Heart Attack and Nursing InterventionsCHAPTER 1

Heart attack? When? Blood pressure and diabetes are not the only silent killers. Heart attack too may occur without any warning signals. Silent heart attack, offers no warning signs and no symptoms. In fact, you may have suffered one without being aware in the least. Scary? It can be scarier, if you are ignorant about it.

Certain atypical signs such as sweating, dizziness and nausea, headache, pallor, nervousness and anxiety may accompany silent heart attack. A feeling of fullness in the center of the chest, mild pain in the arms, breathlessness while doing routine physical activities such as walking to the bus stop. Usually such symptoms are mild and subside within a short span of time.

How can it be detected? It can be detected by talking ECG, talking medical history, testing blood for cardiac enzymes, a stress test, echocardiogram, coronary angiography.

Since clients have not experienced symptoms, they tend to take it lightly, or think that doctors are making a big deal.

The high risk group—You are likely to have silent heart attack if you are above 65 years, are diabetic, high blood pressure, have high elevated serum cholesterol level, are obese, lead a sedentary lifestyle, smoke regularly, had a history of strok, lack of exercise, type of personality.

Treatment—A heart attack is a medical emergency. Delaying treatment can mean lasting damage to your heart or even death. The sooner the treatment begins the better your chances of recovering almost completely.4

Thrombolytic drugs or clot busters are used to dissolve blood clots that are blocking blood flow to the heart. When given soon after a heart attack begins, these drugs can limit or prevent permanent damage to the heart. The drugs to be administered within one hour of silent heart attack. Treatment measures also involve angioplasty to unclog the blocked arteries or a coronary bypass surgery where, in arteries or veins from other areas in your body are used to bypass the blocked arteries.

How to prevent it? Tobacco and passive smokers can damage heart health. Stress levels, which are extremely high in metros, avoid food high in saturated fats, switch to food rich in fibers. Do regular exercise. After age of 35 have yearly checkups and ECG, stress test, lipid profile, sugar is tested.

Angina pectoris is pain in the chest that is caused by hypoxia of the cardiac muscle. It is a sign of myocardial ischemia. Angiana pain comes during activities. Tab. Nitroglycerine placed under the tongue three minutes before activity and repeats the dose in 5 minutes if pain occurs. The two coronary arteries are the 1st branches of the aorta and carry blood with high oxygen content to the myocardium. Coronary occlusion is caused by ischemia of the heart muscles. After cardiac catheterization check pulse distal to the insertion site.

Complication of MI is cardiac dysrhythmia; Catheter in pulmonary artery to provide information of Left Ventricular heart failure. Lab, MI, LDH, CK-MB, is enzymes released into the blood from cardiac muscle cells when myocardium is damaged.

Apical pulse less then 60 and more than 120 contraindicated when talking drugs digoxin at home. Patient receiving anticoagulant drug observe for epitaxis and hemorrhage —INR test anticoagulant cardiac shock is failure of circulatory pump, always drop BP. Adrenaline is used to treat the shock because it increases cardiac output. Atropine blocks vagal stimulation of the SA node, resulting in increased heart rate.

The SA node is the hearts natural pacemaker. Instruct patient to take daily pulse and keep accurate records, pulse remain at least equal to the pacemaker; Lidocaine decreases the irritability of ventricles; Asystole refers to absence of arterial and ventricular contraction. Which causes death? During cardiac arrest time, the patient is anoxic, irreversible brain damage will occur if patient is anoxic for more than 4 minutes.

Patient found unconscious, unresponsive, initiate a code, help must be obtained immediately; Edema comes during the day and disappears night is Right ventricular heart failure; Edema can be classified on a four point scale from 1+ to 4+. Check the degree of edema; Right ventricular heart failed patient complains of dyspoea, edema and fatigue. Elevation of plasma hydrostatic pressure at the venous end of the capillary bed, increases pressure within circulatory system causing ascities- with air conditioning the heart is relived of the strain of pumping blood through many miles of the blood vessels in the skin. Pulmonary edema associated with mitral stenosis. 6L oxygen via nasal cannula, patient in an orthopric position; cardiac catheterization check patients pedal pulses if complains of numbness. After cerebral angiogram procedure asses symmetry of the radial pulses.

Cardiorespiratory failure—The heart consumes more oxygen per minute than any other organ in the body, because it is constantly beating. Consequentently, when the lung stop working, the heart fails occurs. Conversely, the ventilation of the lungs fails soon after the 5heart stops. Due to this medulla oblongata cannot function without the continuous supply of oxygen that is normally transported to it by cardiovascular system.

It is marked by sudden fail in the arterial oxygen tension and rise in the arterial carbon dioxide content. Due to it, the oxygen content in blood fails. Tissues of the body too are affected due to that. Brain is less tolerant of hypoxia then the heart. Brain tissues begin to deteriorate and irreversible changes take place in the brain tissues. Chest pain that is angina pectoris produced due to hypoxia. Clinical death occurs with the cessation of blood flow and the respiratory arrest. If the cardiac arrest is identified quickly and cardiopulmonary resuscitation is started immediately, we will be able to bring back the patient to life from clinical death. However, 5 to 6 minutes of cerebral ischemia results in biologic death and no revival is then possible.

Causes of cardiac arrest airway obstruction, Myocardial Infarction, anesthetic depression, hypotension, retention of carbon dioxide, drowning, electric shock, poisoning, drug reaction, pulmonary embolism, extensive hemorrhage, brain injuries, and hypothermia.

The three cardinal signs are apnea, absence of carotid and femoral pulse and dilated pupils.

Sequence of cardiopulmonary resuscitation is A- Airway; B-Breathing; C-Circulation.

Because of an emergency, no time is lost for this procedure. The success of the CPR depends on the speed with basic life supporting measures are effectively initiated. Noting the cardinal signs and symptoms, get quickly help.

Clean airway to restore respiration and circulation. Keep the heart and neck in a hyper-extended position to prevent tongue falling back and obstructing airway. Place ore-pharyngeal airway if breathing is not restored start artificial ventilation. Pinch the nostrils closed, using an index finger and thumb of the hand near the patients face. Take a deep breath, place your mouth into the rescuers mouth ensures airtight seal. The expansion of the chest ensures ventilation of the lungs.

Suddenly you start experiencing severe pain in your chest that starts to radiate out into your arm and up into your jaw. You are only about five kms from the hospital nearest your home.

Unfortunately, you do not know if you will be able to make it that far. You have been trained in CPR, but the person that taught the course did not tell you how to perform it on yourself.

Since many people are alone when they suffer a heart attack, without help, the person whose heart is beating improperly and who begins to feel faint, has only about 10 seconds left before losing consciousness. However, these victims can help themselves by coughing repeatedly and very vigorously.

A deep breath should be taken before each cough, and the cough must be deep and prolonged, as when producing sputum from deep inside the chest.6

A breath and a cough must be repeated about every two seconds without letup until help arrives, or until the heart is felt to be beating normally again.

Deep breaths get oxygen into the lungs and coughing movements squeeze the heart and keep the blood circulating. The squeezing pressure on the heart also helps it regain normal rhythm.

In this way, heart attack victims can get to a hospital. It could save their lives!

Follow the above mentioned tips to lead a healthy and a happy life.

Hyperextend the head and neck of the patient by tilting it backward as far as possible

Pull the victim's jaw forward by placing the fingers behind the angle of the jaw and is lifted forward until the teeth on the upper jaw and the lower jaw is approximated

If breathing is restored, place on oropharyngeal airway

If breathing is not restored start artificial ventilation

To initiate breathing can be given [mouth to mouth]

Pinch the patient's nostrils closed, using an index finger and thumb of the hand near the patient's face. Take a deep breath, place your widely opened mouth over the patient's mouth and blow forcefully enough to make the patient's chest rise. Turn the face towards the patient's chest to observe its expansion.

After each inflation move, your mouth ensures airtight seal. The expansion of the chest ensures ventilation of the lungs. In children [the rescuer's mouth is placed over the mouth and nose], less volume of air is introduced, but they are given about 20–30 times per minute.7

If cardiac massage is to be given, the artificial breathing should be carried at a rate of 5% or 15 : 2, i.e. one inflation after every 15 cardiac massage when there is only one rescuer.

To maintain circulation begin external cardiac compression immediately following initial four rapid breaths.

Position the patient on his back on a flat, firm surface.

Kneel on bed at the side of patient.

CR cardiac compression at rate of 60–80/Minutes; Assess the vital signs.

Lung inflations and cardiac compressions must be followed until patient starts spontaneous respirations and pulse.

Keep patient under observation 48 to 72 hrs.

Watch pupils, pulse, movements of chest wall no retraction of muscles, blood pressure, temperature, pulse and respirations, watch for convulsions, insert Foley's catheter. Start IV infusion

Record each thing with observation

Basic CPR – follow the ABCD → that is Average Breathing Circulation Defibrillation

Advanced → Drug, ECG

CPCR → Cardiac Pulmonary Cerebral Resuscitation

Congenital heart block can be treated but city needs to make surgeries more easily available to kids. Medical science has progressed to a point where doctors can detect a slew of problems in the fetal stage itself, can detect chromosomal abnormalities, congenital neoplasm a abnormalities that is tumors, skeletal abnormalities, renal cystic disease, congenital infections as well as neurological abnormalities.

The non-invasive test- done between 11 and 13 weeks are:

Low levels of Pregnancy Associated Plasma Protein A (PAPP-A) in maternal serum during the first three months of pregnancy may be associated with fetal chromosomal anomalies that indicate genetic abnormality. Low PAPP-A levels in the first trimester may also predict that the outcome could be different pregnancy.

Triple AAA marker done between 16 and 18 weeks. This includes tests that can detect neural defects. Congenital malformation and genetic disease conditions like tiresome, Ed wards and Downs syndrome.

Nuchal cord translucent C test-done 9 and 13 weeks, it can detect neural defects such as DS, Turners or spina Bifida in which a part of the spinal cord is not formed, leads to a life long disabilities in some.

3D or 4D anomaly scan at 10 weeks. This is a detailed 3D/4D scan. Every single angel and every minor and major physical anomaly ranging from an eye problem to defects in the heart to cleft lip.

Fetal echocardiography done in 20 and 24 weeks.

It gives the complete picture of the heart and any malformation is detected.

The invasive tests are done only when any of the screening tests turn positive. Also recommended if there is a family history of genetic diseases or the parents are old.8

Amniocenteses done at 16 and 18 weeks– a needle is passed into the amniotic cavity inside the uterus. The amniotic fluids contain fetal cells, which can be grown in culture from chromosome analysis biochemical analysis and molecular analysis/it shows genetic abnormality.

Chorionic villus sampling done in 9 and 12 week.

A catheter is passed through the cervix and into the uterus to the placenta under ultrasound guidance. This allows sampling of cells for chromosome analysis for genetic abnormality.

Fetoscopy—An endoscope is introduced into the amniotic sac to get a visualization of the fetus. This helps in getting fetal blood sample, skin biopsy and liver biopsy.

USG based fetal blood sampling. This uses sonography probe/catheter to get sample of fetal blood.

We have to understand that 90% of children born with heart defects are normal after an operation. We cannot change the incident of heart defect, but we need public trust hospitals and government to come together to ensure that such operations are made easily available to children.

Abortion of such a child has adverse moral, ethical, and inhuman consequences. Know the trauma parents who have such child with disability go through. A baby with malfunctioning organs cause unlimited and cannot be explained the tribulation. We have to react when technologies is alerting us. If do not follow why technology at all. Who will be responsible for child's agony? Parents will have to watch child's agony helplessly. Which can be unbearable? Parents are not able to afford to give child latest treatment thus putting child in distress. Life will be hell for such a child. Child will lead a terrible life and will not have normal childhood.

Adding with life long medical expenses

The law is clear no person has the right to kill an unborn child.

The almighty deciding the fate of human beings

Destiny is playing its role people will misuse the law. May use as a pretext for terminating perfectly healthy child. As this issue was discussed few days back and appeared in newspapers remains unanswered.

Ventilation is the movement of air in and out of the lungs. The primary function of the lungs is gas exchange. The physical structure and the airway allow air to be warmer, filtered and humidified as it enters the body. In the alveolar sacs, oz is exchanged for coz. The mechanics of breathing are coordinated by the ribs, diaphragm, pleural space, elastic recoil of the lungs and nervous system provides one form of acid base balance. When there process of structure and function are altered, various disorders can occur.9

During inspiration, air flows from the environment into the trachea, bronchi, bronchioles and alveoli. During expiration, alveolar gas travels the same route in reverse.

Physical factors that govern air flow in and out of the lungs are collectively referred to as the mechanics of ventilation and include air pressure variances, resistance to air flow and lung compliance.

Air flows from a region of higher pressure to a region of lower pressure. During inspiration, movement of the diaphragm and other muscles of respiration enlarge the thoracic cavity and there by lowers the pressure inside the thorax to a level below that of atmospheric pressure. Therefore, air is drawn through the trachea and bronchi into the alveoli.

During normal expiration, the diaphragm relaxes and the lungs recoil, resulting in a decrease in the size of the thoracic cavity. The alveolar pressure then exceeds atmospheric pressure and air flows from the lungs into the atmosphere.

Airway resistance is determined chiefly by the size of the airway through which the air is flowing. Any process that changes the bronchial diameter and alters the rate of air flow for a given pressure gradient during respiration. With increased resistance greater than normal respiratory effect is required by the patient to achieve normal levels of ventilation.

When pressure changes are applied in the normal lung, there is a proportional changes in the lung volume. A measure of the elasticity, expandability and dispensability of the lungs and thoracic structure is called compliance. Factors that determine lung compliance are surface tension of the alveoli and the connective tissue of the lungs. Normal compliance is (1.0 L/cm H₂O) increased compliance occurs when the lungs have lost their elasticity and thorax is over distended. When lungs and thorax are stiff there is decreased compliance. Conditions associated with this pneumothorax, hemothorax, pleural effusion, pulmonary edema, atelectasis etc.

Lung function, which reflects the mechanic of ventilation. It is categorized as tidal volume, inspiratory reserve volume expiratory reserve volume and residual volume.

Tidal volume(TV) is the volume of air inhaled and exhaled with each breath 500 ml which may not vary, even with sever diseases.

Inspiratory reserve volume (IRV) is the maximum volume of air that can be inhaled after a normal inhalation 300 ml.

Expiratory reserve volume (ERV) is the maximum volume of air that can be exhaled forcing after normal exhalation 1100 ml, it is decreased in obesity, ascities and pregnancy.

Residual volume (RV) 1200 ml, it increases in obstructive diseases.

Vital capacity (VC) 4600 ml and inspiratory capacity 3500 ml total lung capacity 5800 ml functional residual volume of air remaining in the lung a normal expiration, coz is waste product of tissue metabolism.

Ventilation air flow and perfusion/blood flow determines the efficiency of gas exchange. The primary function of lung is gas exchange.

The rhythm of breathing is controlled by respiratory centers in the brain. The inspiration and expiratory centers in the medulla oblongata and pons control the rate and depth of ventilation to meet the body's metabolic demands.

Ventilation is the flow of gas in and out of the lungs and perfusion is the filling of pulmonary capillaries with blood.10

Ventilation—Perfusion ratio in different areas of lung, the ratio may vary. Alteration in perfusion may occur with a change in the pulmonary artery pressure, alveolar pressure and gravity. Airway blockage, local changes in compliance and gravity may alter ventilation.

Imbalance occurs from inadequate ventilation. Ventilation and perfusion imbalance causes shunting of blood, resulting in hypoxia. Oxygen can eliminate hypoxia. Once the air enters the trachea, It becomes fully saturated with water vapour, which displays some of the gases so that the air pressure within the lung remains equal to the air pressure outside.

Low ventilation perfusion states may be called shunt producing disorders. When effusion exceeds ventilation, a shunt exists. Blood by passes, the alveoli without gas exchange occurs. Oxygen and carbon dioxide are carried simultaneously by virtue of there abilities to dissolve in blood. Oxygen is carried in the blood in two forms. First as physically dissolved oxygen in the plasma, second in combination with the hemoglobin in RBC.

Paoz partial pressure of alveolar coz

Normal levels paoz above 70 mm Hg

Dangerous levels below 40 mm Hg

Nursing management of the client on mechanical ventilation indicated when the patient is unable to maintain safe levels of oz or coz by spontaneous breathing even with the assistance of other oz delivery devices. Mechanical ventilation helps to minimize the work of breathing while effectively promoting gas exchange oxygenation and ventilation. It requires the establishment of an artificial airway (usually by ET intubations initially) and use of positive pressure ventilator.

Endotracheal tube is a longer, slender hallow tube usually made of polyvinyl, chloride that is inserted into the trachea via the mouth or nose. Oral intubations is usually used for short term airway management nasal intubations is more secure and believed to be more comfortable and does not move as much in the airway. However many instillations are not using nasal intubations because of risk of sinusition if prolonged intubations required ET tube will be replaced with a tracheotomy.

Inserting the tube the client is positioned supine with all dental bridge work plates remove the head of hyperextended the lower except of the neck flexed and the mouth opened this position bring the mouth, pharynx and larynx into a straight line oxygen saturation adequate checked.

Checking tube placemen immediately after on ET tube has been inserted

Tube placement is verified by auscultation and chest X-ray to ensure to see the position of tube and if the tube is slips can correct reestablishing quickly. Secure the ET tube immediately after intubations with adhesive tape specially designed. ET tube holds.

Seal the tube against the tracheal wall to facilitate positive pressure ventilation

Protects the respiratory tract from the aspiration of foreign the amount of air required to seal on ET tube cuff I to replace by the cuff pressure which usually maintained at less than 20 mm Hg. Low cuff pressure is necessary to prevent drainage to the tracheal mucosa arterial pressure in he tracheal wall are approximately 20 to 25 mm Hg while venous pressure is 1120 mm Hg therefore cuff pressure greater than mucosa and necrosis may develop cuff pressure should be every 8 hour.

Care of the cuff-suction and hyperventilate before and after procedure

Clean the area for secretion by suctioning gently deep into the oropharyx, advance the suction catheter to the end of ET tube, deflate the cuff while applying suction to suction catheter, so that any secretion lying above the cuff will be removed. Repeat pharyngeal suctioning.

Managing cuff leaks can be a major problem. It may be because by a rupture or tear in the cuff or pilot system or by the ET tube.

The pilot balloon not filing when air is injected

The client's ability to talk when the cuff inflated

Air heard leaking during positive pressure breathing that the client is at high risk of aspiration while the cuff is leaking during positive pressure breathing.

Sign and symptoms indicate the need for suctioning is noisy breathing restlessness; increase respiration mucus bubbling into the ET tube can identify by auscultation and increase in peak airway pressure during continuous mechanical ventilation.

Turn patient from side-to-side every two hours. Lateral turn of 120 degree is desirable, from right semiprone to left semiprone. Position and make patient sit in upright at regular intervals if possible. Upright posture increases lung compliance. Carry out passive range exercises of all extremities for patients unable to do so. Asses for need of suctioning at least every 2 hours. Patient with MI are unable to clear secretions on their own. Suctioning may help to clear secretion and stimulate the cough reflex.

Asses breath sounds every two hours. Listen with stethoscope to the chest for bottom to top on both sides. To confirm airway patency and placement of ET. Determine breath sounds weather normal or abnormal.

Humidifier must change every 24 hours

Assess airway pressure at frequent intervals12

Monitor for pulmonary infection. This helps for earlier detection of infection

Measure abdominal girth to asses’ degree of distension daily

Test all stool and gastric drainage for occult blood. Abdominal distention occurs frequently with respiratory failure and further hindrance respiration by elevation of the diaphragm.

Establish means of assign effectiveness and progress of treatment.

Maintain adequate ventilation

Deliver precise concentration of froze

Deliver adequate tidal volume is obtains on adequate minute ventilator and oxygenation

Lessen the work of breathing in those clients who cannot suction adequate ventilation on their own.

High frequency positive pressure ventilation delivers 60–100 breaths/min.

High frequency jet ventilation delivers 100–600 cycles/min.

High frequency oscillation delivers 900–300 cycles/min.

Inverse ratio ventilation proportion of inspiratory to expiratory time is greater than 1.1 can be initiated using pressure.

Check ventilation setting drams and connect at lest hourly and after any removal of ventilator from client

Suction as needed provide pre- and post-hyper inflating nebulizer every 2 hours

Secure the ET tube properly

Use block or oral airway

Monitor arterial blood gas values and arterial oximetry

Anxiety related to dependency while on mechanical ventilator—develops means of communication. Place a nurse call device within the clients reach. Be available and visible. Provide distraction, explain all procedure, provide privacy, and provide a calm environment. Medicate as necessary for anxiety.

High risk for complications—assess for acute rising or severe dyspoea, agitation, panic, absence breath sounds localized hyperresonence ring breathing effort tracheal deviation abnormal findings.

Asses for acute or gradual fall in blood pressure tachey cardia, dysrthias, weak peripherals pulses, and acute reduction pulmonary copilot's pressure.

Monitor for signs of adverse estuation vocalization low pressure alarm, bilateral decrease in upper lobe airway sounds, gastric distension clinical manifestation of, inadequate ventilation, keep on incubation tray readily available.

Risk for infection related to impaired defense, wash hands thoroughly, use sterile technique for suctioning. Monitor client for increase breathing effort localized changes in auscultation and change in paoz, provide oral care every two hour. Drain water from ventilator tubing and do not drain water back into humidify. Monitor sputum for changes in colour, consistency, amount and odour. Monitor laboratory values, blood cell count etc.

Continuous mechanical ventilation is used for many different reasons. Ventilation support may be needed for short term care like severe pneumonia or long term stroke, in some emergency cases, ventilator support is to stabilize a patient's condition. Positive benefit is the continuous ventilator allows the lungs to rest so that healing may take place.

Choose a diet low in fat, saturated fat and cholesterol, use salt and sodium on moderation, eat a variety of foods, maintain healthy weight, choose diet with plenty of vegetables, fruits and grain products, use sugar only in moderation, fats and sweets use sparingly.

How important is your health to you? What do you hope to accomplish in your life time? For example, rare children successfully, become rich and famous, have satisfying career? Have you accomplished what you set out to do in your life? Are you satisfied/dissatisfied/ have any of your beliefs and values challenged you? What do you wish you could change about yourself? Describe how you feel when you become ill? Have a balance perspective of life experience, persist despite adversity and discouragement, and believe in oneself and one capability. Realization that life has purpose, realization that each persons life path is unique, some of which must be walked alone.