1

The National Ribat University

College of Post Graduate studies & Scientific Research

Nurses’ Knowledge and Practice Regarding Nursing Care

for Myocardial Infarction Patients in the first 24 hours in

Governmental Hospitals in Khartoum state,

1st Jan. 2014 – 1st Dec. 2015.

Thesis Submitted as a requirement for the degree of Master in

Medical Surgical Nursing, 2015

By: Thuraya Farah Maraghni Hamato

Supervisor: Dr. Hayat Fadlallah Mukhtar

2015

2

قال تعالي

)قالوا سبحانك ال علم لنا إال ما علمتنا إنك أنت العليم

(الحكيم العظيم " "صدق هللا

23 - يتاآل البقرة

I

Dedication To my dear Mother

And my great Father for their endless care,

love and for what they taught me in life

To my brothers and sisters

To my friends and colleagues

II

My sincere appreciation, thanks and respect provided

to Dr. Hayat Faldallah for her valuable and inspiring

guidance and supervision.

Also, thanks provided to staff member of cardiac care

units and emergency departments in study areas for

facilitating data collection and being kind to

participate.

Also, gratitude provided to Talia Center for

Researches who helped in computerizing the study.

Also, thanks to all those who kindly supported

encouraged or facilitated me during my study process.

3

CONTENTS

Dedication …………….…………..…...……….………….………… I

Acknowledgement…………….…….………...……….………….…. II

List of contents…………….………………….…..…….…….…..…. III

List of tables…………………………………....…….…..….….…... IV

List of figures…………..………………….…….………..….…..…. V

List of abbreviations……………………….…..….……….............. VI

English Abstract ……..……………………………..……..………... VIII

Arabic Abstract ………………..………………….…….................... IX

CHAPTER ONE

Introduction ……………………….…………………..…………… 1

Problem statement…………………………..……….…….……….. 3

Justification .………………………………..……….………….…. 4

Objectives….………………………………..……….…….……….. 5

CHAPTER TWO

Literature Review………………………………….……..………... 6

CHAPTER THREE

Methodology…………………………………………………….…. 34

CHAPTER FOUR

Result……………………………………….……..………..……… 38

CHAPTER FIVE

Discussion………………………………….….….……………....…. 53

Conclusions……………..…………………………..….......….…… 59

Recommendations………..………………….……………..……… 60

References…………………………….…………….……...….…… 61

Appendices ……………………..……………………………………....... 68

Questionnaire:……………………..……………………………………... 68

Check List:……………………..…………………………………........... 72

Hospitals consents ……..………………………………………………... 73

4

List of Figure

Figure Page

Figure (1): Age distribution of nurses working in the CCU & ED in the

major teaching hospitals in Khartoum State

41

Figure (2): Gender distribution of nurses working in the CCU & ED in

the major teaching hospitals in Khartoum State

41

Figure (3): Experience of nurses working in the CCU & ED in the major

teaching hospitals in Khartoum State

42

Figure (4): Working Area of nurses in the CCU & ED in the major

teaching hospitals in Khartoum State

42

Figure (5): Knowledge about symptoms of myocardial infarction among

nurses working in the CCU & ED in the major teaching hospitals in

Khartoum State

43

Figure (6): Nurses’ knowledge towards risk factors of myocardial

infarction patients among nurses working in the CCU & ED in the major

teaching hospitals in Khartoum State

44

Figure (7): Nurses’ knowledge towards complications of MI patients

among nurses working in the CCU & ED in the major teaching hospitals

in Khartoum State

45

5

List of Tables

Table Page

Table (1): Knowledge towards Management of MI patients among nurses

working in the CCU & ED in the major teaching hospitals in Khartoum State

46

Table (2): Nurses’ knowledge towards medications of MI among nurses

working in the CCU & ED in the major teaching hospitals in Khartoum State

47

Table (3): Nurses’ knowledge towards diagnostic measures to confirm MI,

among nurses working in the CCU & ED in the major teaching hospitals in

Khartoum State

48

Table (4): Knowledge towards counseling MI patients, among nurses

working in the CCU & ED in the major teaching hospitals in Khartoum State

49

Table (5): Evaluating of practice about care towards MI patients, among

nurses working in the CCU & ED in the major teaching hospitals in

Khartoum State

50

Table (6): Correlation of years of experience and working area with different

knowledge criteria

51

Table (7): Correlation of years of experience and working area with different

practice criteria

52

6

Abbreviation

ACC American College of Cardiology

ACE Angiotensin-converting enzyme

ACS acute coronary syndrome

AHA American Heart Association

AMI Acute myocardial infarction

ARB Angiotensin receptor blocker

AV Atrioventricular

CABG Coronary Artery Bypass Graft

CCU Cardiac care unit

CHD Chronic heart disease

CK Creatine kinase

CTN1 Cardiac-specific troponin-1

CVD Cardiovascular disease

DM Diabetes mellitus

ECG Electrocardiogram

ED Emergency Department

EPHESUS Epleronone Post-Acute Myocardial Infarction Heart Failure Efficacy and

Survival Study

ESR Erythrocyte sedimentation rate

FMoH Federal Ministry of Health

HDL-C High Density Lipoprotein cholesterol

HDU High dependent unit

ICDs implantable cardioverter-defibrillators

IHD Ischaemic heart diseases

IV Intravenous

LDL-C Low Density Lipoprotein cholesterol

LMWH Low-molecular-weight heparin

LVF Left ventricular failure

MI Myocardial Infarction

MONA Morphine, Oxygen, Nitrates, and Aspirin

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NSTMI Non-ST-segment elevation myocardial infraction

NYH New York Heart Association

PCI Percutaneous coronary intervention

PTSD Posttraumatic stress disorder

STEMI ST-segment elevation myocardial infraction

TH Teaching Hospital

UA Unstable angina

WHO World Health Organization

8

Abstract

Background: Myocardial infarction is a critical health status which requires

standardized care policies, as well as it needs qualified and skilled health

provider to obtain good outcome of management.

Objectives: To assess the knowledge and practice of nurses regarding first 24

hours care of patient with myocardial infarction.

Methods: This is a descriptive hospital-based study conducted in 5 hospitals in

Khartoum State (Khartoum TH, Alshab TH, Khartoum, Baharry, Alribat

hospitals, Ahmed Gasium) in period from 2014-2015 at cardiac care unit and

emergency department and it included 200 nurses. The assessment was

performed by using a questionnaire for knowledge and check list for practice

assessment.

Results: Out of 200 participants, females were 71%, most nurses had

experience of 5-10 years and they were represented by 60.5%. Mean of total

knowledge was found very good, when compared to mean of practice which

was moderate. They showed high knowledge about risk factors of MI and less

knowledge about medications. The practice was very good in regard to

connecting monitor (86%) and checking vital signs (85.5%), but poor in the

aspect of oxygen administration (43%) and Inserting urinary catheters (24.5%).

Experience found significantly associated with oxygen administration (0.05),

giving pain killers and thrombolysis (0.041).

Conclusion: The study showed good knowledge, but moderate practice

suggesting increasing the practice to be compatible with nurses’ knowledge.

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ةـص الدراســمستخل

القمبية يعتبر حالة مرضية حرجة تتطمب عناية طبية فائقة كما تحتاج لمقدم إن احتشاء العضمة خلفية: خدمة صحية مؤهل لمحصول عمى نتائج إيجابية والوقاية من المضاعفات.

تقييم معرفة وممارسة طاقم التمريض فيما يخص الرعاية التمريضية المقدمة إلىدراسة هدف الت األهداف: ساعة من دخول قسم الحوادث. 42خالل أول لمرضى احتشاء العضمة القمبية

خمسالفائقة بـ القمبيةرئ والرعاية : هذه دراسة وصفية سريرية تم إجراءها بأقسام الحوادث والطواالمنهجيةمستشفيات حكومية بوالية الخرطوم )مستشفى الخرطوم التعميمي، مستشفى الشعب التعميمي، مستشفى

ممرض 422حيث شممت الدراسة مستشفى أحمد قاسم لمقمب( تعميمي،مستشفي بحري الالرباط الجامعي،م. 4203-4202خالل الفترة ما بين كانوا متواجدون أثناء الدراسة حيث ة العينة المتوفرةوممرضة بطريق

. مالحظة تم استخدام استبيان معد لقياس المعرفة كما تم تقييم التطبيق العممي باستخدام استمارة-3بين راوح تت%، أكثر سنوات الخبرة كانت 50اإلناث نسبة مشارك في الدراسة 422من بين :النتائج

فيما كان األداء العممي متوسط ،%56.4بنسبة %. متوسط المعرفة العامة42.3ت نسبة بمغسنة 02شاء %(. أوضحت الدراسة أن درجة المعرفة كانت عالية فيما يخص العوامل المسببة الحت40.12)بنسبة

%(. األداء كان عاليا في كل من توصيل أجهزة 46األدوية )وكانت متدنية فيما يخص عضمة القمب ي كل من %( فيما كانت ضعيفة ف63.3%( وقياس العالمات الحيوية )64مراقبة العالمات الحيوية )

حصائية مع ذو أهمية إ %(. أظهرت الخبرة 42.3لية )%( وتركيب القسطرة البو 21) األوكسجينإعطاء (، إعطاء مسكنات األلم واألدوية المضادة لمتخثر 2.23كل من إعطاء األوكسجين ) القيمة االحتمالية

(.2.220الدموي )القيمة االحتمالية بتكثيف التدريب حتى يكون الدراسة الدراسة معرفة جيدة وأداء عممي متوسط، وتوصي : أظهرتالخالصة

رجة المعرفة.مستوى األداء العممي مواكبا لد

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1.1 Introduction:

CVD is present in more than 64 million Americans, and it has been the number one killer of

men and women in United States every years.

CVD kills nearly 2600 Americans each day and account for more deaths than the next five

leading causes of death .following the initial myocardial infarction (MI), 25%of men and

38% women will die within one year.[1]

CVD include hypertension, heart failure, ischemic heart diseases, acute coronary syndrome,

arrhythmias, diastolic heart failure, cardiomyopathieses, and venous thromboemblisim

12

.ischemic heart disease, which is the concern of this study (also known as CAD) include

unstable angina, non-ST segment elevation MI (NSTMI), and ST-segment elevation MI

(STMI), is now known to be due to atherosclerosis of the pericardial vessels. An acute

coronary syndrome (ACSs) is a term that includes all clinical syndromes compatible with

acute myocardial ischemia resulting from an imbalance between myocardial oxygen demand

and supply. In contrast to stable angina, and ACS result primarily from diminished

myocardial blood flow, secondary to an occlusive or partially occlusive coronary artery

thrombus[2]

.

CVD remains a major healthcare problem and one of the most consumers of the public health

resources. Ischaemic heart diseases (IHD) remain the commonest cause of death all over the

world. As in statistical reports of the World Health Organization (WHO); 2011, the rate of

death per 100,000 due to coronary artery diseases in Yemen was 238.5, Sudan; 212.0,

Bangladesh; 203.7, Libya; 199.3 and Jordan; 162.5[3]

CVD is a global public health problem contributing to 30% of global mortality and 10% of

the global disease burden.[4]

In 2005, from a total of 58 million deaths worldwide, 17 million

were due to CVD and, among them, 7.6 million were due to coronary heart disease.[5,6]

MI was reported by FMOH in 2013 to be 1883 cases, representing incidence of 100 per 1000

of total reported diseases, 38 per 1000 of total Khartoum State population. Deaths of MI

cases in Khartoum State were 9.4% in 2013 and it was 5.9% in 2012. Number of MI in 2012

was 639 cases in Khartoum State 0.067% of total reported disease, with incidence of 8.5 per

1000 out of total Khartoum population. Reported cases of MI in Sudan in 2013 were 2656 in

the same year, with incidence of 7.5 per 1000 of total country population. Country deaths out

of MI cases were 10.1% in 2013 and it was 7.9% in 2012[7]

.

General treatment measures for MI patients in the first 24 hours include admission to

hospital, oxygen administration, continuous multiplied ST-segment monitoring for

arrhythmias and ischemia, frequent measurement of vital signs, bed rest for 12 hours in

hemodynamic ally stable patients and pain relief, stable patients and pain relief.[8]

Nursing is built on a body of knowledge discreetly synthesized from physical ,biological and

13

social science and uniquely applied as a humanistic discipline of caring for people wherever

the recognizing the health care needs of patient nurses incorporate scientific knowledge and

technical advances into their practice to assist the patient s in remaining well and function at

the maximum level. Especially in critical care units of hospital, with advancing science and

technology with doctors, the nurses should upgrade their knowledge. They must be able to

identify life threatening arrhythmias on electrocardiogram and initially assess document, and

report to physician following assessment of the chest discomfort and other symptoms and

unusual complain, obtain 12 lead ECG, administer oxygen and medication as prescribed and

she meets the demands of patients and the same time rehabilitate[9]

.

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1.2 PROBLEM STATEMENT:

MI a critical health status which requires standardized care policies, as well as its need

qualified and skilled health provider to obtain good outcome of management. With the

change in life style in Sudan, the rate of MI increased since people tend to prefer urban life

with less physical efforts. In such circumstance and due to critical status of the patients

during the first 24 hours, treatment should be supervised by qualified health care providers

among who nurses represents the closest line of care staff. During practice, the author

observed that nurses’ performance towards MI in many times do not satisfy the required

level, this necessitates more evaluation and workup. The opportunities of training provided

for nurses in such field are restricted by many difficulties which expected to be reflected on

developing the nurses’ performance.

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1.3 JUSTIFICATION

MI is now single biggest killer in the western world. it is also afflicts and incapacitates

many people in their most productive time of life. Sudden death is first manifestation of

CHD in 20-30 per cent of cases two third of deaths from MI are sudden and take place

before medical help can be reached .as many die within the first 24 Hours [21]

.

Critical illness requires life–saving intervention and application of high medical

technology and intensive nursing within a specialist critical care unit. An AMI is an

emergency situation requiring immediate diagnosis and treatment.

Monitoring and evaluation of nurses’ competence in Sudan might participate to provide

better future performance which can be accomplished by spotting the defects in

performance, concepts and settings.

16

1.4 OBJECTIVES

1.4.1 General objectives:

The study aimed to evaluate nurses’ knowledge and practice regarding nursing care given for

MI patients in the first 24 hours of admission.

1.4.2 Specific objectives:

To assess:

1. Nurses’ knowledge about MI (disease, complications, risk factors, signs and

symptoms, management and drugs).

2. Nurses’ performance in the first 24 hours regarding care and procedures done for MI

patients (ECG, Oxygen therapy education and vital signs).

17

2. LITERATURE REVIEW

2.1 Definition

Acute myocardial infarction (MI) remains a leading cause of morbidity and mortality

worldwide. MI occurs when myocardial ischemia, (a diminished blood supply to the heart),

exceeds a critical threshold and overwhelms myocardial cellular repair mechanisms designed

to maintain normal operating function and homeostasis. Critical myocardial ischemia can

occur as a result of increased myocardial metabolic demand, decreased delivery of oxygen

and nutrients to the myocardium via the coronary circulation, or both. An interruption in the

supply of myocardial oxygen and nutrients occurs when a thrombus is superimposed on an

ulcerated or unstable atherosclerotic plaque and results in coronary occlusion.[11]

Atherosclerotic plaque and subsequent thrombus formations are the most common causes. It

is identified that nearly 95 per cent of the people who developed a fatal CVD had at least one

of these major risk factors: high blood pressure, smoking, diabetes beside a poor diet and

overweight. [12]

2.2 Classification

MI is generally classified into ST elevation MI (STEMI) and non-ST elevation MI

(NSTEMI). [13]

A STEMI is the combination of symptoms related to poor oxygenation of the

heart with elevation of the ST segments on the electrocardiogram followed by an increase in

proteins in the blood related to heart muscle's death. [14]

A 2007 consensus document classifies MI into five main types: [15]

Type 1 – spontaneous MI related to ischemia due to a primary coronary event such as

plaque erosion and/or rupture, fissuring, or dissection

Type 2 – MI secondary to ischemia due to either increased oxygen demand or

decreased supply, e.g. coronary artery spasm, coronary embolism, anemia,

arrhythmias, hypertension, or hypotension

Type 3 – sudden unexpected cardiac death, including cardiac arrest, often with

symptoms suggestive of myocardial ischemia, accompanied by new ST elevation, or

18

new left bundle branch block (LBBB), or evidence of fresh thrombus in a coronary

artery by angiography and/or at autopsy, but death occurring before blood samples

could be obtained, or at a time before the appearance of cardiac biomarkers in the

blood

Type 4 – associated with coronary angioplasty or stents:

o Type 4a – MI associated with percutaneous coronary intervention (PCI)

o Type 4b – MI associated with stent thrombosis as documented by angiography

or at autopsy

Type 5 – MI associated with CABG

3.2 Signs and symptoms of acute MI

Patients with typical MI may have the following prodromal symptoms in the days preceding

the event (although typical STEMI may occur suddenly, without warning) [16]

:

Fatigue

Chest discomfort

Malaise

Typical chest pain in acute MI has the following characteristics:

Intense and unremitting for 30-60 minutes

Retrosternal and often radiates up to the neck, shoulder, and jaw and down to the

ulnar aspect of the left arm

Usually described as a substernal pressure sensation that also may be characterized as

squeezing, aching, burning, or even sharp

In some patients, the symptom is epigastric, with a feeling of indigestion or of fullness

and gas.

The patient’s vital signs may demonstrate the following in MI:

The patient’s heart rate is often increased secondary to sympathoadrenal discharge

The pulse may be irregular because of ventricular ectopy, an accelerated

idioventricular rhythm, ventricular tachycardia, atrial fibrillation or flutter, or other

supraventricular arrhythmias; bradyarrhythmias may be present.

19

In general, the patient's blood pressure is initially elevated because of peripheral

arterial vasoconstriction resulting from an adrenergic response to pain and ventricular

dysfunction.

However, with right ventricular myocardial infarction or severe left ventricular

dysfunction, hypotension is seen.

The respiratory rate may be increased in response to pulmonary congestion or anxiety

Coughing, wheezing, and the production of frothy sputum may occur.

Fever is usually present within 24-48 hours, with the temperature curve generally

parallel to the time course of elevations of creatine kinase (CK) levels in the blood.

Body temperature may occasionally exceed 102°F.

2.4 Risk factors:

Risk factors for serious disease and mortality in people have been documented in

observational studies. The individual contributions of cigarette smoking, diabetes and

hypertension have been noted in the clinical sphere, other factors, such as self-related health,

physical disability, marital status, social support and physical activity, have been noted in the

sociodemographic sphere.

2.4.1 Non-Modifiable risk factors:

Pre-existing coronary heart diseases, including:

1. A previous heart attack.

2. A prior angioplasty or bypass surgery.

Age

Men: The risk increases after age 45

Women: The risk increases after age 55.

Heredity

Family history of early heart disease -first degree relative- diagnosed before age 55; or a

mother or sister diagnosed before age 65.

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2.4.2 Modifiable risk factors:

Smoking:

Cigarette smoking greatly increases the risk of fatal and nonfatal heart attacks in both men

and women. It also increases the risk of a second heart attack among survivors. Women who

smoke and use oral contraceptives have an even greater risk than smoking alone. The good

news is that quitting smoking greatly reduces the risk of heart attack. One year after quitting

the risk drop to about one-half that of current smokers and gradually returns to normal in

persons without heart disease. Even among persons with heart disease, the risk also drops

sharply one year after quitting smoking and it continues to decline over time but the risk does

not return to normal [17]

.

High blood pressure (Hypertension):

High blood pressure makes the heart work harder. It increases the risk of developing heart

disease, as well as kidney disease and stroke, follow a heart healthy eating plan, including

foods lower in salt, help prevent or control high blood pressure, and, if a medication was

prescribed, compliance is required [18]

.

High blood cholesterol:

The level of cholesterol in the bloodstream greatly affects the risk of developing heart

disease. The higher the level of blood cholesterol, the greater the risk for heart disease or

heart attacks. When there is too much cholesterol (a fat-like substance) in the blood, it builds

up in the walls of arteries. Over time, this buildup causes arteries to become narrowed, and

blood flow to the heart is slowed or blocked. If the blood supply to a portion of the heart is

partially or completely cut off, a heart attacks results. Various factors affect cholesterol

levels: diet, weight, physical activity, age, gender, and heredity.

High cholesterol is treated with lifestyle changes-a heart healthy eating plan, physical

activity, and loss of excess weight-and, if those do not lower it enough, Medications include

statins, bile acid sequestrants, nicotinic acid, and fibric acids [19]

.

21

Overweight and obesity:

Obesity is an important determinant of CVD. Obese children have an elevated risk of

developing CVD in adulthood. The effects of obesity on cardiovascular health and disease are

many, one of the most profound of which is hypertension.

Obesity has a strong effect on lipoprotein metabolism regardless of ethnic group. Increased

weight is a determinant of higher levels of triglycerides, elevated LDL-C, and low HDL-C.

Conversely, weight loss is associated with a healthier lipoprotein profile in both men and

women: triglycerides decrease, HDL-C increases, and LDL-C decreases. ―The public health

approach (to obesity) requires a systematic education of the public about the dangers of

obesity. Various health agencies could work together to promulgate such a message that

would reach all population groups [20]

.

Physical inactivity:

The risk of heart attack increases if there is a physical inactivity or a sedentary lifestyle.

Physical activity improves cholesterol levels, helps control high blood pressure and diabetes,

and controls keeps weight. It also increases physical fitness, promotes psychological well-

being and self-esteem, and reduces depression and anxiety. Thus exercise and physical

activity provides multidimensional benefits,[21]

.

Those who have already had a heart attack also benefit greatly from being physically active,

starting slowly to increase physical activity, and to check with health care provider before

starting a physical activity program. This is especially important among patient over age 55,

have been inactive, or have diabetes or another medical problem.

Diabetes:

Patients with diabetes have a higher case fatality rate in my MI or stroke than those without

diabetes: that is, MI and stroke are more often fatal if diabetes is present. Diabetes mellitus

damages blood vessels, including the coronary arteries of the heart. Up to 75 percent of those

with diabetes develop heart and blood vessel diseases. Diabetes also can lead to stroke,

kidney failure, and other problems [18]

.

22

2.4.3 Other risk factors:

1. Use of oral contraceptive pills, cocaine, or amphetamines may also increase chances for a

heart attack.

2. Certain psychological factors, have been linked to heart attacks and a worse outcome from

a heart attack:

a. Depression

b. Anger and hostility

c. Social isolation and lack of social support

d. Chronic (ongoing) stress

Stress can come from any situation or thought that makes you feel frustrated, angry, or

anxious. What is stressful to one person is not necessarily stressful to another.

Stress is a normal part of life. In small quantities, stress is good – it can motivate you and

help you be more productive

However, too much stress, or a strong response to stress, is harmful. It can set you up for

general poor health as well as specific physical or psychological illnesses like infection, heart

disease, or depressio. Persistent and unrelenting stress often leads to anxiety and unhealthy

behaviors like overeating and abuse of alcohol or drugs [19]

.

2.5 Investigations in the first 24 hours:

2.5.1 Electrocardiogram (ECG):

Show a signs of infarction.

-Raised and coved ST segment

- A pathological Q wave

- T wave inversion

The ECG may also be normal or no diagnostic, when patient comes in ED with a complaint

of chest pain within a few hours, the ECG may change to reflect the infarction process these

changes take place when cellular damage has occurred [10]

2.5.2 Serum cardiac markers;

Certain proteins, called serum cardiac, are released into the blood from necrotic heart muscle

23

after a myocardial infarction. These markers, specifically serum cardiac enzymes and

troponin, are important in the diagnosis of MI. The presence of serum cardiac markers that

occurs after cellular death indicated cardiac damage. creatine kinase (CK) and troponin are

typically measured to diagnose an MI.

CK level begin to rise at about 6 hours after an MI, peak at about 18 hours, and return to

normal within 24 to 36 hours .the CK enzymes are fractionated into bands . The CK-MB

band is specific to myocardial cells and helps quantify myocardial damage [22]

.

Cardiac-specific troponin is a myocardial muscle protein released into circulation after

myocardial injury. In the heart, there are two subtypes: cardiac-specific troponin T (CTN I)

and cardiac –specific troponin I (CTN I).These markers are highly specific indicators to MI

and have greater sensitivity and specificity for myocardial injury than CK-MB troponin is

used for diagnostic purposes in conjunction whit CK-MB. Serum levels of CTNI and CTN T

increase from 4 to 6 hours after onset the MI, peak at 10 to 24 hours, and return to baseline

over 10 to 14 days [22]

.

Myoglobin is released into the circulation within 2hours after MI and peak in 3 to 15 hours.

Although it is one of the first serum cardiac markers to appear after an MI, it lacks cardiac

specificity .in addition, the kidneys rapidly excite it in urine so that blood levels return to the

normal range within 24 hours after MI. [22]

2.5.3 Blood picture:

Usually shows polymorph nuclear leukocytosis and raised ESR

2.5.4 Chest x ray:

Done to exclude LVF

2.5.5 Other investigations:

Some other investigations can be done after 24 hours for MI patients to confirm the

diagnosis:

i. Coronary Angiography:

Is carried out in patients with MI who continue to suffer from repeated attacks of angina pain

or those who develop cardiac Rupture [10]

24

ii. Technetium:

Technetium scan (T99) is sensitive in the diagnosis of acute infarction .it becomes positive

within 24-48 hours of the infarction .the acutely infracted area shows as a hot spot (increased

technetium uptake ) . The test is usually negative 7-10 days after the infarction [10]

.

iii. Echocardiography:

Imaging

An echocardiogram may be performed to compare areas of the left ventricle that are

contracting normally with those that are not. One of the earliest protective actions of

myocardial cells used during limited blood flow is to turn off the energy-requiring

mechanism for contraction; this mechanism begins almost immediately after normal blood

flow is interrupted. The echocardiogram may be helpful in identifying which portion of the

heart is affected by an MI and which of the coronary arteries is most likely to be occluded.

Unfortunately, the presence of wall motion abnormalities on the echocardiogram may be the

result of an acute MI or previous (old) MI or other myopathic processes, limiting its overall

diagnostic utility. Typical rise and fall of cardiac biomarkers following myocardial infarction

[23]

2.6 Management:

2.6.1 Management in the first 24 hours:

The goals of therapy in acute MI in the first 24 hours are the expedient restoration of normal

coronary blood flow and the maximum salvage of functional myocardium. These goals can

be met by a number of medical interventions and adjunctive therapies. The primary obstacles

to achieving these goals are the patient's failure to recognize MI symptoms quickly and the

delay in seeking medical attention. When patients present to a hospital, there are a variety of

interventions to achieve treatment goals. ―Time is muscle‖ guides the management decisions

in acute STEMI, and an early invasive approach is the standard of care for acute NSTEMI.[23]

MONA

The ―MONA‖ mnemonic represents the 4 priority interventions for patients suspected to be

experiencing a MI. these include morphine, oxygen, nitroglycerin, and aspirin. Keep in mind

25

that while MONA is helpful, it doesn’t actually represent the correct order or prioritization of

the interventions. The mnemonic that correctly represents the order of actions is ONAM. This

can be remembered by On A.M. (as is I work in the mornings: I am ON in the A.M. shift, or I

am totally a morning person- I am ON in the A.M.) [24]

.

Oxygen is always given first, allegedly because it’s the mos1t important; Nitro is given next

in order to dilate the vessels, making it a matter of increased space. Aspirin helps

disaggregate the platelets with the goal of clot reduction and prevention of additional ones.

Morphine reduces pain and anxiety, which will in turn assist with the psychosocial aspects

that contribute to the tachypnea, thereby reducing the oxygen demand [24]

.

MONA Acronym (ON-AM) [25]

O: Administer oxygen: by means of nasal cannula or face mask, oxygen

administration provides more concentration for myocardial uptake in order to promote

tissue profusion to meet metabolic demands. It can also decrease the discomfort

associated with tissue ischemia and prevent additional damage.

N: Administer Nitroglycerin, IV: Nitro has a vasodilatation effect, which promotes

perfusion and lowers the myocardial workload and oxygen demand.

A: Administer Aspirin: this works by inhibiting platelet activity and interrupts

aggregation at the rupture site, thrombolysis

M: Administer morphine: this relaxes the endothelial lining and promotes profusion

of the heart tissue by reducing the myocardial workload. It also controls pain and

reduces the risk of developing life-threatening dysarhythmias and other

complications.

Venous Access

Initiating a venous puncture allows for placement of an intravenous access to infuse drugs

such as morphine and nitroglycerin [24,25]

.

Medical Options

Antiplatelet Agents

The use of aspirin has been shown to reduce mortality from MI. Aspirin in a dose of 325 mg

26

should be administered immediately on recognition of MI signs and symptoms. [23,26]

The

nidus of an occlusive coronary thrombus is the adhesion of a small collection of activated

platelets at the site of intimal disruption in an unstable atherosclerotic plaque. Aspirin

irreversibly interferes with function of cyclooxygenase and inhibits the formation of

thromboxane A2. Within minutes, aspirin prevents additional platelet activation and

interferes with platelet adhesion and cohesion. This effect benefits all patients with acute

coronary syndromes, including those with MI. Aspirin alone has one of the greatest impacts

on the reduction of MI mortality. Its beneficial effect is observed early in therapy and persists

for years with continued use. The long-term benefit is sustained, even at doses as low as

75 mg/day.

The Clopidogrel and Metoprolol in Myocardial Infarction Trial/Second Chinese Cardiac

Study trial evaluated the use of clopidogrel versus placebo in patients who were taking

aspirin but not undergoing reperfusion therapy. It demonstrated a benefit in favor of

clopidogrel when used with aspirin.[27,28]

Supplemental Oxygen

Oxygen should be administered to patients with symptoms or signs of pulmonary edema or

with pulse oximetry less than 90% saturation.[23]

The rationale for using oxygen is the

assurance that erythrocytes will be saturated to maximum carrying capacity. Because MI

impairs the circulatory function of the heart, oxygen extraction by the heart and by other

tissues may be diminished. In some cases, elevated pulmonary capillary pressure and

pulmonary edema can decrease oxygen uptake as a result of impaired pulmonary alveolar-

capillary diffusion. Supplemental oxygen increases the driving gradient for oxygen uptake.[29]

Arterial blood that is at its maximum oxygen-carrying capacity can potentially deliver oxygen

to myocardium in jeopardy during an MI via collateral coronary circulation. The

recommended duration of supplemental oxygen administration in a MI is 2 to 6 hours, longer

if congestive heart failure occurs or arterial oxygen saturation is less than 90%. However,

there are no published studies demonstrating that oxygen therapy reduces the mortality or

morbidity of an MI.

27

Nitrates

Intravenous nitrates should be administered to patients with MI and congestive heart failure,

persistent ischemia, hypertension, or large anterior wall MI [23,26]

The primary benefit of

nitrates is derived from its vasodilator effect. Nitrates are metabolized to nitric oxide in the

vascular endothelium. Nitric oxide relaxes vascular smooth muscle and dilates the blood

vessel lumen. Vasodilatation reduces cardiac preload and after load and decreases the

myocardial oxygen requirements needed for circulation at a fixed flow rate. Vasodilatation of

the coronary arteries improves blood flow through the partially obstructed vessels as well as

through collateral vessels. Nitrates can reverse the vasoconstriction associated with

thrombosis and coronary occlusion.

When administered sublingually or intravenously, nitroglycerin has a rapid onset of action.

Clinical trial data have supported the initial use of nitroglycerin for up to 48 hours in MI.

There is little evidence that nitroglycerin provides substantive benefit as long-term post-MI

therapy, except when severe pump dysfunction or residual ischemia is present. [27]

Low BP,

headache, and tachyphylaxis limit the use of nitroglycerin. Nitrate tolerance can be overcome

by increasing the dose or by providing a daily nitrate-free interval of 8 to 12 hours. Nitrates

must be avoided in patients who have taken a phosphodiesterase inhibitor within the previous

24 hours. [23]

Pain Control

Pain from MI is often intense and requires prompt and adequate analgesia. The agent of

choice is morphine sulfate, given initially IV at 5 to 15 minute intervals at typical doses of 2

to 4 mg. [23]

Reduction in myocardial ischemia also serves to reduce pain, so oxygen therapy,

nitrates, and beta blockers remain the mainstay of therapy. Because morphine can mask

ongoing ischemic symptoms, it should be reserved for patients being sent for coronary

angiography.

Beta Blockers

Beta blocker therapy is recommended within 12 hours of MI symptoms and is continued

indefinitely.[24,25]

Treatment with a beta blocker decreases the incidence of ventricular

28

arrhythmias, recurrent ischemia, reinfarction, and, if given early enough, infarct size and

short-term mortality. Beta blockade decreases the rate and force of myocardial contraction

and decreases overall myocardial oxygen demand. In the setting of reduced oxygen supply in

MI, the reduction in oxygen demand provided by beta blockade can minimize myocardial

injury and death.

The use of a beta blocker has a number of recognized adverse effects. The most serious are

heart failure, bradycardia, and bronchospasm. During the acute phase of an MI, beta blocker

therapy may be initiated intravenously; later, patients can switch to oral therapy for long-term

treatment. The COMMIT-CCS 2 trial raised safety concerns about the use of early

intravenous beta blockers in high-risk patients. [27]

In some patients who are considered high

risk due to age or hemodynamic instability, it may be reasonable to hold off on early

intravenous therapy [23]

.

Unfractionated Heparin

Unfractionated heparin is beneficial until the inciting thrombotic cause (ruptured plaque) has

completely resolved or healed. Unfractionated heparin has been shown to be effective when

administered intravenously or subcutaneously according to specific guidelines. The minimum

duration of heparin therapy after MI is generally 48 hours, but it may be longer, depending on

the individual clinical scenario. Heparin has the added benefit of preventing thrombus

through a different mechanism than aspirin.

Low-Molecular-Weight Heparin

Low-molecular-weight heparin (LMWH) can be administered to MI patients who are not

treated with fibrinolytic therapy and who have no contraindications to heparin. The LMWH

class of drugs includes several agents that have distinctly different anticoagulant effects.

LMWHs are proved to be effective for treating acute coronary syndromes characterized by

unstable angina and NSTEMI.[23]

Their fixed doses are easy to administer, and laboratory

testing to measure their therapeutic effect is usually not necessary.

Warfarin

Warfarin is not routinely used after MI, but it does have a role in selected clinical settings.

29

The latest guidelines recommend the use of warfarin for at least 3 months in patients with left

ventricular aneurysm or thrombus, a left ventricular ejection fraction less than 30%, or

chronic atrial fibrillation.

Fibrinolytics

Restoration of coronary blood flow in MI patients can be accomplished pharmacologically

with the use of a fibrinolytic agent. Fibrinolytic therapy is indicated for patients who present

with a STEMI within 12 hours of symptom onset without a contraindication. Absolute

contraindications to fibrinolytic therapy include history of intracranial hemorrhage, ischemic

stroke or closed head injury within the past 3 months, presence of an intracranial malignancy,

signs of an aortic dissection, or active bleeding. Fibrinolytic therapy is primarily used at

facilities without access to an experienced interventionalist within 90 minutes of

presentation.[26]

As a class, the plasminogen activators have been shown to restore normal coronary blood

flow in 50% to 60% of STEMI patients. The successful use of fibrinolytic agents provides a

definite survival benefit that is maintained for years. The most critical variable in achieving

successful fibrinolysis is time from symptom onset to drug administration. A fibrinolytic is

most effective within the first hour of symptom onset and when the door-to-needle time is 30

minutes or less. [26]

Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor Blockers

Angiotensin-converting enzyme (ACE) inhibitors should be used in all patients with a

STEMI without contraindications. ACE inhibitors are also recommended in patients with

NSTEMI who have diabetes, heart failure, hypertension, or an ejection fraction less than

40%. In such patients, an ACE inhibitor should be administered within 24 hours of admission

and continued indefinitely. Further evidence has shown that the benefit of ACE inhibitor

therapy can likely be extended to all patients with an MI and should be started before

discharge. Contraindications to ACE inhibitor use include hypotension and declining renal

function[23,26]

.

ACE inhibitors decrease myocardial after load through vasodilatation. One effective strategy

30

for instituting an ACE inhibitor is to start with a low-dose, short-acting agent and titrate the

dose upward toward a stable target maintenance dose at 24 to 48 hours after symptom onset.

Once a stable maintenance dose has been achieved, the short-acting agent can be continued or

converted to an equivalent-dose long-acting agent to simplify dosing and encourage patient

compliance. For patients intolerant of ACE inhibitors, angiotensin receptor blocker (ARB)

therapy may be considered [26]

.

Glycoprotein IIb/IIIa Antagonists

Glycoprotein IIb/IIIa receptors on platelets bind to fibrinogen in the final common pathway

of platelet aggregation. Antagonists to glycoprotein IIb/IIIa receptors are potent inhibitors of

platelet aggregation. The use of glycoprotein IIb/IIIa inhibitors during percutaneous coronary

intervention (PCI) and in patients with MI and acute coronary syndromes has been shown to

reduce the composite end point of death, reinfarction , and the need to revascularize the target

lesion at follow-up. The current guidelines recommend the use of a IIb/IIIa inhibitor for

patients in whom PCI is planned. For high-risk patients with NSTEMI who do not undergo

PCI, a IIb/IIIa inhibitor may be used for 48 to 72 hours. [23]

Statin Therapy

A statin should be started in all patients with a myocardial infarction without known

intolerance or adverse reaction prior to hospital discharge. Preferably, a statin would be

started as soon as a patient is stabilized after presentation. The Pravastatin or Atorvastatin

Evaluation and Infection—Thrombolysis in MI-22 trial suggested a benefit of starting

patients on high-dose therapy from the start (e.g., atorvastatin 80 mg/day)[230,31]

.

Percutaneous Coronary Intervention

Patients with STEMI or MI with new left bundle branch block should have PCI within 90

minutes of arrival at the hospital if skilled cardiac catheterization services are available.[28]

Patients with NSTEMI and high-risk features such as elevated cardiac enzymes, ST-segment

depression, recurrent angina, hemodynamic instability, sustained ventricular tachycardia,

diabetes, prior PCI, or bypass surgery are recommended to undergo early PCI (<48 hours).

PCI consists of diagnostic angiography combined with angioplasty and, usually, stenting. It is

31

well established that emergency PCI is more effective than fibrinolytic therapy in centers in

which PCI can be performed by experienced personnel in a timely fashion [32]

An operator is

considered experienced with more than 75 interventional procedures per year. A well-

equipped catheterization laboratory with experienced personnel performs more than 200

interventional procedures per year and has surgical backup available. Centers that are unable

to provide such support should consider administering fibrinolytic therapy as their primary

MI treatment.

Restoration of coronary blood flow in a MI can be accomplished mechanically by PCI. PCI

can successfully restore coronary blood flow in 90% to 95% of MI patients. Several studies

have demonstrated that PCI has an advantage over fibrinolysis with respect to short-term

mortality, bleeding rates, and reinfarction rates. However, the short-term mortality advantage

is not durable, and PCI and fibrinolysis appear to yield similar survival rates over the long

term. PCI provides a definite survival advantage over fibrinolysis for MI patients who are in

cardiogenic shock. The use of stents with PCI for MI is superior to the use of PCI without

stents, primarily because stenting reduces the need for subsequent target vessel

revascularization.[33]

2.6.2 Other Treatment Options

Surgical Revascularization

Emergent or urgent coronary artery bypass grafting (CABG) is warranted in the setting of

failed PCI in patients with hemodynamic instability and coronary anatomy amenable to

surgical grafting.[26]

Surgical revascularization is also indicated in the setting of mechanical

complications of MI, such as ventricular septal defect, free wall rupture, or acute mitral

regurgitation. Restoration of coronary blood flow with emergency CABG can limit

myocardial injury and cell death if performed within 2 or 3 hours of symptom onset.

Emergency CABG carries a higher risk of perioperative morbidity (bleeding and MI

extension) and mortality than elective CABG. Elective CABG improves survival in post-MI

patients who have left main artery disease, three-vessel disease, or two-vessel disease not

amenable to PCI.

32

Implantable Cardiac Defibrillators

The results of a multicenter automatic defibrillator implantation trial have expanded the

indications for automatic implantable cardioverter-defibrillators (ICDs) in post-MI patients.

The trial demonstrated a 31% relative risk reduction in all-cause mortality with the

prophylactic use of an ICD in post-MI patients with depressed ejection fractions. [34]

The

current guidelines recommend waiting 40 days after an MI to evaluate the need for ICD

implantation. ICD implantation is appropriate for patients in NYHA functional class II or III

with an ejection fraction less than 35%. For patients in NYHA functional class I, the ejection

fraction should be less than 30% before considering ICD placement. ICDs are not

recommended while patients are in NYHA functional class IV. [25]

Treatment Outcomes

An individual patient's long-term outcome following an MI depends on numerous variables,

some of which are not modifiable from a clinical standpoint. However, patients can modify

other variables by complying with prescribed therapy and adopting lifestyle changes.

Stress Testing

Cardiac stress testing after MI has established value in risk stratification and assessment of

functional capacity.[27]

The timing of performing cardiac stress testing remains debatable. The

degree of allowable physiologic stress during testing depends on the length of time from MI

presentation. Stress testing is not recommended within several days after a myocardial

infarction. Only sub maximal stress tests should be performed in stable patients 4 to 7 days

after an MI. Symptom-limited stress tests are recommended 14 to 21 days after an MI.

Imaging modalities can be added to stress testing in patients whose electrocardiographic

response to exercise is inadequate to confidently assess for ischemia (e.g., complete left

bundle branch block, paced rhythm, accessory pathway, left ventricular hypertrophy, digitalis

use, and resting ST-segment abnormalities). [23]

From a prognostic standpoint, an inability to exercise and exercise-induced ST-segment

depression are associated with higher cardiac morbidity and mortality compared with patients

able to exercise and without ST-segment depression. [23]

Exercise testing identifies patients

33

with residual ischemia for additional efforts at revascularization. Exercise testing also

provides prognostic information and acts as a guide for post-MI exercise prescription and

cardiac rehabilitation.

Smoking Cessation

Smoking is a major risk factor for coronary artery disease and MI. For patients who have

undergone an MI, smoking cessation is essential to recovery, long-term health, and

prevention of reinfarction. In one study, the risk of recurrent MI decreased by 50% after 1

year of smoking cessation.[[36]

All STEMI and NSTEMI patients with a history of smoking

should be advised to quit and offered smoking cessation resources, including nicotine

replacement therapy, pharmacologic therapy, and referral to behavioral counseling or support

groups. [23,26]

Smoking cessation counseling should begin in the hospital, at discharge, and

during follow-up.

Long-Term Medications

Most oral medications instituted in the hospital at the time of MI will be continued long term.

Therapy with aspirin and beta blockade is continued indefinitely in all patients. ACE

inhibitors are continued indefinitely in patients with congestive heart failure, left ventricular

dysfunction, hypertension, or diabetes. [23,26]

A lipid-lowering agent, specifically a statin, in

addition to diet modification, is continued indefinitely as well. Post-MI patients with diabetes

should have tight glycolic control according to earlier studies. The latest ACC/AHA

guidelines recommend a goal HbA1c of less than 7%.

Cardiac Rehabilitation

Cardiac rehabilitation provides a venue for continued education, reinforcement of lifestyle

modification, and adherence to a comprehensive prescription of therapies for recovery from

MI including exercise training. Participation in cardiac rehabilitation programs after MI is

associated with decreases in subsequent cardiac morbidity and mortality. Other benefits

include improvements in quality of life, functional capacity, and social support. However,

only a minority of post-MI patients actually participate in formal cardiac rehabilitation

programs because of several factors, including lack of structured programs, physician

34

referrals, low patient motivation, noncompliance, and financial constraints.

Immediate complications of MI:

Severe left ventricular dysfunction or one of the other mechanical complications of acute

myocardial infarction (AMI) causes most of the deaths following AMI. Complications of

AMI include: [37,38]

Ischemic (including failure of reperfusion): angina, re-infarction, infarct extension.

Mechanical: heart failure, cardiogenic shock, mitral valve dysfunction, aneurysms,

cardiac rupture.

Arrhythmic: atrial or ventricular arrhythmias, sinus or atrioventricular (AV) node

dysfunction.

Thrombosis and embolic: central nervous system or peripheral embolisation.

Inflammatory: pericarditis.

Psychosocial complications (including depression).

Ischemic complications [39]

Failure of reperfusion is less likely with the availability of primary percutaneous coronary

intervention (PCI). Reperfusion should reduce ST elevation to less than 50% within one hour.

Re-occlusion of an infarct-related artery

Occurs in a minority but significant number of patients following fibrinolytic therapy.

These patients also tend to have a poorer outcome.

Can be difficult to diagnose.

Infarction in a separate territory (recurrent infarction)

May be difficult to diagnose within the first 24 to 48 hours after the initial event.

Multivessel coronary artery disease is common in patients with AMI.

Post infarction angina

Angina may occur from a few hours to 30 days after AMI.

The incidence is highest in patients with non-ST-elevation myocardial infarction and

those treated with fibrinolytics compared with PCI.

35

Mechanical complications

Left ventricular dysfunction and heart failure

Pulmonary oedema is common following a myocardial infarction. Overt cardiac

failure following a myocardial infarction is a poor prognostic feature.

The severity of the heart failure depends on the extent of the infarction and the

presence of any other complications - e.g. acute mitral regurgitation.

Cardiogenic shock occurs in 5-20% of patients following myocardial infarction.

Killip's classification is one method used to assess the severity of cardiac failure

following a myocardial infarction: [40]

Cardiac failure usually responds well to oxygen, diuretics and ACE

inhibitors/angiotensin receptor antagonists (and intravenous nitrates if no

hypotension).

Ventricular septal rupture and free wall rupture

Risk factors: older age, female gender, non-smoker, anterior infarction, worse Killed

class on admission, increasing heart rate on admission, first myocardial infarction and

hypertension. [41]

Post infarction VSD is relatively infrequent but life-threatening. [42]

The incidence has

dramatically decreased with reperfusion therapy.

May develop as early as 24 hours after myocardial infarction but often presents 2-7

days afterwards. Mortality rates are greater than 90%.

Ventricular septal rupture:

Free wall rupture:

Pseudo aneurysm (false aneurysm):[ [38]

Acute mitral regurgitation

Most common with an infero-posterior infarction and may be due to ischemia ,

necrosis, or rupture of the papillary muscle.

Mitral regurgitation following myocardial infarction predicts a poor prognosis but is

often transient and asymptomatic.

36

Rupture of papillary muscle or chordate tendinae [38, 43]

:

Mitral regurgitation is often accompanied by a pan systolic murmur, but the murmur

may be inaudible if left a trial pressure rises sharply.

Echocardiogram is required to confirm the diagnosis, especially to differentiate from

rupture of the interventricular septum, and to assess severity.

Left ventricular aneurysm

The vulnerable myocardium following an AMI is susceptible to wall stress, resulting

in infarct expansion. Sub acute cardiac rupture is an extreme form of infarct

expansion, whereas ventricular aneurysm is its chronic form.[44]

Occurs after 2-15%

of infarcts. Patients who do not receive reperfusion therapy are at greatest risk (10%

to 30%). [38]

Five-year survival is 10-25%. May be clinically silent or cause recurrent

tachyarrhythmias, heart failure or systemic emboli.

Right ventricular failure

Right ventricle myocardial infarctions accompany inferior wall ischemia in up to one

half of cases. [45]

Mild right ventricular dysfunction is common after infero-posterior

infarcts but right heart failure only occurs in a minority of these patients. May present

with hypotension, jugular venous distention with clear lungs and no dyspnoea. Severe

right ventricular failure may present with a low cardiac output state, including oliguria

and altered mental state. Diagnosis is made by echocardiography.

Left ventricular outflow tract obstruction [38]

Dynamic left ventricular outflow tract obstruction can independently result from

various causes such as left ventricular hypertrophy, reduced left ventricular chamber

size (dehydration, bleeding, or dieresis), mitral valve abnormalities, and hyper

contractility (stress, anxiety, or isotropic agents such as dobutamine).[46]

Arrhythmias

A life-threatening arrhythmia (e.g., ventricular tachycardia, ventricular fibrillation and total

AV block) may be the first manifestation of ischemia. These arrhythmias may cause many of

the reported sudden cardiac deaths in patients with acute coronary syndromes. Ventricular

37

fibrillation or sustained ventricular tachycardia has been reported in up to 20% of patients.

The risk of arrhythmic death in survivors of acute myocardial infarction is highest in the first

six months after myocardial infarction and remains high for the subsequent two years.[47]

Ant arrhythmic agents are negatively isotropic and may encourage arrhythmias in

acute coronary ischemia. Minor arrhythmias should not be treated.

Ventricular arrhythmias: [48]

o Defibrillation should be administered for patients with ventricular fibrillation

or pulse less ventricular tachycardia.

o Intravenous adrenaline (epinephrine) should be used (as a last resort) for

patients with refractory ventricular tachycardia or ventricular fibrillation.

Bradycardia, sinoatrial dysfunction or heart block:

o Sinus bradycardia may be due to drugs, ischemia or a vagal response.

o Atropine should be used for patients with symptomatic bradycardia.

o Temporary transcutaneous pacing should be initiated for patients not

responding to atropine. Temporary transcutaneous pacing is only an interim

measure until a more permanent method can be employed.

Sinus tachycardia may be due to pain, anxiety, or drugs.

Atrial fibrillation and other supraventricular tachycardia's may also occur. Atrial

fibrillation complicates 10-20% of AMIs but other supraventricular tachycardia's are

rare and usually self-limited.

Thrombosis and embolic complications

Deep vein thrombosis and pulmonary embolism are now relatively uncommon after

infarction, except in patients kept in bed because of heart failure.

Prophylactic doses of a low molecular weight heparin (LMWH) and compression

stockings should be used for prevention.

Treatment should be with therapeutic doses of LMWH, followed by oral

anticoagulation for 3-6 months.

38

Mural thrombosis and systemic embolism

Echocardiography may reveal intraventricular thrombi. Left ventricular thrombus

occurs in 20% after infarction but in up to 60% of those after a large anterior

infarction.

The thrombus may be large and may be associated with embolisation.

The rate of thrombus formation is similar for patients treated with primary

percutaneous coronary intervention when compared with patients currently treated

conservatively or with thrombolysis.

Left ventricular mural thrombus has not been shown to be related to increased

intermediate-term mortality when patients are treated with warfarin.[49]

Pericarditis

Pericarditis is most common following an anterior infarction. The incidence of early

pericarditis after AMI is approximately 10%. Pericarditis usually develops between

24 and 96 hours after AMI.[38]

Dressler's syndrome

Dressler's syndrome presents as pericarditis 2-5 weeks after AMI, often accompanied

by pleural and pericardial effusions. The incidence is between 1% and 3%.[40][40]

Dressler's syndrome typically presents 2-5 weeks after a myocardial infarction with a

self-limiting febrile illness accompanied by pericardial or pleural pain.

Depression [51]

Significant depression occurs in about 20% of patients following myocardial

infarction.

Myocardial infarction increases the risk of suicide, and depression following

myocardial infarction impairs the overall prognosis.

39

Nursing intervention in the first 24 hours:

Treatment

Goals of Treatment

The primary goals of immediate interventions are to decrease the myocardial workload while

increasing the available oxygenation. Rapid identification and actions will minimize the

damage caused to the heart muscle and reduce tissue necrosis. Chances of survival are

increased and long-term disabilities are reduced if tissue necrosis can be prevented or

minimized[24]

.

Immediate Interventions

Obtain vitals

Establish venous access

Administer medications (oxygen, nitroglycerin, aspirin, morphine, ACE-inhibitor)

Draw labs

ECG

ECG

An ECG should be done within 10 minutes of admission so that the health care team

can gather data to treat the patient.

The ECG will help to confirm that the patient is experiencing a MI.

The ECG will also help to determine the location of the occlusion, which is crucial in

predicting the prognosis and guiding the course of treatment.

Classic presentation: The ECG reading for a patient with a MI often demonstrate a

inverted T wave. However, this pattern can also be seen in patients who formally had

a MI

Presentation of an Anterior Wall MI: On a 12 led ECG of an Anterior Wall MI, the

characteristic findings present with a ST-segment elevation MI (STEMI). There will

be changes in leads V1 through V4 with a loss of the normal R-wave progression and

reciprocal changes in the lateral leads[52]

.

40

Nursing Care Planning

Nursing Assessment

Assess vitals, including pain, frequently in the early phase of treatment and recovery

Monitor cardiovascular function for dysrhythmias with an ECG (remember: the first

ECG should be performed within 10 minutes of arrival)

Heart sounds should be assessed for the emergence of a new murmur

Once stable: Collect data from the patient about co morbidities, including

hypertension, smoking, and family history or heart disease and MI’s. Inquire about

stress levels, such as work-related and personal stressors [52]

.

Nursing Diagnoses

Impaired tissue profusion

Acute pain

Anxiety

Activity intolerance

Nursing Interventions [52]

Impaired tissue profusion related to issue ischemia secondary to coronary artery

occlusion as evidenced by patient report of chest pain, ECG readings, restlessness,

and changes in level of consciousness.

Acute pain: Assess pain levels and administer medications as ordered. Instruct patient

to do relaxation techniques, including deep and slow breathing, distraction behaviors,

visualization, and guided imagery. Assist as needed

Anxiety: Administer medications as ordered (or via protocol per policy), including

supplemental oxygen. Enhancing oxygenation may relieve anxiety associated with

hypoxia.

Activity intolerance: Assess tolerance levels for activity. Cluster care activities to

provide periods of uninterrupted tasks. Instruct patient to reserve energy as possible

by spacing out activities

41

Discharge Preparation: Medication Management

The medication regimen the patient will need must be established prior to discharge

The provider uses the nurse’s assessment findings to determine what medications to

prescribe

Possible Medication Regimen [24]

ACE Inhibitor: Maintains blood pressure within optimal range and promotes vascular

health by reducing cardiac workload. This prevents (or slows down the process of)

ventricular remodeling and reduces the risk of future cardiac events

Beta-blockers: Maintains blood pressure within optimal range. Common beta-

blockers include atenolol (Tenormin), pindolol (Visken), propranolol (Inderal),

nadolol (Corgard), and metoprolol (Lopressor)

Aspirin: A low daily dose reduces the risk of subsequent cardiac events

A different ant platelet agent, such as clopidogrel (Plavix), may be given instead

Nitroglycerin: A vasodilator that’s ordered as a sublingual tablet for the patient to use

at home in the event of chest pain related to angina

Wilburton or Chantix: For smoking cessation, as smoking is a known risk factor for

MI

Nursing counseling

Following a MI, it’s important to educate patients on reducing preventable risks factors. This

includes smoking cessation, weight control, and stress reduction, dietary changes, reducing

LDL while keeping HDL high, and lowering blood pressure. The patient should understand

the treatment regimen, such as how many times to take nitro before seeking health care

provider [52]

.

Diet:

Initially, keep the patient on nothing by mouth until his or her condition has been stabilized

and treated. Following the patient’s initial therapy and admission, a dietitian should instruct

the patient regarding appropriate diet. A low-salt, low-fat, and low-cholesterol diet is

generally recommended.

42

Activity

Confine patients to bed rest to minimize oxygen consumption until reperfusion and initial

therapy are complete. This usually lasts about 24-48 hours; after that, the patient's activity

may be accelerated slowly as tolerated and as the clinical situation allows. Initiate cardiac

rehabilitation prior to discharge.

Transfer

A study showed that the transfer of patients to an invasive-treatment center for primary PCI is

superior to on-site fibrinolysis provided that the transfer can be accomplished within 2 hours.

Transfer should be considered for those patients who are likely to benefit from PCI or cardiac

surgery but who are in an institution where access to such interventions is not immediate. The

benefits of transferring such a patient must outweigh the risks. Patients for whom transfer

might be considered include the following:

Patients with new or worsening hemodynamically significant mitral regurgitant

murmurs

Patients with known or suspected critical aortic stenosis and either ongoing ischemia

or hemodynamic instability

Patients who have received thrombolysis and fail to reperfusion

Patients with significant LV dysfunction or cardiogenic shock

In an aforementioned study by Cantor et al, a significant decrease in ischemic complications

was observed in high-risk patients with STEMI who were treated with fibrinolysis and

transferred for PCI within 6 hours following fibrinolysis [53,54]

.

Previous studies:

An experimental study was conducted to assess the knowledge of nursing personnel’s on first

24 hours care of the patients with Myocardial Infarction in Osmania General Hospital,

Hyderabad. 50 nursing personnel’s were randomly selected and structured questionnaire was

used for data collection. The results of the study showed that 26 per cent of nursing

personnel’s had below average knowledge, 44 per cent had average level of knowledge, and

43

30 per cent had above average knowledge. The study concluded by saying that the nurses

need to be given special training in caring the cardiac patients in ordered to improve their

knowledge.[55]

An experimental study was conducted to assess the knowledge regarding 12 lead

electrocardiogram and continuous cardiac monitoring procedure among cardiac nurses in

India. 24 cardiac nurses were selected by simple random sampling. Data was collected by

using observation checklist. Their explanatory skill, placement of leads, way of taking

tracings, interpretation of electrocardiogram; nurse’s responsibilities during

electrocardiogram procedure were also assessed. Pretest was done and structured teaching

programmed was implemented, later post test was conducted. The study results reported that

knowledge of nurses was increased from 23.4 per cent in pretest to 72 per cent in posttest.

The study concluded by saying that structured teaching programmed was effective in

improving the knowledge of cardiac nurses on 12 lead electrocardiogram and continuous

cardiac monitoring procedure.[56]

A descriptive study was conducted to assess the knowledge of risk factors, life habits

and personal beliefs of nurses and nursing students about cardiovascular prevention in Italy.

A sample of 182 nurses were selected by using random sampling technique in which 98

students attending the last year course in School of Nursing, and 84 nurses working in a

cardiovascular department were there. Data were collected by using questionnaire. The

results showed that among heritable risk factors, hypertension ranked first in the awareness of

both students and nurses. The risk inherent in a family history of Myocardial Infarction was

recognized only by 36 per cent of subjects, 15 per cent of staff nurses and 30 per cent of

students recognized that 5 to 10 of cigarettes per day are not harmful respectively. The

knowledge of upper normal limits for blood pressure, plasma cholesterol and triglycerides

was often poor in both the cohorts. The study concluded by saying that majority of the staff

44

nurses and student nurses life style was a credible model for patients.[57]

A Sudanese study conducted by Elbashir H, et al among 139 nurses and aimed to assess their

knowledge towards MI management./ their findings found that, (females 84% and males

16%); with various qualification degrees master 10 %, Bachelor 67% and diploma 23%

randomly selected from the already mentioned departments. About 55% of the participants

had level of knowledge in management of acute myocardial infarction below average while

42% of the study sample had attitude below average. Moreover, 58% of the participants had

below average skill. By testing the factors that affect the competence components it appeared

that training, management guidelines, qualification, experience in nursing and number of

years expended in CCU and emergency department had got significant effect. They

concluded that, the level of the nurse competence in the management of patients with acute

myocardial infarction depends on the advanced level of training and setting of clear

guidelines for management [58].

A study in Iraq conducted by Dergham MH and colleagues resulted in that, the nursing care

did not reach the desired level due to the deficiency in the level of knowledge and practice of

the nursing staff and its effect on the type of nursing care. Based on the research of the study,

Based on the above results, the study recommends the necessity for a specialized nursing care

when dealing with such disease and the importance of the continuous development of the

nursing care through a well prepared educational programs [59].

45

3. METHODOLGY

Study design:

A descriptive hospital-based study conducted in Khartoum State to assess nurses’ knowledge

and practice regarding management of patients with myocardial infarction in the first 24

hours.

Study area:

The study was conducted in the main public teaching hospitals in Khartoum State (Khartoum

TH, Alshab TH, Khartoum, Khartoum North TH, Ribat University Hospitals, Ahmed Gasim

Hospital) in period from 2014-2015 at cardiac care unit and emergency department.

Ribat University Hospital: It is the one of the tertiary hospitals in Sudan with large

catchment's area, where many patients are in regular visits. It is a university hospital has

about 700 beds for different units including the emergency department, the medical surgical

wards, dialysis unit, pharmacy, blood bank and laboratory. The hospital also have

ophthalmology department, dental, pediatric, obstetric and gynecology department. The

hospital services for police sector mainly and their families, staff and students of Al Ribat

university and general population. The hospital includes ICU, CCU and emergency

department.

Khartoum North Teaching Hospital: It is located in Sudan, serves Khartoum North area,

especially East Nile and Northern rural areas. Hospital facilities included blood bank, well-

equipped theatre, 20 beds in the intensive care unit, and 189 beds in addition to all major and

minor clinical departments.

Khartoum Teaching hospital: It is the major hospital in Sudan; it provides clinical services

for all Sudan States in the different departments. It has 20 beds in CCU. ED is divided into

hot cases and cold cases.

46

Ahmed Gasim Hospital: It is located in Khartoum North. The major departments are; Renal

Departments, Pediatrics Department and Cardiac Departments. The cardiac department

includes CCU with 10 beds, cardiac wards and catheterization unit.

Alshaab Teaching Hospital: It is of the major Chest and Cardiac Hospitals in Sudan, it

include ED, 20 beds in the CCU, HDU and Ward.

Study period:

During the period from Jan 2014 to Dec2015.

Study population:

Nurses working in CCU & ED in the study hospitals.

Inclusion criteria:

Nurses with bachelor degree.

Nurses have experience of more than 6 months in CCU and ED units.

Exclusion criteria:

Nurses who refused to participate.

Nurses who were in duty of ―national services‖

Sample size:

Convenience sampling determined sample size of 200 nurses.

Data collection tools:

The data was collected by using close-ended questionnaire (Appendix-1) and check list

(Appendix-2). The close-ended questionnaire included 30 questions; every question had 4

options answers. The practice check list contained 19 criteria, classified into ―done and not

done‖.

The questionnaire included:

Personal data: Age, sex, total work experience, Knowledge: About nursing of MI in the first

24 hours, symptoms of MI, complication, risk factors, management, medication, counseling

47

and diagnostic measures. The questionnaire consisted of 30 close question questions. The

check list: aimed to evaluate nurses’ performance which was observed in regard to

medication, nurses’ procedures (vital signs, ECG, .. .), using the relevant devices and

equipments, documentation.

Data collection technique:

The data of the questionnaire was fulfilled by the participants, after 24 hours it was handled

to the author, revised and coded before data entry. The check list was fulfilled by observing

the nurses’ practice without being informed starting at patients admission up to the first 4

hours at the CCU. All data collection was managed by the author, the data was collected

during period of 1 year, 3 times per week, attending the morning and noon shifts.

Data analysis:

Data were collected, cleaned and coded by SPSS program (Version 17). Result was presented

as percent, means of percent and frequency. For cross-tabulation calculation confidence

intervals was 95% and P value of 0.05. Every question contained four items, for which the

degree of knowledge was evaluated by scoring out of 4 (percent of knowledge x 4)/100.

Check list was determined by two options (Done & Not done). The findings were presented

as tables and figures.

Score of knowledge:

The full score was 4, which calculated from frequency and percent as follows; Score =

percent x 4/ 100

Evaluation was done according to Ribat Evaluation System:

Evaluation measures Measurement Range

Excellent > 90

V. Good > 80

Good 70 – 79

Moderate 50 – 69

Poor < 50

48

Ethical considerations:

Permission to carry out this study was granted by the ethics and research committee of

college of post graduate at Ribat University. Agreement was granted after within consents

from authorities in the ministry of health, hospitals, CCU & ED. All participants provided

consent prior to beginning of the interview after thorough explanation of what the study was

all about by interviewers and full information of nurses’ staff and agreement.

49

4. Results

The study was conducted at cardiac care unit and emergency department in five hospitals in

Khartoum state (Khartoum TH, Alshab TH, Khartoum, Baharry, Alribat hospitals, Ahmed

Gasim) during the period from 2014-2015 among 200 nurses working in the CCU & ED, and

they were assessed for their knowledge and practices towards care about MI patients in the

first 24 hours of admission.

Age distribution showed that, 97 (48%) of nurses participated in the study were in the age of

26-30 years, 66(33%) had age less than 25 years, 31(15.5%) had age of 31-35 years and 6

(3%) had age more than 35 years, as shown in Figure (1).

Gender distribution showed that, 58(29%) were males and 142(71) were females, shown in

figure (2).

In regard to experience, 121 (60.5%) had experience of 1-5 years, 67(33.5%) had experience

of 6-10 years, 8(4%) had experience less than one year and 4(2%) had experience more than

10 years, and this was shown in figure (3).

Distribution of participants according to working area showed that, 73(36.5%) found working

at CCU, the same percentage found working at ER and 54(27%) found working at HDU, as

shown in figure (4).

Knowledge towards symptoms of MI showed that, 177(88.5%) identified symptoms of MI,

139(69.5%) identified chest pain characteristics of MI and 133(66.5%) identified radiated

pain in MI, as illustrated in figure (5).

In regard to knowledge towards risk factors of MI, 192(96%) of nurses mentioned smoking

as risk factor, 186(93%) mentioned DM and hypertension, 179(89.5%) mentioned

hyperlipidemia and obesity while 161(80.5%) mentioned family history, this was illustrated

in figure (6).

50

Out of total, 177(88.2%) of nurses knew the knowledge about complications of MI in

general, while 158(79%) reported to know complications of MI through observing the

monitor, figure (7).

Assessing knowledge towards management of MI showed that, immediate management of

MI was reported by 177(88.%), vital signs of MI were reported by 179(89.5%), pain

management in patients of MI was reported by 163(81.5%), Pain assessment was reported by

156(78%), Daily nursing procedures in CCU was reported by 146(73%), 144(72%) reported

assessment of cardiac output, 123(61.5%) reported other management for STE MI patients,

121(60.5%) knew the main of cry, mean of carrying MI patients to CCU, as shown in table

(1).

In regard to medications of MI, 159(79.5%) knew drug given immediately, 150(75%) knew

observation for streptokinase, 149(74.5%) knew contra-indication of streptokinase,

143(71.5%) knew anti-ischemic drugs, 136(68%) knew streptokinase side effect, 126(63%)

knew nitrate side effects, 116(58%) knew oxygen therapy and 108(54%) knew typical

indications for immediate thrombolysis, table (2).

Knowledge towards diagnosis of MI showed that, 176(88%) of nurses reported 12 Leads

ECG as diagnosis method, and the same percentage mentioned Lab. Investigations + cardiac

enzymes, 148(74%) mentioned echocardiography and 120(60%) mentioned coronary

angiography, this was illustrated in table (3).

Nurses’ knowledge towards counseling MI patients showed that, 167(83.5%) said that, the

patients should be counseled about drug and side effect, 166(83%) chose educating the

patients about the MI disease and self-management, 165(82.5%) said that the patients should

be advised to change his life style, 161(80.5%) chose counseling the MI patients about long-

51

term management and 146(73%) said that, the patients should be educated about diet, as

shown in table (4).

The nurses’ practice was assessed by checking interventional items done; it was found that,

171(85.5%) interacted with patient’s arrive, 172(86%) connected the monitor, 171(85.5%)

checked the vital signs, 157(78.5%) put the patient in cardiac bed, 132(66%) did 12 lead

ECG, 86(43%) applied administration of oxygen, 102(51%)inserted IV lines, 164(82%) took

blood sample for investigations, 49(24.5%) inserted urinary catheters, 166(83%) agave pain

killers and thrombolysis, 58(29%) psychologically reassured and supported the patients,

74(29%) provide education for the patient, 99(49.5%) assessed the pain level, 98(49%) did a

psychological support and education for the family. 98(49%) check prescribed drugs,

112(56%) advised patient to decrease exercise, 125(62.5%) assessed serial investigation,

123(61.5%) gave the proper diet and 123(61.5%) made full report about PT conditions, table

(5).

Years of experience were correlated with criteria of symptoms, risk factors and management

of MI. all criteria showed insignificant association (P value > 0.05), except diabetes mellitus

and hypertension as risk factors, which revealed a significant association (P value = 0.025).

Assessing the association of years of experience and working area with different practice

criteria showed no significant association (P value > 0.05). However, correlation between

years of experience and identification of pain level in MI patients and checking prescribed

drugs for MI patients was significant (P value < 0.05). Also, there was significant association

between years of experience and (giving pain killers and thrombolysis) (P value = 0.041), and

other significant association between working area and (giving pain killer and thrombolysis)

(0.036) and also a significant association between working area and making full report about

the patient's condition (P value = 0.044), as shown in table (6).

52

Figure (1): Age distribution of nurses working in the CCU & ED (n = 200)

Figure (2): Gender distribution of nurses working in the CCU (n = 200)

53

Figure (3): Experience of nurses working in the CCU & ED (n = 200)

Figure (4): Working Area of nurses in the CCU & ED (n = 200)

ED

54

Figure (5): Knowledge about symptoms of myocardial infarction among nurses working in

the CCU & ED (n = 200)

Note: Mean of knowledge regarding symptoms of MI, chest pain characteristics of MI and Radiated pain in MI

were: 3.52 and 2.47, 2.66 respectively

55

Figure (6): Nurses’ knowledge towards risk factors of myocardial infarction patients among

nurses working in the CCU & ED, (n = 200)

Note: Mean of knowledge regarding Risk factors, Smoking, Hyperlipidemia & obesity, DM & hypertension and

Family history was 3.54.

56

Figure (7): Nurses’ knowledge towards complications of MI patients among nurses working

in the CCU & ED (n = 200)

Note: Means of knowledge regarding complications of MI and complications of MI observed on monitor were

3.01 and 3.14.

57

Table (1): Knowledge towards Management of MI patients among nurses working in the

CCU & ED (n = 200)

Management s Freq % Mean of percent

immediate management of MI 177 88.5% 3.53

vital signs of MI 179 89.5% 3.57

mean of carrying MI patients to CCU 121 60.5% 2.36

Pain assessment 156 78% 3.12

Daily nursing procedures in CCU 146 73% 2.90

other management for STE MI patients 123 61.5% 2.45

pain management in patients of MI 163 81.5% 3.26

Assessment of cardiac output 144 72% 2.89

58

Table (2): Nurses’ knowledge towards medications of MI among nurses working in the CCU

& ED , (n = 200):

Medication Freq % Mean of percent

Drug given immediately 159 79.5% 3.17

Typical indications for immediate thrombolysis 108 54% 2.16

Anti-ischemic drugs 143 71.5% 2.86

Oxygen therapy 116 58% 2.32

Contra-indication of streptokinase 149 74.5% 2.98

Streptokinase side effect 136 68% 2.69

observation for streptokinase 150 75% 3.0

Nitrate side effects 126 63% 2.50

59

Table (3): Nurses’ knowledge towards diagnostic measures to confirm MI, among nurses

working in the CCU & ED , (n = 200)

Diagnosis Freq % Mean of percent

12 LEADS ECG 176 88.0

3.70

Coronary angiography 120 60.0

Echocardiography 148 74.0

Cardiac Enzymes 176 88.0

60

Table (4): Knowledge towards counseling MI patients, among nurses working in the CCU &

ED, (n = 200)

Counseling Freq % Points out of 4

education about diet 146 73 2.88

education about disease and self-management 166 83 3.3

Long-term management 161 80.5 3.22

Change life-style 165 82.5 3.3

Drug and side effect 167 83.5 3.34

61

Table (5): Evaluating of practice about care towards MI patients, among nurses working in

the CCU & ED, (n = 200)

Check list

Done Not Done

Freq % Freq %

Interaction when patient arrive 171 85.5% 29 14.5%

Put in cardiac bed 157 78.5 43 21.5%

Connect monitor 172 86% 28 14%

Check vital signs 171 85.5% 29 14.5%

Do 12 leads ECG 132 66% 68 34%

Administration of oxygen 86 43% 132 66%

Insert IV lines 102 51% 98 49%

Take blood sample for investigations 164 82% 36 18%

Insert urinary catheters 49 24.5% 151 75%

Give pain killers and thrombolysis 166 83% 34 17%

Reassurance and psychological support 58 29% 142 71%

Patient education 74 37% 126 63%

Assessment of pain level 99 49.5% 101 50.5%

Psychological support and education for the

family 98 49% 102 51%

Check prescribed drugs 143 71.5 57 28.5%

Advice pt to decrease Exercise 112 56% 88 44%

Assessment of serial investigation 125 62.5% 75 37.5%

Give the proper diet 123 61.5% 77 38.5%

Make full report about PT conditions 123 61.5% 77 38.5%

62

Table (6): Correlation of years of experience and working area with different knowledge

criteria

Correlation P

value

Symptoms

Chest pain 0.573

Epigastric pain (nausea & vomiting) 0.307

Shortness of breath 0.534

Sweating 0.877

Risk factors

Family history 0.239

DM & hypertension 0.025

Smoking 0.164

Hyperlipidemia & obesity 0.775

Management

Administration of oxygen therapy 0.074

Connect monitors and ECG 0.680

Aspirin and clopidogrel 0.308

Nitrate 0.397

Morphine and antiemetic 0.533

Thrombolytic (streptokinase & heparin) 0.555

63

Table (7): Correlation of years of experience and working area with different practice criteria

Correlation P value

Correlation of practice with years of experience

Nurses’ interaction when MI patients arrive 0.831

Putting MI patients in cardiac bed 0.676

Connecting monitor for MI patients 0.422

Checking vital signs for MI patients 0.545

Oxygen administration by MI patients 0.05

Giving pain killers and thrombolysis to MI patients 0.041

Reassurance & psychological support for MI patients 0.121

Patients education about MI 0.282

Assessment of pain level in MI patients 0.045

Checking prescribed drugs for MI patients 0.037

Exercise for MI patients 0.200

Giving the proper diet for MI patients 0.086

Correlation of practice with working area

Connecting the monitor for MI patients 0.980

Doing 12 leads ECG for MI patients 0.795

Administration of oxygen by MI patients 0.816

Giving pain killer and thrombolysis for MI patients 0.036

Psychological support and education provided for MI patients 0.439

Making full report about the MI patients condition 0.044

Chest pain among MI patients 0.573

64

5. Discussion

Nursing care is important in survival of a patient with MI. The competence of the nurse in

charge is very crucial in such patient care. The current study is an attempt to assess the

knowledge and practice of 200 staff nurses regarding first 24 hours care of patient with MI

admitted to the CCU/ HDU in major governmental hospitals in Khartoum State.

Demographic characteristics:

Demographic characteristics of the current study showed that, nurses with age of 30 years or

less represented the vast majority of participants (81.5%), indicating that most nurses were

juniors 64.5% had experience of 5 years or less versus 35.5% who had experience for more

than 5 years. The advantage of nurses in young age is fulfilling the hyperactivity required in

such critical departments as well as they can be modified to the ideally required performance,

on the other hand experienced nurses help in decision making and supervision of juniors. A

similar findings were reported by the study in Iraq which showed that, the majority of nurses

(36.8%) were between the ages (22-27) years, and they reported that, those with experience

from (1 -9 years) years were (57.9%), (10-19 years) were (15.8%), and nurses with (20-29

years) were (26.3%) [55].

Gender distribution revealed that, most participants were females (71%). profession of

nursing in Sudan has long history of association with females in different levels of nursing.

Professional qualification of males (B.Sc. degree) was applied recently. This is compatible

with findings reported by Elbashir H and colleagues in Sudan, who found that, females

represented 84% while males represented 16% [56]

. But the study in Iraq by done Al- Ftlawy

DM showed different result showing that, males were 52.6%, while females represented

47.4%[55]

.

Distribution of participants according to practicing area was selected randomly 36.5% of

practicing in CCU, the same percentage in ED, while 27% in HDU.

65

Knowledge:

Assessing nurses’ knowledge about MI in the current study revealed that, they had very good

knowledge regarding the symptoms (88.5%) with rate of 3.52 out of 4, but they showed

average knowledge regarding characteristics of chest pain and radiated pain in MI with

percentages of 69.5% and 66.5% respectively. Early knowledge about symptoms of MI

enabling early diagnosis and accordingly early management as well as it prevents

complications and safe patients’ life. This disagrees with findings reported by Newens AJ1,

and colleagues earlier who have shown that, the percentage of nurses who correctly estimated

the incidence of symptoms was low, 25% of nurses did not make any correct estimates, and

the mean number of correct estimates was not associated with nurses' experience or

qualifications[57]

.

Nurses’ knowledge in regard to risk factors of MI was found excellent; smoking was reported

as the topmost risk factors for MI (96%), followed by diabetes and hypertension (93%). The

current finding was higher than the rate of knowledge among nurses reported by Steffeninog

et al in Italy in which risk factors were answered correctly by only 15% of staff nurses [58]

.

Complications of MI and its identifying in the monitor were found very good and good

respectively; most of participants answered positively, knowledge of MI complications and

complications observed in the monitor scored 88.27% and 79% respectively. The good

knowledge about MI complications positively affects early management as reported in

literature which showed that, nurses who are knowledgeable about potential complications

will be able to detect early signs and symptoms, initiate emergency treatment, and prevent

profound haemodynamic compromise occurring [59]

.

The participants were assessed for the different skills of management of MI, and they showed

good knowledge about management (75.6%), it included variables differed from immediate

management to CCU procedures, the highest score of knowledge were reported in the aspect

of vital signs of MI, immediate management, pain assessment and pain management with

66

percentages of 89.5%, 88.5% and 81.5% respectively. A similar finding were reported in

Uganda which showed that, majority of the participants (91.2%) had adequate knowledge [60]

.

The ideal method of carrying the patients to the CCU and other management for STEMI

patients’ criteria (PCI) showed moderate score of knowledge; with percentages of 60.5%

61.5% respectively. In Sudan, the PCI mostly not had done as emergency procedure in

emergency department. Method of transfer the patients usually done by the available carrier

due to unavailability or scarcity of the ideal mean (Wheel chair, ambulance, cardiac bed).

Transferring patients was discussed in literature; Bosk EA, et al reported that, but the current

process may lead to sub-optimal patient outcomes, mentioning that some issues should be

considered during transferring patients; identifying transfer-eligible patients; identifying a

destination hospital; negotiating the transfer; and accomplishing the transfer[61]

.

Knowledge towards medications of MI found moderate (67.9%); they showed good

knowledge regarding immediately provision of drug (MONA according to Advanced Life

Support), observing the patients during administration of streptokinase and contra-indication

of streptokinase with percentages of 79.5%, 75% and 74.5% respectively.

On the other hand, they showed poor knowledge towards typical indications for immediate

thrombolysis and moderate knowledge towards oxygen therapy with percentages of 54% and

58% respectively. Typical indication for thrombolysis and administered oxygen usually

nurses depend on doctor’s instructions.

Literature has reviewed the importance of nurses’ knowledge about medication and they

reported that, one of nurses’ fundamental roles is to be aware of the expected effects, side

effects, contraindications and dosage of medications and to inform and counsel their patients

about these. However studies conducted in Turkey have shown that nurses in general do not

satisfactorily meet this responsibility [62]

.

In regard to knowledge about diagnostic measures to confirm the MI, nurses showed very

good knowledge with percentage of 88% for each, they had very good knowledge towards

67

leads ECG and cardiac enzymes, very good knowledge might be due to the fact that, both

leads ECG and cardiac enzymes are available and done as routine. On the other hand, they

showed good knowledge towards echocardiography (74%) and moderate knowledge towards

coronary angiography (60%), this might be due to the familiarity of ECG among nurses while

coronary angiography is less used. This is higher than degree of knowledge shown in the

Indian study in Madurai which reported that, the mean of knowledge regarding

electrocardiogram among bachelor degree nurses was poor (33.3%) [63]

.

Nurses showed good knowledge regarding counseling provided for MI patients; they showed

very good knowledge towards counseling about drug and side effects (83.5%), education

about disease and self-management (83%) and changing life-style (82.5%). The organized

and targeting programs of counseling and education of patients have revealed its positive

outcome, as reported by Johnston M, et al who reviewed that, admitted patients. Cardiac

counseling and rehabilitation resulted in more knowledge, less anxiety, less depression, and

greater satisfaction with care in both patients in less disability in patients, with effects

enduring to 1 year. There was some evidence of additional benefit from the extended

program. Both nurse counselors achieved benefits on all outcome variables [64]

.

Practice:

Many different criteria of practice by nurses were assessed during the study period, out of

which they showed moderate degree of performance; specifically their practice was very

good in the aspect of interaction when patient arrive (85.5%), connect monitor (86%), check

vital signs (85.5%), take blood sample for investigations (82%) and give pain killers and

thrombolysis (83%), while they showed poor practice regarding administration of oxygen

(43%), insert urinary catheters (24.5%), reassurance and psychological support (29%), patient

education (37%), assessment of pain level(49.5%) and psychological support and education

for the family respectively(49%). hospital policy might affect some of these practice criteria;

e.g. some practices might be restricted to certain level of qualification (senior nurse, registrar

68

or consultant).

Reporting the patient's condition and other patients’ record showed moderate practice with

percentages of 61.5% and 12 leads ECG which found moderate (66%.). Nurses’

performance in the current study found less when compared to the percentage of knowledge,

which compatible with the previous studies. Since the incidence of sudden death is very high

during the first hour of an MI, it is essential to monitor the patient closely and be prepared for

an emergency. Observing the monitor, checking the vital signs, irritation or dryness, etc will

help avoiding further deterioration of cardiovascular status and discomfort if the nasal route

is used for oxygen administration. The study conducted by Suvitha R.A reported less degree

of performance showing that, practice of nurses with bachelor degree was reported to be

29.73% [63]

.

The study by Kizza IB in Uganda showed poor performance in different aspects of practice;

he reported that, nurses in this study had lack of education on assessment tools with

percentage of 82.4%, poor documentation of pain assessment and management was 77.6%[60]

.

Knowledge-practice assessment:

This study assessed knowledge and performance of nurses about the different care procedures

provided for MI patients in 1st 24 hours. The general outcome has shown that, there is some

variation between knowledge and its own practice in some procedures. In regard to

immediate management their practice was very good and it was close to knowledge in most

procedures, except administration of oxygen and inserting urinary catheter which reported

practice among (51% and 24.5% of nurses respectively). Their knowledge about 12 Leads

ECG was high (88%), but they show less percentage of performance (66%). Knowledge

about investigations was found in concurrent with their performance (88% for each).

Knowledge about Streptokinase (thrombolysis) was 75%, but they showed higher percentage

of performance (88%). General evaluation of knowledge counseling was estimated to be high

(80.5%), while their performance was 41.1%. Knowledge about diet reported percentage of

69

73%, while their performance reported 61.5%.

Correlations:

Out of 19 criteria of knowledge and performance assessed, only 6 criteria were significantly

affected by years of experience in the aspect of oxygen administration (0.05), giving pain

killers and thrombolysis (0.041), assessment of pain level (0.045) and checking prescribed

drugs for MI patients (0.037). On the other hand, giving pain killer and thrombolysis for MI

patients and making full report about the MI patients’ full condition shown to be associated

with certain working areas.

A study in Egypt reported a similar findings of insignificance of experience and other

variables in some performance, they mentioned that, there was no significant correlations

existed between gender, age, years of experience, and their level of knowledge and practice,

except negative correlation which existed between practice and years of experience regarding

cardiac pacing[65]

.

There is a significant relationship between level of knowledge and years of experience, this

result means that the experience has a great effect on the nurses level of knowledge and the

nurses can be develop their knowledge through the experience [55]

.

70

Conclusion

According to findings of the current study, it was concluded that, the total

evaluation of knowledge was found good representing 78.6% (mean of 3.16 out

of 4), while the total evaluation of practice was found moderate with percentage

of 61.34% (Mean of 2.5 out of 4), suggesting that, practice was incompatible

with the level of knowledge.

The study showed higher percentage of knowledge regarding risk factors and

complications which identified by vast majority, while they showed less

knowledge towards medications and symptoms which were moderate and good

respectively. They showed poor practice about diet, counseling, insertion of

urinary catheter and education for patients and families.

Also, the study showed very good practice in connecting monitor, checking

vital signs and interaction when patient arrive, but they showed poor practice in

inserting urinary catheters, reassurance and psychological support for patient

and family and educating patients.

Degree of knowledge and performance found significantly affected by years of

experience in the aspect of oxygen administration, giving pain killers and

thrombolysis, assessment of pain level and checking prescribed drugs for MI

patients.

71

Recommendations

Routine supportive supervision of nursing staff working in the coronary care

unit (CCU) and Emergency department (ED) units after training and

focusing on medication and practice (inserting urinary catheters, reassurance

and psychological support for patient and family and educating patients.).

Educational sessions are necessary to improve the nurse’s ability dealing

with management with such diseases.

Further studies are needed to elaborate the effects of different variables on

the knowledge and practice of nursing.

Increase the number of training sessions to nurses as general and special

training session to nurse work in cardiac unit, with encouraging nurses with

good level of knowledge to join the cardiac units.

72

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79

Appendix-1

Ribat National University

College of Postgraduate Studies

Master of Medical Surgical Nursing

Questionnaire

Assessment of Nurses’ Knowledge and Practice Regarding

Nursing Care Given for Myocardial Infarction Patients in First 24 hours

Note: please put ( ) in the right answer, and ( X ) in wrong answer,

Many questions require more than one correct answer to be chosen

No.: …………….

1. Age: ……………

2. Gender: Male Female

3. Years of experience: …………………………..

4. Working area: CCU ER HDU

5. Symptoms of MI include:

1. Chest pain 2. Epigastric pain & (nausea & vomiting)

3. Shortness of breath 4. Sweating

6. The chest pain of MI characterized by:

1. crushed 2. Prolong

3. Heaviness and Tidiness 4. Severe

7. The pain is radiated to:

1. Arm and shoulder 2. Neck 3. back

4. Posterior intrascapular area

8. Risk factors of MI include:

1. Smoking 2. Hyperlipidemia & Obesity

3. DM & Hypertension 4. Family history

9. Complications of MI include:

1. Cardiogenic shock 2. Heart failure

3. Arrhythmias 4. Cardiomegaly

80

10. Immediate management when patients arrive to ER:

1. Put patient in cardiac bed

2. Insert IV lines and take investigations

3. Administration of oxygen therapy

4. Connect monitors an ECG

11. Pain management includes:

1. Put patients in comfortable position

2. Give IV morphine

3. Supplemental oxygen

4. Nitroglycerides (GTN)

12. The drug can be given when patient arrive:

1. Aspirin & Clopidogrel

2. Nitrate

3. Morphine and antiemetic

4. Thrombolytic (Streptokinase & heparin)

13. The diagnostic measures to confirm MI include:

1. 12 Leads ECG

2. Cardiac enzymes

3. Angiography

4. Echocardiography

14. Typical indication for immediate thrombolytic therapy for acute MI:

1. Presentation within 12 hrs. of onset of chest pain

2. ST segment elevation > 0.2 mv in 2 chest leeds or > 0.1 mv in limb

leeds

3. Dominant R waves & ST depression in V1 – V3 in ECG (posterior MI)

4. New onset LBBB (Left Bundle Branch Block)

15. Other management for STE MI:

1. Re-perfusion therapy

2. Immediate Percutaneous coronary intervention (PCI)

81

3. Rescue Angioplasty

4. Cardiac pacing

16. The vital signs include:

1. Blood pressure

2. Oxygen saturation

3. Respiratory rate

4. Pulse rate

17. Other lab investigations should be taken:

1. Lipid profile 2.Bleeding profile

3. Renal profile 4. Blood glucose

18. Other drugs can be given to MI patient include:

1. Beta blockers 2. ACE inhibitors

3. Anti-arrhythmias 4. Anticoagulant

19. Oxygen can be given by:

1. Face mask 2. Nasal canula

3. Non-rebreathing mask 4. Room air

20. Assessment of pain include:

1. Duration 2. Location and pain radiation

3. Pain nature 4. Associated manifestations

21. When given streptokinase, close observation for:

1. Vital signs 2. Signs of bleeding

3. Cardiac output 4. Allergy

22. Contraindications of streptokinase include:

1. Bleeding disorder 2. Major surgery

2. Active internal bleeding 4. Previous hemorrhagic stroke

23. Side effects of streptokinase include:

1. Bleeding 2. Hypotension

3. Skin rash 4. Drowsiness

82

24. Nitrate side effects:

1. Flushing 2. Tachycardia

3. Postural hypotension 4. Headache

25. Assessment of cardiac output can be done through:

1.Urine output 2. Blood pressure

3. Mental status 4. Heart beats

26. The complications observed On-monitor:

1. Arrhythmias 2. Hypoxia

3. cardiac arrest 4. Hypotension

27. Referring patient to CCU can be by:

1. Wheel chair 2. Couch

3. Ambulance 4. Bed

28. The diet given to MI patient include:

1 Easy digestion 2. Fibers

2. Low salt & low fat 4. Free-gases diet

29. Patient’s Counseling should include:

1. The disease and self-management:

a. Signs and symptoms b. signs of complications

a. Physical activities b. Life style

2. Treatment:

a. Procedure of nursing b. Drug and side effect

c. Follow up d. Long term management

30. The daily nursing procedure in CCU include:

a. Weighing the patients b. intake and output chart

c. gradual exercise d. daily routine investigations

83

Appendix-2 Ribat National University

College of Postgraduate Studies

Master of Medical Surgical Nursing

Check List

Assessment of Nurses’ Practice in ER and CCU

Item Done Not done

Interaction when patient arrive

Put in cardiac bed

Insert IV lines

Take blood sample for investigations

Check vital signs

Connect monitor

Do 12 leads ECG

Administration of oxygen

Insert urinary catheters

Give pain killers and thrombolysis

Reassurance and psychological support

Patient education

Assessment of pain level

Check vital signs according to condition

Psychological support and education for

the family

Connect monitor and reassessment

Check prescribed drugs

Reduce exercise for patient

Assessment of serial investigation

Give the proper diet

Documentation