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Myocardial Infarction with ST Elevation

The whole journey

By Michelle KingPublished 3 years ago 31 min read
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Nursing Assignment for - Myocardial Infarction with ST-segment Elevation

Myocardial Infarction with ST-segment elevation (STEMI) also known as a heart attack (Nair, 2009). Myocardial infarction according to the National Institute for Health and Clinical Excellence (NICE) (2013a) belongs to a group of heart conditions known as acute coronary syndromes. The purpose of this assignment is to explore and discuss a number of key issues that help to determine and underpin complex nursing care delivery for patients who have suffered from a STEMI and as a result of this have undergone a procedure known as percutaneous coronary intervention (PCI) (Cooper, 2015). Complex nursing care is a term used to describe care given to patients who have complex needs due to a health condition or as a result of comorbidities (Scottish Government, 2009). The key issues being discussed will include the pathophysiology of a STEMI, the nursing and medical management of this condition, holistic nursing care taking into consideration the physical, emotional, psychological, social and spiritual needs of the patient. The contemporary issue chosen is the interface between primary and secondary care for patients who have recently suffered a STEMI and who have recovered but are now living with the potential of having a chronic condition (Baldacchino, 2011). The identified key issues are linked closely together, it is through the study of pathophysiology that medical and nursing staff are able to identify, assess, diagnose, initiate treatment and provide care for patients who have suffered a STEMI (Webster and Thompson, 2012). The pathophysiology of the disease process can therefore determine what care and treatment a person will need while in hospital and at home. Once the patient is well enough to be discharged they will then begin the transition of being cared for in a hospital setting to being cared for by health care professionals in the community (Goddard et al., 2015). Finally the assignment will finish with a conclusion that will tie all discussed issues together.

The heart is a muscular organ that acts as a circulatory pump, its main function is to pump blood containing oxygen, nutrients and water through a large network of blood vessels to every organ, muscle, tissue and cell throughout the body (Tortora and Derrickson, 2013). The heart consists of three layers, the outer layer is the pericardium, the middle layer is the myocardium (also known as the heart muscle) and the inner most layer is called the endocardium (Watson, 2011). The heart pumps continuously and as a result of this it requires a constant blood supply so it can receive the oxygen and nutrients it needs to function effectively (Clancy et al., 2011). Blood is supplied to the heart via the coronary circulation (Nair, 2009). Clare (2011) and Gregory (2012) have identified this to consist of three main coronary arteries called the right coronary artery (RCA), the left anterior descending artery (LAD) and the left circumflex artery. Each artery branches off to provide blood to different parts of the heart. The RCA is responsible for supplying blood to the right ventricle, the base of the heart and the septum. The LAD supplies blood to the front and side of the left ventricle and the apex of the heart. The left circumflex artery supplies blood to the back and side of the left ventricle (Clare, 2011; Jowett and Thompson, 2007).

A myocardial infarction with ST-segment elevation occurs as a result of complete occlusion to one or more of the main arteries previously mentioned. Cooper (2015) and O’Donovan (2015) both identify that this occlusion happens as a result of plaque formation that has ruptured, thus causing the body to initiate a platelet response resulting in the formation of a thrombus that subsequently leads to cessation of blood flow to the myocardium. Green (2012) agrees with this and states that the main underlying cause of myocardial infarction is this formation of plaque, this underlying condition is known as atherosclerosis (Porth, 2011). Gould and Dyer (2011) identify atherosclerosis to be a process in which fatty deposits mainly low density lipoproteins (LDL) accumulate within the vessel wall over a long period of time. Porth (2011) and McCance (2008) believe this process begins with the endothelial cells that line the arteries becoming damaged due to risk factors such as increasing age, smoking, obesity, diabetes, hypertension and hyperlipidaemia. McCance (2008) states that once the LDL have entered into the vessel wall it triggers an immune response in which activated macrophages oxidise and engulf the LDL, once the LDL have been engulfed it results in the macrophages undergoing a process that causes them to turn into foam cells. Porth (2011) identifies that once the foam cells die their lipid content becomes released resulting in the formation of a lipid core that becomes covered in a thin fibrous cap consisting of collagen and elastin (McCance, 2008). If plaque continues to grow as a result of further LDL accumulation the elastic membrane of the vessel expands undergoing the process of compensatory enlargement, this enables the vessel to maintain an adequate blood flow through the lumen (Cooper, 2015). McCance et al (2014) recognises that once plaque accumulation reaches 40% of the arteries circumference it can no longer compensate by expanding outwards, therefore plaque can start to occupy the lumen of the artery causing it to become narrower over time. Porth (2011) and Cooper (2015) both state that some plaques may become vulnerable and rupture suddenly spilling its lipid content into the blood. McCance (2008) believes this to be caused by either prolonged hypertension or as a result of increased blood flow due to strenuous exercise. Once the plaque ruptures Porth (2011) states that this initiates a platelet response that results in the formation of a thrombus at the site of the rupture. As the thrombus grows the artery it occupies will gradually become narrower until eventually total occlusion of the vessel will occur (Porth, 2011; Gould and Dyer, 2011).

McCance et al (2014) and Porth (2011) both identify the heart muscle to be made up of specialised cardiac cells that enables the heart to contract and function effectively, these cells need oxygen in order to do this. As blood flow through the vessel becomes reduced it results in the cardiac cells receiving less oxygen which initiates pain signals being sent to the brain, this triggers the first symptom of a STEMI to manifest (Porth, 2011). According to Porth (2011) and Gould and Dyer (2011) this initial symptom of pain can sometimes be misinterpreted as having gastric upset rather than pain radiating from the heart, this can sometimes delay a patient seeking help. As oxygen depletion to the cells continue Porth (2011) and McCance et al (2014) both state that this pain can become worse often being described as feeling like a dull, crushing ache across the chest, pain can also begin to radiate down the arms and up into the jaw. As the thrombus grows, oxygen delivery to the cells continue to reduce and this causes the cardiac cells to begin to malfunction, this initiates further signals being sent to the brain that the heart is in trouble so a surge of adrenaline is released into the blood stream (McCance et al., 2014). McCance et al (2014) identifies that once this surge of adrenaline reaches the heart it stimulates the heart to work harder by beating faster. This however, puts further stress on the heart resulting in the area of cells that are oxygen depleted to slow down until eventually ceasing to work all together (Jowett and Thompson, 2007). McCance (2008) identifies that the heart will continue to work harder in an attempt to try and compensate for the area of cells that have stopped. Gould and Dyer (2011) state that once cells become completely starved of oxygen and stop working they begin to break down and die resulting in ischemia and eventual necrosis of the area affected by the thrombus. Collinson (2006) states that once damage to the cardiac muscle has occurred it results in a protein called cardiac troponin T (cTnT) and cardiac troponin I (cTnI) being released into the blood stream, troponins are proteins found in cardiac muscle cells and are released only if there is definite necrosis to the heart muscle (Gould and Dyer, 2011). Once the vessel becomes completely occluded the area of tissue it supplies is unable to receive blood containing the essential oxygen it needs, it is this oxygen depletion that triggers further symptoms to manifest (Porth, 2011). Porth (2011) identifies that the pumping action of the heart will eventually slow down resulting in a build-up of blood to accumulate and this may back up into the lungs, this results in the patient having dyspnoea. The heart will try and continue to work harder which will result in tachycardia, due to the pumping action of the heart beginning to slow down it will result in blood flow through the systemic circulation to also slow down causing the patient to feel dizzy, confused and disoriented (Porth, 2011). McCance (2008) and Johnson and Rawlings-Anderson (2007) identify other signs and symptoms to include fatigue, weakness of the arms and legs, pallor, clammy skin, nausea, vomiting, restlessness, anxiety, fear and a feeling of impending doom. Porth (2011) also identifies that hypotension and shock can also occur and if treatment is not sought quickly the person may go into cardiac arrest and die. Once death occurs to the cardiac cells the damage is irreversible, the damage to the heart depends highly upon the size and location of the infarct and the length of time the vessel has been occluded (Gould and Dyer, 2011). Porth (2011) identifies that it takes 20-40 minutes of severe ischemia to cause irreversible cardiac cell death, if this happens it can subsequently lead to additional problems for example the area that has become damaged may never regain function and this can lead to other cardiac health problems arising (Porth, 2011; Gould and Dyer 2011). Porth (2011) and McCance et al (2014) therefore, both emphasise that a STEMI is a medical emergency that requires urgent treatment within a hospital setting as soon as possible.

NICE (2010) and NHS Quality Improvement Scotland (2009) both state that in the event of someone having a STEMI it is again paramount that they receive medical attention as soon as possible. A majority of patients will experience the onset of symptoms in the community resulting in emergency services being called (British Heart Foundation, 2014). Paramedics first on the scene have specialised training and can identify symptoms, assess and even diagnose a STEMI through the use of a 12-lead electrocardiography (ECG) which enables them to begin treatment immediately (NHS Scotland and Scottish Ambulance Service, 2010). Linden (2013) and Johnson and Rawlings-Anderson (2007) both identify that on the way to hospital the patient will be cannulated and have morphine sulphate running slowly through an intravenous (IV) infusion, the patient will also have been given 300mg of aspirin orally, administration of sublingual glycerol trinitrate (GTN) spray, oxygen administration, continuous monitoring of blood pressure, respirations, temperature, oxygen saturations and pulse rate and if symptoms are within one hour of onset thrombolysis may also be administered if the paramedics are trained to do so and if the patient has been risk assessed (NICE, 2013a), thrombolysis is a term used to describe drugs given to patients that are aimed at dispersing blood clots so blood flow can be restored through the vessel that has become occluded (Johnson and Rawlings-Anderson, 2007; Edwards, 2008). McLean et al (2008) and Freeman and Hughes (2010) both agree that this pre-hospital care is essential because it allows the patient to receive treatment early and can reduce delays once admitted to hospital. On route to hospital paramedics will alert staff that they have a patient experiencing symptoms of a STEMI on their way, ECG results can also be transmitted using mobile phone technology so results can be reviewed before the patient arrives at hospital (McLean et al., 2008). This communication then enables the staff to prepare and have everything they need ready as soon as the patient arrives. This collaborate care provides patients with continuity which can result in better patient outcomes, reduce the risk of complications arising and reduce the risk of mortality (McLean et al., 2008). Paramedics can also take a patient straight to a catheterisation laboratory for a procedure called percutaneous coronary intervention (PCI), PCI is another form of treatment for patients suffering a STEMI and will be covered later in the assignment (NHS Scotland and Scottish Ambulance Service, 2010; Freeman and Hughes, 2010).

Webster et al (2007) identify that nurses are one of the first health care professionals to come into contact with a patient on arrival to hospital. Edwards (2008) and Webster et al (2007) both agree that the nurse has a pivotal role here because they are responsible for carrying out essential tasks and observations that enables rapid assessment which in turn helps towards the final diagnosis of the patient. The nurse will begin this process by attaching the patient to a machine that enables continuous monitoring of their blood pressure, oxygen saturations and pulse rate, in addition to this the nurse will also take the patients temperature every 15 minutes, take respiration rates and administer oxygen therapy if needed via a nasal cannula or mask depending upon oxygen saturation levels of the patient (Edwards, 2008). The nurse will also obtain a blood sample that will be sent to the laboratory for urgent examination, the purpose of this sample according to Johnson and Rawlings-Anderson (2007) is to receive results on urea and electrolytes, full blood count, cholesterol levels, liver function test, glucose levels, clotting time of the blood and most importantly cardiac troponin levels, troponin levels are important because they give indication of myocardial damage and in conjunction with ECG results can confirm the final diagnosis of a STEMI (Collinson, 2006; NICE, 2013a) The nurse will attach the patient to an ECG machine and if trained in the interpretation of ECG will carry out continuous monitoring of the results looking particularly to see if there is ST-segment elevation present (Gregory, 2012). The nurse will also administer any IV drugs including fluids that have been prescribed by the doctor, carry out ongoing assessments of pain using a pain assessment tool and monitor the patient for signs of deterioration for example changes to blood pressure, heart rate, respirations, oxygen saturations and levels of consciousness (Webster and Thompson, 2012; Edwards, 2008).

Davidson and Webster (2010) state that nurses not only assess and tend to a patients physical needs they will assess all aspects of a person including emotional and psychological needs. Webster et al (2007) emphasise the importance of this at this stage because patients will be frightened and very anxious about the uncertainty of being faced with a life threatening illness such as a STEMI. Quinn (2009) therefore states that it is very important for the nurse to communicate and provide constant reassurance to the patient and their family throughout the entire process of their care. Danchin et al (2011) believe that nurses are in a good position to reduce stress and alleviate worry in patients if care given takes on a person- centred approach. Nurses can do this by explaining and gaining consent before each procedure is carried out, ensuring that the patient is well informed on what is happening and why, by empowering them to make informed decisions regarding each stage of their care, respecting their dignity and privacy at all times and by providing psychological support and reassurance throughout the entire process (NICE, 2010; Nursing and Midwifery Council (NMC), 2015). Quinn (2009) emphasise that reassurance becomes increasingly important during the initial stages of a STEMI because in addition to being anxious and frightened patients also face the possibility of undergoing an emergency surgical procedure.

Once the patient is admitted and the nurse has carried out all the essential duties previously mentioned Linden (2013) and Gregory (2012) both emphasise that the main goal is to re-establish blood flow through the occluded artery as soon as possible. Johnson and Rawlings-Anderson (2007) emphasise the importance of this and state that restoring blood flow quickly can limit the size of the infarction, prevent complications such as left ventricular failure or arrhythmias occurring and most importantly it can save their life (Johnson and Rawlings-Anderson, 2007). According to research and clinical guidelines the treatment of choice for a patient experiencing an acute STEMI is undergoing a procedure known as PCI (Linden, 2015; NICE, 2013a; Scottish Intercollegiate Guidelines Network (SIGN), 2013). According to Green (2012) and Clancy et al (2011) PCI is a procedure in which an incision is made to an artery either in the arm or the leg, a catheter tube is then inserted and fed through until it reaches the artery that has become occluded. Once situated in the right spot a guidewire with a balloon tip is inserted. The balloon is then inflated at the site of occlusion causing the artery to widen, a small mesh tube called a stent is then used which keeps the artery open thus resulting in restored blood flow through the artery (Young, 2014; Neal, 2007; Mendes, 2015). SIGN guidelines (2013) state that PCI is the chosen treatment for an acute STEMI over thrombolysis because it has shown to be more effective by reducing mortality rates, reducing the risk of complications arising and has shown to achieve better patient outcomes, PCI also has a quick recovery time thus reducing the length of stay in hospital. This however, is providing that it is done in a timely manner recommendations state no longer than 120 minutes from the time the patient has called for help (NICE, 2013a; NHS Quality Improvement Scotland, 2009; Department of Health, 2008).

When a patient undergoes any procedure it is the nurse’s responsibility to ensure that the patient is ready and effectively prepared (Gibson and Magowan, 2012). According to Gibson and Magowan (2012) and Farrell (2007) a nurse can do this by ensuring the patient is wearing a hospital theatre gown, a pre-operative check list has been carried out and recent observations of vital signs have been taken including blood pressure, pulse rate, oxygen saturations, respiration rate and temperature. The nurse will also ensure that the patient understands the procedure, the reasons why it needs done and that they give full verbal and written consent prior to the procedure being carried out, the nurse will also provide the patient with ongoing psychological support before, during and after their procedure (Young, 2014). The procedure itself is carried out in a specialised catheterisation laboratory by a specialised team of health care professionals including specialist nurses (Neal, 2007; Farrell, 2007). The nurse in this case is responsible for setting up the equipment, supporting the consultant cardiologist carrying out the procedure, carrying out essential monitoring of the patients vital signs and ensuring that the patient is kept informed and provided with support and reassurance throughout the entire process (Farrell, 2007; Mendes, 2015).

Once the patient has had their procedure they will then be transferred to an appropriate ward to start their recuperation and undergo close monitoring (Cooper, 2015). Siefers et al (2015) and Cooper (2015) both state that patients should be cared for in a specialist cardiac ward by highly skilled nurses who will provide continuous cardiac monitoring of blood pressure, heart rate, oxygen saturations and respiration rate. Patients are also immediately started on a drug regime that is aimed at reducing symptoms, improving overall health status and as a preventative measure in reducing the risk of further cardiac events occurring in the future, due to it being a preventative measure patients will remain on this medication regime for the rest of their life (Linden, 2014; NHS Quality Improvement Scotland, 2009; NICE, 2013b). NICE (2013b) and NHS Quality Improvement Scotland (2009) state this drug regime to include angiotensin-converting enzyme inhibitor, antiplatelet medication such as aspirin and clopidogrel, beta-blocker, GTN spray and statin therapy. In hospital it is the nurses responsibility to administer this medication to the patient and document and record this on their prescription sheet and within their nursing notes on a daily basis (Kozier et al., 2012) Siefers et al (2015) and Quinn (2009) also identify that the patient will have continuous ECG monitoring, this is so the nurse can see if the ECG has returned to normal or whether ST-segment elevation is still present which would give indications that the procedure has been unsuccessful. Ludman (2015) states that complications can arise post-procedure but are rare with under 1% of patients being affected however, when complications arise they can be serious so nurses must have the skills and the ability to identify and respond quickly if this was to occur therefore making close monitoring extremely important in the early stages of recovery (Cooper, 2015). According to Cooper (2015), Farrell (2007) and Siefers et al (2015) these complications can include cardiogenic shock, no-reflow through the vessel, atrio-ventricular heart block, arrhythmias, peri-procedural complications such as side-branch occlusion, dissection, emboli, and structural damage such as mitral valve regurgitation. Young (2014) and Cooper (2015) both state that observation of the entry wound should also be monitored for signs of bleeding and the development of a haematoma, if bleeding occurs nurses are to apply firm pressure for 10 minutes and apply a small compression dressing (Cooper, 2015). Haematomas according to Farrell (2007) is an accumulation of clotted blood that has gathered outside the blood vessel as a result of the trauma caused by the incision and catheter insertion during PCI. Higgins et al (2008) state that haematomas usually resolve with no intervention but still require close monitoring. The nurse will do this by checking it daily and documenting its appearance and size on a wound chart, if it appears to be getting bigger or the patient complains of pain the nurse will notify the doctor and the patient will be reviewed (Farrell, 2007).

If patients recover well showing no signs of complications and if they have undergone an assessment on left ventricular function with satisfactory results they can be discharged home 3-4 days after their procedure (NHS Quality Improvement Scotland, 2009; Neal, 2007; Cooper, 2015). Advice given to patients on discharge is very important. Young (2014) and Linden (2013) both agree that this is an anxious time for patients so it is important for the nurse to provide extensive evidenced based advice and give psychological support. Swanton and Banerjee (2008) state that information is important because it can help patients gain a better understanding of their condition, provides information on their new medication regime including why they need it and how to take it effectively and safely, it also helps them to develop the knowledge and skills needed for effective self-management which in turn empowers them to have control over their own life (Garvey and Noonan, 2011). Garvey and Noonan (2011) and Cooper (2015) both identify that information plays a major part in a patient’s recovery because it provides reassurance and can help to reduce feelings of anxiety, this in turn can help some patients come to terms with the impact of their diagnosis. Sitting down with a patient can also provide opportunities for patients to ask questions and explore any worries they may have regarding their diagnosis and treatment (Swanton and Banerjee, 2008). Clinical guidelines state information provided to patients should be delivered verbally and in writing and should include advice on diet, exercise, smoking cessation, alcohol consumption, weight management, the importance of medication compliance, advice on when to return to work, sexual activity, driving and psychological issues such as depression and anxiety (NICE, 2015; SIGN, 2013). Psychological assessments are really important for patients who have experienced a STEMI because they are at higher risk of developing depression due to the impact the diagnosis has on their life (Baldacchino, 2011). Martin (2010) and Barker et al (2009) state that patients may live in fear of it happening again and struggle to adapt their life around their diagnosis for example making changes to their life-style such as stopping smoking or changing their diet and this can contribute to the development of depression. Guidelines state that patients should have an assessment on their psychological wellbeing while in hospital and at regular intervals after discharge (NICE, 2013b). It is also emphasised that patients should be offered and encouraged to undertake cardiac rehabilitation before and as soon as possible after discharge from hospital (NHS Quality Improvement Scotland, 2009; NICE, 2013b). Barker et al (2009) state cardiac rehabilitation to consist of patient education and structured exercise routines that is tailored to meet the needs of individual patients. Barker et al (2009) and Young (2014) both emphasise the importance of cardiac rehabilitation because it has shown to reduce the progression of cardiovascular disease and reduce the risk of morbidity and mortality (Young, 2014). In addition to this it has also shown to improve psychological wellbeing and reduce the risk of depression which can be a debilitating factor for some patients after discharge (Martin, 2010; Barker et al., 2009).

Discharge planning is an integral part of nursing care that is both complex and challenging especially if patients have complex needs that require further input from other health care professionals in the community (Swanton and Banerjee, 2008; British Medical Association, 2014). Patients who have suffered a STEMI fall into this category because they will require ongoing care from their General Practitioner (GP) and members of the cardiac rehabilitation team once they have been discharged from hospital (NICE, 2013b). The Royal College of Nursing (RCN) (2014) and Currie and Watterson (2008) both agree that the nurse plays an important role here because they are responsibility for coordinating care and ensuring that the transition from primary to secondary care runs smoothly for the patient. Goddard et al (2015) state that the nurse will begin this process by putting in referrals for cardiac rehabilitation, ensuring that the patient has a prescription ordered and medication to go home with, ensuring that a letter has been generated and sent to their GP notifying them of the diagnosis, treatment and medication regime, ensuring that a community nurse has been notified so the patient can have a follow up appointment arranged, ensuring that the patient has people who can support them after discharge and organise transport to take them home (SIGN, 2012; NICE, 2015; Katikireddi and Cloud, 2008). Wade (2007) agrees that the nurse plays a central role however, for this transition to run smoothly it requires a person-centred multidisciplinary approach and impeccable communication skills between the nurse, patient, their family and all members of the multidisciplinary team involved in the patients care. Currie and Watterson (2008) emphasise the importance of discharge planning and effective communication because if it is not done effectively it can lead to problems such as poor adherence to treatment, patients may lack knowledge on how to identify complications and lack skills on self-management which can result in unnecessary distress for the patient. The Royal College of Nursing (2014) therefore agree that communication and collaborative working in partnership with the patient and their family is key if the patient is to experience continuity of healthcare services (Scottish Government, 2010). This is extremely important for patients who have been diagnosed with an acute coronary syndrome because they will require life-long care from health care professionals (Quinn, 2009). Effective discharge planning and effective communication are therefore important components if the smooth transition from primary to secondary care is to be facilitated and if done correctly can greatly improve patient experience and quality of life (Scottish Government, 2010).

In conclusion, it is evident that a STEMI is a complex and life-threatening illness that needs urgent treatment as soon as possible. There is definite consensus within national and clinical guidelines on the acute management of a STEMI. This is positive as it provides a clear structured care pathway that is aimed at quick treatment and recovery. This however, is only achievable if health care professionals are familiar with guidelines and protocol on how to treat and care for patients who have suffered a STEMI. It is evident that a STEMI not only affects patients physically but can also impact upon other aspects of their life especially their emotional and psychological wellbeing. This therefore makes holistic assessment very important as it addresses all needs of the patient. It is clear to see that nurses are an important part of a patient’s journey through healthcare services because they not only provide care and give support they also advise, provide information and coordinate care for the patient after discharge. The nurse is important but for a patient to experience continuity it requires all members of the multidisciplinary team to work closely together in partnership with the patient and this requires impeccable communication skills. Providing continuity for patients has greatly shown to improve experience and improve quality of life, this is important for cardiac patients because they will require ongoing care for the duration of their life. It is therefore emphasised that holistic, person-centred and compassionate care along with good communication skills are important factors and if done correctly really benefits the patients physical and psychological wellbeing.

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