOCARDIAL INFARCTION
What is Myocardial Infarction?
Myocardial infarction (MI), is used synonymously with
coronary occlusion and heart attack, yet MI is the most
preferred term as myocardial ischemia causes acute
coronary syndrome (ACS) that can result in myocardial
death.
In an MI, an area of the myocardium is permanently
destroyed because plaque rupture and
subsequent thrombus formation result in complete
occlusion of the artery.
The spectrum of ACS includes unstable angina, non-ST-
segment elevation MI, and ST-segment elevation MI.

4. PATHOPHYSIOLOGY
In each case of MI, a profound imbalance exists
between myocardial oxygen supply and demand.
Unstable angina. There is reduced blood flow in a
coronary artery, often due to rupture of an
atherosclerotic plaque, but the artery is not
completely occluded.
Development of infarction. As the cells are
deprived of oxygen, ischemia develops,
cellular injury occurs, and lack of oxygen leads to
infarction or death of the cells.

6. STATISTICS AND EPIDEMIOLOGY
“Time is muscle”; this is the reflection of the
urgency of appropriate treatments to improve
patient outcome.
Each year in the United States, nearly 1 million
people have acute MIs.
One fourth of the people with the disease die of
MI.
Half of the people who die with acute MI never
reach the hospital.

7. CAUSES
The causes of MI primarily stems from the
vascular system.
Vasospasm. This is the sudden constriction or
narrowing of the coronary artery.
Decreased oxygen supply. The decrease in
oxygen supply occurs from acute blood
loss, anemia, or low blood pressure.
Increased demand for oxygen. A rapid heart
rate, thyrotoxicosis, or ingestion
of cocaine causes an increase in the demand for
oxygen.

8. CLINICAL MANIFESTATIONS
Some of the patients have prodromal
symptoms or a previous diagnosis of CAD, but
about half report no previous symptoms.

10. CHEST PAIN
This is the cardinal symptom of MI. Persistent and crushing
substernal pain that may radiate to the left arm, jaw, neck, or
shoulder blades. Pain is usually described as heavy, squeezing,
or crushing and may persist for 12 hours or more.
Shortness of breath.
Because of increased oxygen demand and a decrease in the
supply of oxygen, shortness of breath occurs.
Indigestion. Indigestion is present as a result of the stimulation
of the sympathetic nervous system.
Tachycardia and tachypnea.
To compensate for the decreased oxygen supply, the heart rate
and respiratory rate speed up.
Catecholamine responses. The patient may experience such as
coolness in extremities, perspiration, anxiety, and restlessness.
Fever. Unusually occurs at the onset of MI, but a low-grade
temperature elevation may develop during the next few days.

11. PREVENTION
A healthy lifestyle could help prevent the
development of MI.
Exercise. Exercising at least thrice a week could
help lower cholesterol levels that cause
vasoconstriction of the blood vessels.
Balanced diet. Fruits, vegetables, meat and fish
should be incorporated in the patient’s daily diet
to ensure that he or she gets the right amount of
nutrients he or she needs.
Smoking cessation. Nicotine
causes vasoconstriction which can increase the
pressure of the blood and result in MI.

12. ASSESSMENT AND DIAGNOSTIC
FINDINGS
The diagnosis of MI is generally based on the
presenting symptoms.
Patient history. The patient history includes the
description of the presenting symptoms, the history of
previous cardiac and other illnesses, and the family
history of heart diseases.
ECG. ST elevation signifying ischemia; peaked upright
or inverted T wave indicating injury; development of Q
waves signifying prolonged ischemia or necrosis.
Cardiac enzymes and isoenzymes.
CPK-MB (isoenzyme in cardiac muscle): Elevates within
4–8 hr, peaks in 12–20 hr, returns to normal in 48–72
hr.

13. ASSESSMENT AND DIAGNOSTIC
FINDINGS
.
Technetium. Accumulates in ischemic cells, outlining necrotic area(s).
Coronary angiography. Visualizes narrowing/occlusion of coronary
arteries and is usually done in conjunction with measurements of
chamber pressures and assessment of left ventricular function (ejection
fraction). Procedure is not usually done in acute phase of MI unless
angioplasty or emergency heart surgery is imminent.
Digital subtraction angiography (DSA). Technique used to visualize
status of arterial bypass grafts and to detect peripheral artery disease.
Magnetic resonance imaging (MRI). Allows visualization of blood flow,
cardiac chambers or intraventricular septum, valves, vascular lesions,
plaque formations, areas of necrosis/infarction, and blood clots.
Exercise stress test. Determines cardiovascular response to activity
(often done in conjunction with thallium imaging in the recovery phase).

14. ASSESSMENT AND DIAGNOSTIC
FINDING
• LDH. Elevates within 8–24 hr, peaks within 72–144 hr, and may take as long as
14 days to return to normal. An LDH1 greater than LDH2 (flipped ratio) helps
confirm/diagnose MI if not detected in acute phase.
• Troponins. Troponin I (cTnI) and troponin T (cTnT): Levels are elevated at 4–6 hr,
peak at 14–18 hr, and return to baseline over 6–7 days. These enzymes have
increased specificity for necrosis and are therefore useful in diagnosing
postoperative MI when MB-CPK may be elevated related to skeletal trauma.
• Myoglobin.
• A heme protein of small molecular weight that is more rapidly released from
damaged muscle tissue with elevation within 2 hr after an acute MI, and peak
levels occurring in 3–15 hr.
• ELECTROLYTE. Imbalances of sodium and potassium can alter conduction and
compromise contractility.
• WBC. Leukocytosis (10,000–20,000) usually appears on the second day after MI
because of the inflammatory process.
• ESR.
• Rises on second or third day after MI, indicating inflammatory response.

15. ASSESSMENT AND DIAGNOSTIC
FINDING
• CHEMISTRY PROFILES. May be abnormal, depending on acute/chronic abnormal
organ function/perfusion.
• ABG/pulse oximetry. May indicate hypoxia or acute/chronic lung disease
processes.
• Lipids (total lipids, HDL, LDL, VLDL, total cholesterol, triglycerides, phospholipids):
Elevations may reflect arteriosclerosis as a cause for coronary narrowing or spasm.
• CHEXT X-RAY: May be normal or show an enlarged cardiac shadow suggestive of
HF or ventricular aneurysm.
• TWO-DIMENSIONAL ECHOCARDIOGRAM : May be done to determine
dimensions of chambers, septal/ventricular wall motion, ejection fraction (blood
flow), and valve configuration/function.
• NUCLEAR IMAGING STUDIES: PERSANTINE OR THALLIUM : Evaluates
myocardial blood flow and status of myocardial cells, e.g., location/extent of
acute/previous MI.
• CARDIAC BLOOD IMAGING/MUGA : Evaluates specific and general
ventricular performance, regional wall motion, and ejection fraction.

17. MEDICAL MANAGEMENT
The goals of medical management are to minimize
myocardial damage, preserve myocardial function,
and prevent complications.
MORPHINE : administered in IV boluses is used
for MI to reduce pain and anxiety.
ACE INHIBITORS. ACE inhibitors prevent the
conversion of angiotensin I to angiotensin II to
decrease blood pressure and for the kidneys to
secrete sodium and fluid, decreasing the oxygen
demand of the heart.
THROMBOLYTICS. Thrombolytic dissolve
the thrombus in the coronary artery, allowing
blood to flow through the coronary artery again,
minimizing the size of the infarction and
preserving ventricular function.

18. EMERGENT PERCUTANEOUS
CORONARY INTERVENTION
The procedure is used to open the occluded
coronary artery and promote reperfusion to
the area that has been deprived of oxygen.
PCI may also be indicated in patients with
unstable angina and NSTEMI for patients who
are at high risk due to persistent ischemia.

19. NURSING MANAGEMENT
The nursing management involved in MI is
critical and systematic, and efficiency is needed
to implement the care for a patient with MI.
NURSING ASSESSMENT
One of the most important aspects of care of the
patient with MI is the assessment.

20. NURSING ASSESSMENT
Assess for chest pain not relieved by rest or medications.
Monitor vital signs, especially the blood pressure and pulse
rate.
Assess for presence of shortness of breath, dyspnea
tachypnea, and crackles.
Assess for nausea and vomiting .
Assess for decreased urinary output.
Assess for the history of illnesses.
Perform a precise and complete physical assessment to
detect complications and changes in the patient’s status.
Assess IV sites frequently.

21. NSG DIAGNOSIS
Based on the clinical manifestations, history,
and diagnostic assessment data, major nursing
diagnosis may include.
ineffective cardiac tissue perfusion: related to
reduced coronary blood flow.
Risk for ineffective peripheral tissue perfusion:
related to decreased cardiac output from left
ventricular dysfunction.
DEFICIENT KNOWLEDGE :
related to post-MI self-care.

22. PLANNING & GOALS
To establish a plan of care, the focus should be on the following.
1. Relief of pain or ischemic signs and symptoms.
2. Prevention of myocardial damage.
3. Absence of respiratory dysfunction.
4. Maintenance or attainment of adequate tissue perfusion.
5. Reduced anxiety.
6. Absence or early detection of complications.
7. Chest pain absent/controlled.
8. Heart rate/rhythm sufficient to sustain adequate cardiac
output/tissue perfusion.
9. Achievement of activity level sufficient for basic self-care.
10. Anxiety reduced/managed.
11. Disease process, treatment plan, and prognosis understood.
12. Plan in place to meet needs after discharge.

23. NURSING PRIORITIES
1. Relieve pain, anxiety.
2. Reduce myocardial workload.
3. Prevent/detect and assist in treatment of life-
threatening dysrhythmias or complications.
4. Promote cardiac health, self-care.

24. NURSING INTERVENTIONS
1. Nursing interventions should be anchored on the goals in
the nursing care plan.
2. Administer oxygen along with medication therapy to assist
with relief of symptoms.
3. Encourage bed rest with the back rest elevated to help
decrease chest discomfort and dyspnea.
4. Encourage changing of positions frequently to help keep
fluid from pooling in the bases of the lungs.
5. Check skin temperature and peripheral pulses frequently to
monitor tissue perfusion.
6. Provide information in an honest and supportive manner.
7. 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.

25. EVALUATION
After the implementation of the interventions within
the time specified, the nurse should check if:
1. There is an absence of pain or ischemic signs and
symptoms.
2. Myocardial damage is prevented.
3. Absence of respiratory dysfunction.
4. Adequate tissue perfusion maintained.
5. Anxiety is reduced.

26. DISCHARGE AND HOME CARE
GUIDELINES
.
The most effective way to increase the
probability that the patient will
implement a self-care regimen after
discharge is to identify the patient’s
priorities.

27. EDUCATION
Education. This is one of the priorities that the nurse
must teach the patient about heart-healthy living.
Home care. The home care nurse assists the patient
with scheduling and keeping up with the follow-up
appointments and with adhering to the prescribed
cardiac rehabilitation management.
Follow-up monitoring. The patient may need
reminders about follow-up monitoring including
periodic laboratory testing and ECGs, as well as
general health screening.
Adherence. The nurse should also monitor the
patient’s adherence to dietary restrictions and
prescribed medications.

28. DOCUMENTATION GUIDELINES
To ensure that every action documented is an action
done, documentation must be secured. The following
should be documented:
1. Individual findings.
2. Vital signs, cardiac rhythm, presence of
dysrhythmias.
3. Plan of care and those involved in planning.
4. Teaching plan.
5. Response to interventions, teaching, and actions
performed.
6. Attainment or progress towards desired outcomes.
7. Modifications to plan of care.

29. PRACTICE QUIZ: MYOCARDIAL
INFARCTION
1. Which of the following is the most common symptom of myocardial infarction (MI)?
A. Chest pain
B. Dyspnea
C. Edema
D. Palpitations
2. An intravenous analgesic frequently administered to relieve chest pain associated with MI is:
A. Meperidine hydrochloride
B. Hydromorphone hydrochloride
C. Morphine sulfate
D. Codeine sulfate
3. The classic ECG changes that occur with an MI include all of the following except:
A. An absent P wave
B. An abnormal Q wave
C. T-wave inversion
D. ST segment elevation
4. Which of the following statements about myocardial infarction pain is incorrect?
A. It is relieved by rest and inactivity.
B. It is substernal in location.
C. It is sudden in onset and prolonged in duration.
D. It is viselike and radiates to the shoulders and arms.
5. Myocardial cell damage can be reflected by high levels of cardiac enzymes. The cardiac-specific
isoenzyme is:
A. Alkaline phosphatase
B. Creatine kinase (CK-MB)
C. Myoglobin
D. Troponin

30. Practice Quiz: Myocardial Infarction
A: The most common symptom of an MI is chest pain, resulting from deprivation of oxygen to the heart.
B: Dyspnea is the second most common symptom, related to an increase in the metabolic needs of the body during an MI.
C: Edema is a later sign of heart failure, often seen after an MI.
D: Palpitations may result from reduced cardiac output, producing arrhythmias.
2. Answer: C. Morphine sulfate
C: Morphine administered in IV boluses is used for MI to reduce pain and anxiety.
A: Meperidine hydrochloride is not the analgesic of choice for MI.
B: Hydromorphone hydrochloride is not the analgesic of choice for MI.
D: Codeine sulfate is not the analgesic of choice for MI.
3. Answer: A. An absent P wave
A: An absent P wave is not part of the classic changes seen in an ECG result.
B: An abnormal Q wave is an indication of MI.
C: T-wave inversion is a classic ECG change in a patient with MI.
D: ST segment elevation is an indication of MI.
4. Answer: A. It is relieved by rest and inactivity.
A: MI pain continues despite rest and medications.
B: The pain occurs substernally or at the chest area.
C: MI pain occurs suddenly and is prolonged in duration.
D: The pain grips the patient like a vise and radiates towards the arms or the shoulders.
5. Answer: B. Creatine kinase (CK-MB)
B: CK-MB is the isoenzyme for the heart muscle and the cardiac-specific enzyme.
A: Alkaline phosphatase is not part of the creatine kinase isoenzymes.
C: Myoglobin is a heme protein that helps transport oxygen.
D: Troponin regulates the myocardial contractile process.