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Review &/or modify guideline to meet patient’s individual plan of care daily & prn. If an expected treatment is not performed, indicate modification on the attached Guideline Modification Record Affix Label here Care Guideline Date Initiated: Initiated By: Acute Myocardial Infarction (Nurse) (Page 1 of 4) This is a base standard of care for Acute Myocardial Infarction, please refer to corresponding Guideline Physician’s Orders. This Guideline should be modified to meet individual patient needs, and is not intended to replace individual patient care plan. Category Step 1 - Admission CCU Lab Tests If 1. 2. If 3. Diagnostic Procedures 2D Step 2 – Step 3 – Transfer Step 4 – Discharge (24-36 hour target) (48-72 hour target) (86+ hour target) <24 hours from onset of pain Cardiac profile with coag on admission CKMB @ 8-16-24 hrs > 24 hours from onset of pain Troponin cardiac profile with coag on admission Fasting cholesterol fractionation in am ECG ECG prn for chest pain CXR (portable on admission) echocardiogram (as indicated) Consults Cardiology: Interventions/ Treatments Outpatient lab (as necessary) ECG ECG Consider outpt lowlevel treadmill test or cardiac catheterization (as indicated) Cardiac monitor Oxygen pathway: 3L/min on admission x3 hours & prn chest pain, may discontinue if SaO2 >92% and pain free Consider IV thrombolytic therapy (30 min door-drug for eligible pts) Consider cath/PTCR as alternative to thrombolysis (90 min door-inflation) Consider cath/PTCR for persistent pain, ischemia or failed thrombolysis Page 1 of 5 Telemetry monitoring Discontinue telemetry outpt cardiac rehab referral Care Guideline Affix Label here Acute Myocardial Infarction (Page 2 of 4) This is a base standard of care for Acute Myocardial Infarction, please refer to corresponding Guideline Physician’s Orders. This Guideline should be modified to meet individual patient needs, and is not intended to replace individual patient care plan. Category Medications Step 1 - Admission CCU Aspirin Saline lock with flush IV heparin initial bolus & infusion, then wt based protocol Lovenox (low molecular wt Heparin) Beta-blockers (Contraindications include • Step 2 – Step 3 – Transfer (24-36 hour target) (48-72 hour target) Statin Discontinue IV nitrates Discontinue continuous IV Antiarrhythmics cardiogenic shock or hypotension, bradycardia with HR less than 50, advanced AV block, active asthma, severe reactive airway disease) ACE inhibitors: ______________________ Nitrates: ___________________________ IV morphine sulfate pm Antiarrhythmics Stool softener Analgesics (mild) ACLS emergency drugs per protocol Antacids Sleep aid Page 2 of 5 • • • Convert IV to saline lock Discontinue IV heparin Discontinue IV morphine Step 4 – Discharge (86+ hour target) • Discontinue saline lock Home Medications (if indicated) • • • Aspirin Beta blocker ACE inhibitor Statin Patient Care Intervention I&O (critical care unit) VS per unit routine Monitor patient response to initial reperfusion strategy (primary PTCA) Assess for any bleeding q 2 hrs x4, then q 4 hrs x 24 with GP IIb/IIIa antagonist Physical assessment & reassessment per unit standard ST Segment monitoring Assess patient response to any antianginal therapy Evaluate cardiac rhythm q 8 hrs & prn Physician notification (primary & cardiologist) symptomatic HR <60 or >110, SBP <90 or >150, resp rate <8 or >22, recurrence of chest pain unrelieved with nitro Transfer to ___________ • VS per unit routine • D/C I&O Care Guideline Affix Label here Acute Myocardial Infarction (Page 3 of 4) This is a base standard of care for Acute Myocardial Infarction, please refer to corresponding Guideline Physician’s Orders. This Guideline should be modified to meet individual patient needs, and is not intended to replace individual patient care plan. Category Step 1 – Admission CCU Activity BSC, chair, OOB-if pain free/hemodynamically stable ADLs with assistance Nutrition Clear liquids advance as tolerated to cardiac diet Dietary evaluation Psychosocial/ Pastoral Care Encourage patient/SO to discuss anxieties Explore successful coping mechanism Step 2 – Step 3 – Transfer Step 4 – Discharge (24-36 hour target) (48-72 hour target) (86+ hour target) • Ambulate as tolerated Bathroom privileges • Reassure pt/SO regarding pt’s progress Page 3 of 5 Review available resources and support systems Shower Ambulation ad lib Discuss any concerns related to discharge and lifestyle changes Education Initiate teaching of basic disease pathophysiology to patient/SO Explain rationale for treatment plan (e.g., bedrest and frequent labs), thrombolytic /primary PTCA teaching if indicated Provide written AMI material Instruct patient to verbalize any chest pain or associated symptoms Emphasize need for rest Evaluate current smoking/tobacco use and need for cessation education/intervention Provide smoking cessation counseling/ advice for pts who have smoked during the previous year. Provide reinforcement for those who have never smoked or have quit. Case Management Case Manager interviews patient/SO and begins coordinating discharge plan/services Outcomes Patient will be pain-free within 30 minutes of arrival to ED Eligible patient will receive thrombolytics within 30 minutes or PTCA within 90 minutes, then transferred to CCU Patient will remain hemodynamically stable Patient will explain importance of notifying RN of any chest pain Patient will be able to explain thrombolytics or catheterization/PTCA if needed Affix Label here Reinforce pathophysiology and treatment teaching Discuss AMI and identify risk factors Provide initial teaching for new meds (i.e., betablockers, aspirin, ACE inhibitors, statins) Pt will remain painfree/hemodynamically stable Lab values will begin to normalize ECG will be evolving with ST segment returning to baseline Pt/SO will be able to describe basic pathophysiology of AMI Reinforce teaching on risk factor modification; continue medication teaching Initiate risk factor modification Reinforce discharge plan Complete discharge plan Pt will be pain-free, up, and out of bed Pt will be progressing with activity Patient/SO will be able to explain medication rationale/side effects Patient/SO will be able to describe risk factor modification techniques Patient/SO will be able to explain home meds schedule, discharge instructions for home, diet instruction, and activity guidelines Reinforce all discharge teaching Reinforce home medication schedule Provide postprocedure education materials Care Guidelines are to be reviewed and modified once each day and prn, to meet the patient’s individual plan of care. Modifications to Guideline Expected Care Criteria are to be documented on this Guideline Modification Record. Guideline/Review Modification Record Acute Myocardial Infarction (Page 4 of 4) Date Guideline Reviewed/Modified Signature Date Guideline Reviewed/Modified Page 4 of 5 Signature Date Category Modification - Signature MO-03-05-AMI March 2003 This material was prepared by Primaris under contract with the Centers for Medicare & Medicaid Services (CMS). The contents presented do not necessarily reflect CMS policy. Page 5 of 5