Myocardial Infarction Nursing Care Plans Diagnosis and Interventions
Myocardial Infarction NCLEX Review and Nursing Care Plans
Myocardial infarction (M.I.), also known as heart attack, is a serious medical emergency that occurs when the blood supply to the heart is suddenly cut off.
The blockage is usually caused by a clot. Prolonged lack of blood supply to the heart muscles can result in permanent damage and can be life-threatening.
Immediate medical intervention is necessary to prevent serious complications.
Myocardial infarction is the most common form of coronary heart disease and is highly associated with morbidity and mortality.
The most common cause of heart attacks is a clot built up from a ruptured plaque.
Plaques are fatty deposits on the walls of arteries that can trigger clot formation when they rupture.
The clot can partially or completely block an artery, which could then impede the flow of blood.
Signs and Symptoms of Myocardial Infarction
The signs and symptoms of myocardial infarction may vary from person to person.
Others may not have any symptoms at all, while some may have warning signs before the attack occurs.
The following are the signs and symptoms which may be noted in a person having a myocardial infarction:
- Chest pain – this is the most common symptom associated with M.I. The chest pain is often described as similar to the feeling of being squeezed or pressed by a heavy object on the chest. The pain may radiate to the jaw, neck, back, and arms.
- Shortness of breath
- Feeling weak, lightheaded, or both
- An overwhelming feeling of anxiety
In some cases, chest pain may not always be severe, particularly in women. It may even be mistaken for indigestion.
However, it should be noted that the severity of chest pain is not definitive and conclusive of myocardial infarction.
The chest pain should be assessed in combination of the other symptoms to determine a heart attack.
Causes of Myocardial Infarction
- Coronary artery disease (CAD). Coronary artery disease is a condition referring to the reduction in the blood flow to the heart muscles due to the build-up of plaques in the arteries of the heart. Plaques are fatty deposits including cholesterol, saturated fat, and trans fat.
- Spasm of the coronary artery. The coronary artery is the major artery that supplies blood to the heart muscles. The spasm of this artery can be caused by certain drugs and tobacco use.
The following are the risk factors that predispose an individual to develop myocardial infarction:
- Age – men aged 45 years and above and women aged 55 years and older are noted to have higher risks of having a myocardial infarction
- Tobacco use
- High blood pressure
- High blood cholesterol
- Metabolic syndrome
- Family history
- Lack of physical activity
- Drug use
- History of preeclampsia
- Autoimmune condition
Complications of Myocardial Infarction
- Arrhythmias. These are abnormal heart rhythms that can lead to death.
- Heart failure. Significant damage to the heart can cause strain to the remaining healthy heart muscles leading to heart failure.
- Cardiac arrest. While heart attack involves the lack of blood flow to the heart muscles, cardiac arrest refers to electrical disturbances in the heart rhythms, causing the heart to stop pumping.
Diagnosis of Myocardial Infarction
Immediate treatment is necessary to prevent permanent and serious damage when a heart attack is suspected.
A series of diagnostic tests may be performed to support the diagnosis and they will need to be performed as soon as possible so treatment can be started.
- Medical history and physical examination – A detailed history and thorough medical examination are helpful in the diagnosis of myocardial infarction. The assessment will focus on the presence of risk factors and signs and symptoms. Machines will be hooked to continuously monitor the heart tracing and vital signs.
- Electrocardiogram (ECG) – an ECG will be performed immediately to record the tracing of the heart.
- Partial blockage – non-ST elevation myocardial infarction (NSTEMI)
- Complete blockage – ST elevation myocardial infarction (STEMI)
- Blood tests – enzymes and protein markers such as troponin I and T and CKMB are often measured to identify muscle damage and wasting.
- Additional tests may also be performed to help treat the condition:
- Chest X-ray – chest x-ray will display the size of the heart and may identify the presence of fluid build-up in the lungs and other associated conditions.
- Echocardiogram – this test can help identify the area of the heart damaged by the infarction.
- Coronary catheterization – this procedure is done under fluoroscopy. A catheter is inserted thru an artery on the arms or the groin which will then thread to the coronary artery. Images are taken while a contrast agent is injected.
- Cardiac CT or MRI – these imaging techniques can help identify heart damage or associated heart problems.
Treatment of Myocardial Infarction
- Thrombolytics – these drugs can dissolve clots to improve flow.
- Antiplatelet agents – these drugs are given to prevent clots from getting worse and prevent future clot formation.
- Blood thinners – other forms of blood thinners are often given to make blood less viscous.
- Analgesic – pain killers may be given to help manage chest pain.
- Nitroglycerin – this drug is a common treatment for angina as it promotes the dilation of blood vessels and improves flow.
- Beta blockers – these drugs help the heart pump more effectively.
- ACE-inhibitors – these drugs help by lowering blood pressure and reducing the strain on the heart muscles.
- Statins – these drugs help manage blood cholesterol levels.
- Coronary angioplasty stenting – this procedure involves the insertion of a balloon stent guided by fluoroscopy or ultrasound. A stent is inserted through a small catheter inserted from an artery in the arm or groin into the narrowed coronary artery to keep the vessel open.
- Coronary artery bypass surgery – this procedure is more invasive, and it involves the cutting and sewing of arteries to bypass the blocked part.
- Lifestyle changes. Smoking cessation, committing to a low cholesterol, low sugar diet, and stress management can help prevent M.I. or reduce the risk of another episode in a person who had a previous heart attack. Foods rich in omega-3 fatty acids such as fish, soybeans, and flaxseeds are recommended. Regular taking of prescribed blood pressure medications also helps control hypertension. Increasing physical activity by doing at least 150 minutes of moderate aerobic exercises will help promote an active lifestyle.
Nursing Diagnosis for Myocardial Infarction
Nursing Care Plan for Myocardial Infarction 1
Nursing Diagnosis: Acute Pain related to coronary artery occlusion secondary to M.I. as evidenced by pain score of 10 out of 10, verbalization of pressure-like/ squeezing chest pain (angina), guarding sign on the chest, blood pressure level of 190/100, respiratory rate of 30 bpm, and restlessness
Desired Outcome: The patient will demonstrate relief of pain as evidenced by a pain score of 0 out of 10, stable vital signs, and absence of restlessness.
|Nursing Interventions for Myocardial Infarction||Rationale|
|Administer prescribed medications that alleviate the symptoms of angina.||Nitrates may be given to relax the blood vessels. Pain killers may be given to help manage chest pain. Other medications that help treat angina include anti-cholesterol drugs (e.g. statins), beta blockers, and calcium channel blockers.|
|Assess the patient’s vital signs and characteristics of pain at least 30 minutes after administration of medication.||To monitor effectiveness of medical treatment for the relief of angina. The time of monitoring of vital signs may depend on the peak time of the drug administered.|
|Elevate the head of the bed if the patient is short of breath. Administer supplemental oxygen, as prescribed. Discontinue if SpO2 level is above the target range, or as ordered by the physician.||To increase the oxygen level and achieve an SpO2 value within the target range.|
|Place the patient in complete bed rest during angina attacks. Educate patient on stress management, deep breathing exercises, and relaxation techniques.||Stress causes a persistent increase in cortisol levels, which has been linked to people with cardiac issues. The effects of stress are likely to increase myocardial workload.|
Nursing Care Plan for Myocardial Infarction 2
Nursing Diagnosis: Risk for Decreased Cardiac Output related to lack of blood supply to the heart secondary to myocardial infarction
Desired outcome: The patient will be able to maintain adequate cardiac output.
|Nursing Interventions for Myocardial Infarction||Rationales|
|Assess the patient’s vital signs and characteristics of heartbeat through attaching the patient to a continuous vital signs monitor. Assess breath sounds via auscultation. Observe for signs of decreasing peripheral tissue perfusion such as slow capillary refill, facial pallor, cyanosis, and cool, clammy skin.||To assist in creating an accurate diagnosis and monitor effectiveness of medical treatment. Breath sounds of crackles/rales are important signs of heart failure. The presence of signs of decreasing peripheral tissue perfusion indicate deterioration of the patient’s status which require immediate referral to the physician.|
|Administer the cardiac medications, and diuretics as prescribed.||To alleviate the symptoms of heart failure and to treat the underlying condition.|
|Administer supplemental oxygen, as prescribed. Discontinue if SpO2 level is above the target range, or as ordered by the physician.||To increase the oxygen level and achieve an SpO2 value within the target range.|
|Educate patient on stress management, smoking cessation, proper diet, blood pressure and blood sugar control, exercise, deep breathing exercises, and relaxation techniques.||Smoking cessation, committing to a low cholesterol, low sugar diet, and stress management can help prevent M.I. or reduce the risk of another episode in a person who had a previous heart attack. Foods rich in omega-3 fatty acids such as fish, soybeans, and flaxseeds are recommended. Regular taking of prescribed blood pressure medications also helps control hypertension. Increasing physical activity by doing at least 150 minutes of moderate aerobic exercises will help promote an active lifestyle.|
Nursing Care Plan for Myocardial Infarction 3
Nursing Diagnosis: Activity intolerance related to myocardial imbalance between oxygen supply and demand secondary to M.I. as evidenced by fatigue, overwhelming lack of energy, verbalization of tiredness, generalized weakness, and shortness of breath upon exertion
Desired Outcome: The patient will demonstrate active participation in necessary and desired activities and demonstrate increase in activity levels.
|Nursing Interventions for Myocardial Infarction||Rationales|
|Assess the patient’s activities of daily living, as well as actual and perceived limitations to physical activity. Ask for any form of exercise that he/she used to do or wants to try.||To create a baseline of activity levels and mental status related to fatigue and activity intolerance.|
|Encourage progressive activity through self-care and exercise as tolerated. Alternate periods of physical activity with 60-90 minutes of undisturbed rest.||To gradually increase the patient’s tolerance to physical activity.|
|Teach deep breathing exercises and relaxation techniques. Provide adequate ventilation in the room.||To allow the patient to relax while at rest and to facilitate effective stress management. To allow enough oxygenation in the room.|
|Refer the patient to physiotherapy / occupational therapy team as required.||To provide a more specialized care for the patient in terms of helping him/her build confidence in increasing daily physical activity.|
|Educate the patient on energy conservation techniques, which include:Working or moving at an even pacePushing rather than pullingSliding rather than pullingSitting to perform some tasksPositioning frequently used items within reach||Energy conservation techniques help reduce the body’s demand for oxygen, which allows the patient to accomplish more ADLs.|
Nursing Care Plan for Myocardial Infarction 4
Risk for Ineffective Tissue Perfusion
Nursing Diagnosis: Risk for Ineffective Tissue Perfusion related to the interruption of blood flow due to vasoconstriction and thromboembolic formation, secondary to myocardial infarction.
Desired Outcome: The patient will be able to show adequate perfusion as appropriate for the patient by having the following: skin warm and dry, presence of strong peripheral pulses, vital signs within normal limits, patient alert and oriented, Intake and output equilibrium, absence of edema and free of discomfort.
|Nursing Interventions for Myocardial Infarction||Rationale|
|Probe for sudden or continued deviations in the patient’s mental status such as loss of consciousness, stupor, etc.||Cardiac output and quality can directly affect the cerebral perfusion to the brain. Likewise, any deviations in the electrolytes, acid-base balance, oxygen saturation levels and presence of systemic emboli can create variations in the blood circulation to the brain that will affect the patient’s neurologic health.|
|Assess for the presence of pallor, cyanosis, or cool and clammy skin. Pay attention to the strength of pulses, especially the peripheral pulses.||The presence of generalized vasoconstriction due to limited cardiac output can be observed in the patient with diminished skin perfusion and weakening of pulses.|
|Observe the patient’s quality of respirations, especially the breathing effort and the respiratory rate.||Respiratory distress may consequently occur due to heart-pumping failure or the presence of ischemic pain. However, the sudden, or irrational occurrence of dyspnea may mean the development of thromboembolic pulmonary deviations.|
|Take note of the patient’s fluid balance, particularly any deviations in urine output. If capable, monitor and encode the urine specific gravity as ordered.||The patient who exhibits diminished fluid intake or incessant nausea because of myocardial infarction may experience decreased circulating blood volume, which will adversely compromise perfusion and organ function. Urine-specific gravity is a good indication for evaluating hydration and kidney function.|
|Evaluate the patient’s gastrointestinal (GI) integrity, observing for anorexia, deviations in bowel sounds, abdominal distention, constipation, and other GI issues.||Due to the decreased circulating volume supplying the mesentery arteries of the abdomen, GI dysfunction is apparent (i.e., loss of peristalsis). The use of analgesics, presence of limited physical activity, and untoward dietary changes may further complicate the GI status of the patient.|
|Promote and advocate for the patient to do passive or active leg exercises. Avoid isometric exercises.||Active or passive leg exercises can improve the venous return from the lower limbs, thereby reducing stasis and reducing the risk for thrombophlebitis formation. However, isometric exercises that increase heart workload and oxygen utilization can negatively affect the cardiac output.|
|Evaluate the patient for episodes of calf pain on dorsiflexion (i.e., Homans’ sign), edema, and erythema.||A positive Homans’ sign is highly indicative of deep vein thrombosis (DVT) although DVT can occur even with a negative result.|
|Take note of the patient’s laboratory values such as: ABG’s, BUN, creatinine, electrolytes, coagulation factors (PT, aPTT, clotting and bleeding times, etc.)||These lab values are good indicators of organ function. Any deviations in coagulation may happen due to the therapeutic effect of rendered medical management.|
|Anticipate administration of the following medications as ordered: |
H2 receptor blockers, and antacids
|These medications, which are taken daily, assist in lowering mortality rates in MI patients by reducing coronary re-obstruction after percutaneous transluminal coronary angioplasty (PTCA). Certain types of parenteral anticoagulants are also given to patients during PTCA. It is also given as a precaution for patients tagged as high risk (e.g., those with atrial fibrillation) to limit thrombophlebitis risk. These medications are administered as both preventive agents and treatment for thromboembolic deviations associated with MI. They decrease or neutralize gastric acid in the stomach, thereby relieving discomfort and mucosal irritation.|
|Anticipate and aid with reperfusion therapy through: |
Administration of thrombolytic agents
Prepare for PTCA, either using intracoronary stents or not.
Move the patient to a specialized care unit
|Thrombolytic therapy is the default medication management (when done within 6 hours) to disintegrate MI-related clots and reestablish heart perfusion. Stent placements are utilized to structurally support the vessels, thereby improving patency. MI patients would need a higher level of care in order to prevent complications and reduce mortality rates.|
|Educate the patient on the use and removal of anti-embolic stockings, including scheduling patterns.||Anti-embolic stockings are helpful in limiting venous stasis. Limiting stasis results in better venous blood return and diminishes the risk for thrombophlebitis formation. Anti-embolic stockings are particularly effective for the bed-bound patients with compromised mobility.|
Nursing Care Plan for Myocardial Infarction 5
Nursing Diagnosis: Anxiety related to a sudden change in health status secondary to myocardial infarction as evidenced by fearful decorum, feelings of apprehension, restlessness, facial tension, and verbalizations of uncertainty and inadequacy.
Desired Outcome: The patient will be able to recognize emotions and feelings, verbalize reduction of apprehensiveness and demonstrate constructive problem-solving skills.
|Nursing Interventions for Myocardial Infarction||Rationale|
|Recognize the patient’s outlook with regard to the current health situation. Promote verbalization and expression of anger, grief, sadness, etc.||The patient with MI oftentimes may find coping difficult due to the associated pain and emotional trauma of the condition. The patient may have feelings of fear of dying or of the sudden changes in the environment. Continuous anxiety (related to the impact of the heart attack on the life of the patient and other issues) may be present and consequently, develop into deeper issues like depression.|
|Project a confident, but calm demeanor, free from false reassuring attitude.||At times of apprehension, the patient and family can be readily affected if the health care team is also anxious. Maintaining a confident and secure demeanor will help alleviate the anxiety of the patient. Giving honest explanations will also help in reducing apprehensiveness.|
|Take note of the verbal and non-verbal cues of anxiety such as restlessness, deviations in vital signs, etc. Ensure to stay with the patient and intervene as necessary when the patient expresses destructive behavior.||The patient with MI may have difficulties expressing concerns openly and may utilize aggressive and hostile behavior to vent out these feelings. On-time professional intervention can assist the patient to regain control of destructive behavior.|
|Accept but prevent the use of denial. Stay clear if the patient becomes confrontational.||Denial can help in reducing anxiety in the short term but can prolong in resolution of the reality of present issues. Confrontations can give rise to anger and increased use of denial that will eventually limit the cooperation and recovery of the patient.|
|Educate the patient and significant others of scheduled procedures and activities. Encourage patient participation to care when not contraindicated.||Giving out information and practicing the patient to predictability can help address the anxiety levels of the patient with MI.|
|Address patient inquiries as truthfully as possible. Give out consistent and accurate information and repeat as necessary.||Accurate data about the patient’s current issues diminishes fear and improves the patient-nurse relationship. It also helps the patient and relatives to address the issues head-on. Repeating information to an anxious patient helps with retention for better cooperation and attainment of care goals.|
|Promote improving communication between the patient and his significant others through sharing issues and questions.||Information sharing with trusted people promotes a supportive and comforting environment. Furthermore, it can relieve unnecessary tension and unspoken worries and issues that may impede the patient’s progress.|
|Ensure privacy is kept for both the patient and significant other (SO).||Letting the patient and their significant other have their own privacy will ensure the expression of feelings that may help address anxiety. It also improves the patient’s support system, thereby allowing for better-coping behaviors.|
|Promote consistent rest periods and uninterrupted sleeping time. Provide a safe and quiet environment, free from external stimuli as much as possible.||Better rest times for the patient will help in the conservation of energy reserves. It promotes adaptive mechanisms and improvement of patient outlook to present situation.|
|Advise the patient to seek independent behavior, ownership of self-care, and formulation of own decisions within the prescribed therapeutic regimen.||The patient with MI would oftentimes feel powerless due to the debilitating effect of the condition. Allowing the patient to increase their independence will help in elevating self-confidence and self-worth that will be crucial for recovery and achievement of health goals until the discharge from the hospital.|
|Allow the patient to openly discuss expectations, especially anticipated issues when the patient is discharged from the hospital.||Open discussion assists the patient and family to recognize realistic goals that will reduce the risk of fall-out and discouragement with the established care goals, especially the associated limitation to full recovery.|
|Anticipate administration of anti-anxiety medications and hypnotics as ordered by the physician.||These medications are prescribed to address the patient’s anxiety, thereby reducing unnecessary stress, and improving relaxation patterns.|
|Tolerate normalizing the grieving process. Ensure to include ample time for resolution of issues.||Supporting the patient can help provide assistance and reassurance to feelings that are currently affecting the patient. Assuring the patient that grieving is a normal process and respond to sudden changes and deviations from the usual, especially to anticipated changes post-admission.|
|Observe for presence of withdrawal symptoms, episodes of hostility or denial episodes (as a refusal to comply with treatment).||Some research stipulates that type A and type B individuals’ survival rates when correlated with denial ideations are obscure and ambivalent. However, certain studies have found links that the degree of expressing anger is relationally proportional to an elevated risk of MI.|
Nursing Care Plan for Myocardial Infarction 6
Nursing Diagnosis: Risk for Excess Fluid Volume due to diminished renal perfusion secondary to myocardial infarction.
- The patient will be able to achieve body fluid equilibrium as displayed by blood pressure within normal range.
- The patient will be able to remain free of peripheral vein distention, dependent edema; and achieve clear lung fields and stable patient weight.
|Nursing Interventions for Myocardial Infarction||Rationale|
|Assess the patient’s breath sounds. Observe and watch out for the presence of adventitious breath sounds, particularly crackles.||Due to the kidneys not receiving adequate blood, the patient may develop pulmonary edema as a result of poor renal function. The formation of pulmonary edema is a direct result of the associated cardiac decompensation brought about by myocardial infarction to the rest of the body.|
|Observe for the development of jugular vein distention (JVD) and formation of dependent edema.||Presence of JVD and dependent edema is suggestive of congestive heart failure. It occurs due to the inadequacy of the heart to control body circulation, thereby resulting to fluid volume excesses in the body.|
|Take note of the patient’s intake and output (I & O). Observe for diminishing urine output and concentrated features. Strive to maintain fluid equilibrium.||Ineffective cardiac output consequently develops into impaired renal perfusion. The associated impairment will promote sodium and water retention, thereby reducing urine output and compromising fluid and electrolyte balance in the body.|
|Ensure to take patient weights daily.||The patient’s weight is a good indicator for monitoring alterations in the fluid balance that may suddenly shift in the presence of MI complications.|
|Ensure that the patient’s total intake is at 2000 ml within 24 hours, within the tolerance levels of the patient.||Fluid intake of 2000 ml in 24 hours is within the body requirements to facilitate proper body functioning. However, volume adjustments may be warranted if the patient develops cardiac issues and decompensation.|
|Ensure the patient takes a low sodium diet and beverages.||The action of sodium is to attract fluid and promote its retention in the body. Considering this, restricting sodium is beneficial during the active phase of MI. This is also applicable once the patient develops heart failure.|
|Anticipate administration of diuretics as ordered.||Diuretics are medications that address excess body fluid by drawing them out of interstitial spaces to be redirected to the kidneys for elimination. However, the type of diuretic will depend on the nature of clinical manifestation (either acute or chronic).|
|Observe the patient’s electrolyte levels, particularly the serum potassium.||Deviations in serum potassium have debilitating effects on the body. Hypokalemia can diminish the therapeutic effects of prescribed therapy, especially those with potassium-depleting diuretics.|
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