Patients that require critical care are those patients with devastating health conditions. They present in the emergency unit in a crucial state due to serious medical illness. Critical patients are catered for at the emergency unit and referred to intensive care or high-dependency units. There, essential nurses of care actively monitor them closely and offer them critical care with an interprofessional care approach. Critical care nursing focuses on providing care for clinically unstable patients, chronically ill, or post-surgical patients with those patients at high risk of life-threatening injuries or diseases (Morton & Thurman, 2023). These patients require much attention and monitoring every minute; thus, critical care nurses must be equipped with skills that can help them identify any subtle changes in vital signs, clinical presentation, or condition warranting emergency care or further consultations. For this reason, this paper will focus on exploring critical care for a heart attack (acute myocardial infarction) patient in intensive care. This paper will offer an understanding of heart attack, the necessity for critical care, interventions, outcomes, and discharge planning, including patient education and follow-up care.
Introduction
Heart attack is a widespread illness affecting a multitude of individuals, predominantly geriatric populations with prevalent ages above 55 years. It accounts for a high rate of mortality globally. Among many complications of non-communicable diseases, heart attack affects a lot of geriatric patients. According to Morton & Thurman, 2023, the increasing mortality and morbidity rate is highly associated with a lack of critical care or delayed emergency care. However, Heart attack/MI can be generally divided into ST-segment elevation MI (STEMI) and non-ST-segment elevation MI (NSTEMI). NSTEMI is often similar to unstable angina with non-elevated cardiac markers. A heart attack occurs due to sudden occlusion of coronary blood vessels by a thrombus or embolic, causing a lack of blood supply distal to the point of occlusion. This causes irreversible damage to the cardiac muscles due to a lack of enough oxygen and nutrient supply. Additionally, an MI causes impairment of systolic and diastolic cardiac functioning, predisposing the patient to cardiac arrhythmia. It is a detrimental disease that requires immediate critical care; delayed care can lead to detrimental complications or even death. Restoring cardiac function by reperfusion by early diagnosis and treatment less than 6 hours from onset can help improve patient prognosis. Yasuhara & Alston, 2022, report that Heart attack is diagnosed when two criteria are met: Presence of ischemia symptoms, new changes in ST-segment, pathological Q waves present on ECG, regional wall motion abnormality noted on imaging, and presence of intracoronary emboli or thrombi noted on autopsy or angiography. Affected patients are often brought to the emergency unit due to sudden symptoms of severe chest pain, which is stabbing in nature, graded at eight on a scale of one to 10, with the pain radiating to the neck, jaw, and upper arm. Other associated symptoms include diaphoresis, cough, wheezing, palpitations, lightheadedness, and anxiety with a choking sensation (Yasuhara & Alston, 2022, p. 1031). Physical examination findings reveal displaced apex beat palpable s4, soft s1, new mitral regurgitation murmur, distended neck veins, tachypnea, fever, tachycardia, hypertension, and atrial fibrillation. Lab tests reveal elevated cardiac troponins, hyperlipidemia, elevated platelet levels, deranged renal function, and metabolic panel. Nursing diagnoses for heart attack patients include acute pain, intolerance to activities, fluid overload, risk for tissue hypoperfusion, risk for poor cardiac output, and fear/anxiety.
Interventions
Critical urgent care aims to restore normal cardiac perfusion and normal oxygen and nutrient levels for cardiac muscles to relieve pain, improve cardiac muscle function, and prevent mortality. The nurse must thus immediately secure intravenous access using two wide-bore cannulas followed by urgent oxygen administration through nasal cannulas at a rate of 2L/min until oxygen saturation levels of above 94% on room air are achieved (Urden et al., 2019). Medication interventions include Immediate chewable aspirin 160mg to 325mg start. Opioids like morphine can be used for pain relief with sublingual nitroglycerine if blood pressure is normotensive. For patients with STEMI, reperfusion must be done by either using emergent percutaneous coronary intervention (PCI). However, before PCI, the patient must receive dual antiplatelet therapy using intravenous heparin infusion with an adenosine diphosphate inhibitor receptor (P2Y2 inhibitor) like ticagrelor (Urden et al., 2019). In cases where PCI is not available within one hour of diagnosis of STEMI, reperfusion must be done using an intravenous thrombolytic agent. Patients with NSTEMI who are stable or asymptomatic should be managed using antiplatelet agents as they may not benefit from percutaneous coronary intervention. However, if PCI is considered, it can be done within 48 hours of diagnosis and may reduce in-hospital stay and in-hospital-related mortality. However, in patients with ischemia with hemodynamic or refractory ischemia, PCI must be done immediately. Medications given before discharge include Beta blockers, ACE inhibitors, high-dose statin, and aspirin. Fibrinolytic therapy should be done within 120 minutes, and PCI should be done within 12 hours (Yasuhara & Alston, 2022, p. 1032). All heart attack patients must receive parenteral anticoagulation therapy with antiplatelet therapy. Nursing management includes daily ECG monitoring, always ensuring the patient has two patent wide bore IV cannulas in situ, daily monitoring of cardiac enzymes, and initiating acute MI medications that are administering morphine for pain, aspirin, and 0.4 sublingual nitroglycerine and oxygen therapy with strict monitoring of oxygen saturation using pulse oximetry which must be more than 94% at room air (Writing Committee Members et al., 2022, p. 1665). The nurse must also involve the cardiologist and ensure the cardiologist has reviewed the patient. Monitor daily weight, vital signs, and urine output. Administer ordered heparin for STEMI. Evaluate the patient in a timely if they have cardiac catheterization by checking the groin for hematomas and assessing peripheral pulses on both arms and legs. The nurse must also involve a dietician for patient review. However, there are signs that the nurse must look for that indicate poor prognosis and must seek immediate assistance from a cardiologist or physician (Hardin & Kaplow, 2019). These signs include hypotension, continuing chest pain, nausea, and vomiting, diminished peripheral pulses, predominantly distal leg pulses, sudden deterioration in mental status, and continuing oxygen desaturation. Other signs are arrhythmias, tachycardia, or sudden loud murmur onset, which might indicate ventricular rupture or new onset mitral regurgitation.
Outcome
Expected outcomes during critical care for a heart attack patient include improved breathing, relief from chest pain, and improved cardiac and muscle tissue perfusion with the ability to regain normal function. These outcomes are achieved through emergency care and interprofessional care approaches. This care team involves the cardiologist, cardiac rehabilitation specialist, dietician, physical therapist, critical care nurse or cardiology nurse, intensivist, and pharmacist. Each care individual must execute their tasks fast and effectively and work together with others for improved patient prognosis (Hardin & Kaplow, 2019). Many patients succumb even before reaching the hospital. Thus, patients must be educated on symptoms and early hospital arrival. They must be educated that when symptoms and medications fail on the first attempt, they must call 911 immediately. Statistics indicate that about half of heart attack patients die before reaching the hospital, and about 50% are dead on arrival (Hardin & Kaplow, 2019). However, about 5% to 10% will succumb to heart attack after 12 months of MI. The readmission rate is 50% within the first 12 months of initial MI. Prognosis initially depends on age, ejection fraction, and other associated comorbidities. Patients who do not undergo revascularization will have a poor prognosis compared to those who undergo revascularization. Early diagnosis and treatment with immediate reperfusion and preserved left ventricular functionality improve the prognosis of patients.
Discharge Planning
Ensure total and complete adherence to medications. Follow the prescription instructions as directed by the pharmacist. In case of any pain recurrence or symptoms worsening after discharge, visit the ER immediately and do not delay at home (Yasuhara & Alston, 2022, p. 1032). Eat Healthy with a low sodium and sugar diet as directed by the dietician. Reduce intake of calories and junk foods. Improve intake of vegetables and self-prepared meals. Maintain a healthy body weight by enrolling in controlled physical exercise to reach no less than 8 hours of physical activity weekly (Yasuhara & Alston, 2022, p. 1031). Enroll also in cardiac rehabilitation program. Control blood sugars, blood pressure, and cholesterol levels. Do not smoke or take alcohol at all. If the patient is a smoker, they must enroll in a smoking cessation program immediately. The patient must comply with follow-up care created and directed by the cardiologist.
Summary
Critical care patients require much attention. Offering skilled critical care helps improve patient outcomes. However, teamwork must also be ensured during critical care, as many professionals must be involved for optimum care (Hardin & Kaplow, 2019). Heart attack/MI is a serious critical condition that requires emergency care. Early diagnosis and treatment improve the patient’s prognosis by improving cardiac muscle oxygen and nutrient perfusion, improving ejection fraction, and reducing symptoms of chest pain and diaphoresis (Hardin & Kaplow, 2019). Critical care nurses must be vigilant about MI signs and symptoms. Nurses, in general, must take an active part in educating the patients and communities about the symptoms of MI and the benefits of seeking early emergency care. Community health education and promotion will help improve outcomes by reducing risk factors.
References
Hardin, S. R., & Kaplow, R. (2019). Cardiac surgery essentials for critical care nursing. Jones & Bartlett Learning. https://books.google.com/books?hl=en&lr=&id=1ByMDwAAQBAJ&oi=fnd&pg=PP1&dq=critical+nursing+care+for+heart+attack&ots=AqPLNG29na&sig=-OPxi2wJYnlJsPImJeefGNWyC5Y
Morton, P. G., & Thurman, P. (2023). Critical care nursing: a holistic approach. Lippincott Williams & Wilkins. https://books.google.com/books?hl=en&lr=&id=EXSnEAAAQBAJ&oi=fnd&pg=PT62&dq=critical+nursing+care+for+heart+attack&ots=X3rGot28m_&sig=irjOA4uF05LXiD9Yz89hkc5PDzM
Urden, L. D., Stacy, K. M., & Lough, M. E. (2019). Priorities in critical care nursing-E-Book. Elsevier Health Sciences. https://books.google.com/books?hl=en&lr=&id=jySDDwAAQBAJ&oi=fnd&pg=PP1&dq=critical+nursing+care+for+heart+attack&ots=-ZGu-lM-FD&sig=mr6emgc2XbC_Gu8QVWYFhQala9o
Writing Committee Members, Anderson, H. V., Masri, S. C., Abdallah, M. S., Chang, A. M., Cohen, M. G., … & Williams, M. S. (2022). 2022 ACC/AHA key data elements and definitions for chest pain and acute myocardial infarction: a report of the American Heart Association/American College of Cardiology Joint Committee on clinical data standards. Journal of the American College of Cardiology, 80(17), 1660-1700. https://www.jacc.org/doi/abs/10.1016/j.jacc.2022.05.012
Yasuhara, S., & Alston, T. A. (2022). After a Heart Attack, Who Should Care?. Critical Care Medicine, 50(6), 1030-1032. https://journals.lww.com/ccmjournal/Fulltext/2022/06000/After_a_Heart_Attack,_Who_Should_Care__.18.aspx?context=LatestArticles
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