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.
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.
Risk Factors
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
- Obesity
- Diabetes
- Metabolic syndrome
- Family history
- Lack of physical activity
- Stress
- Drug use
- History of preeclampsia
- Autoimmune condition
Signs and Symptoms of Myocardial Infarction
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.
The chest pain should be assessed in combination of the other symptoms to determine a heart attack.
Expected Outcomes and Goals
- Prompt recognition and intervention
- Pain relief and comfort
- Cardiovascular stability
- Oxygenation and respiratory support
- Emotional support and education
- Complication prevention
- Collaborative care and discharge planning
Nursing Assessment and Rationales of Myocardial Infarction
- Conduct a comprehensive initial assessment upon admission to gather baseline data. This includes assessing the patient’s vital signs, pain level, oxygen saturation, cardiac rhythm, and respiratory status. It also involves obtaining a detailed medical history, including risk factors for coronary artery disease, previous cardiac events, and current medications. Rationale: This assessment helps establish a baseline for ongoing monitoring and provides crucial information for immediate interventions.
- Perform a thorough cardiac assessment to evaluate the patient’s heart function. Assess heart sounds, including the presence of abnormal sounds such as murmurs or gallops. Monitor for signs of impaired cardiac output, such as changes in mentation, decreased urine output, and peripheral edema. Rationale: These assessments help detect any cardiac complications and guide appropriate interventions.
- Assess the patient’s pain level using a validated pain scale and monitor its location, intensity, duration, and factors that aggravate or alleviate the pain. Rationale: Prompt and adequate pain management is essential in myocardial infarction to relieve discomfort, reduce anxiety, and prevent complications such as increased sympathetic stimulation and decreased cardiac output.
- Monitor the patient’s respiratory status closely, assessing for signs of respiratory distress, such as shortness of breath, orthopnea (difficulty breathing when lying flat), or crackles in lung fields. Assess oxygen saturation levels and respiratory rate regularly. Rationale: This helps identify any pulmonary complications or signs of inadequate oxygenation.
- Conduct a psychosocial assessment to evaluate the patient’s emotional well-being, coping mechanisms, and support systems. Rationale: A myocardial infarction can cause significant psychological distress, including anxiety, depression, or fear of recurrence. Assessing the patient’s psychosocial status allows for the provision of appropriate emotional support and referral to counseling services if needed.
- Identify and assess the patient’s risk factors for coronary artery disease and myocardial infarction. This includes evaluating lifestyle factors such as smoking, sedentary behavior, unhealthy diet, and obesity. Rationale: Assessing these risk factors helps in educating the patient about necessary lifestyle modifications and planning appropriate interventions for secondary prevention.
- Collaborate with the healthcare team to obtain and interpret laboratory and diagnostic tests. This may include cardiac enzyme levels (such as troponin), electrocardiogram (ECG) findings, echocardiogram, or coronary angiography results. Rationale: These tests provide objective data on the extent of myocardial damage, guide treatment decisions, and assist in monitoring the patient’s progress.
Nursing Interventions and Rationales for Myocardial Infarction
Administer oxygen therapy: Provide supplemental oxygen as prescribed to maintain adequate oxygenation. Rationale: Oxygen therapy improves oxygen delivery to the myocardium, decreases myocardial workload, and promotes tissue perfusion.
Administer prescribed medications: Ensure timely administration of medications such as antiplatelets (e.g., aspirin), nitroglycerin, beta-blockers, angiotensin-converting enzyme (ACE) inhibitors, or statins. Rationale: These medications help alleviate symptoms, reduce myocardial ischemia, prevent clot formation, lower blood pressure, and manage lipid levels.
Manage pain: Administer pain relief medications promptly and reassess pain levels regularly. Rationale: Effective pain management reduces anxiety, promotes comfort, decreases sympathetic stimulation, and improves overall patient well-being.
Monitor cardiac rhythm: Continuously monitor the patient’s cardiac rhythm using cardiac telemetry or electrocardiogram (ECG). Rationale: Promptly identify and report any dysrhythmias or changes in the rhythm, as they may indicate ongoing myocardial damage or the need for further interventions.
Promote rest and activity balance: Encourage an appropriate balance between rest and activity to prevent excessive strain on the heart. Gradually introduce activity as tolerated, ensuring periods of rest in between. Rationale: This helps prevent complications such as cardiac overload or fatigue.
Provide emotional support: Be empathetic, compassionate, and provide emotional support to patients and their families. Rationale: A myocardial infarction can be a distressing experience, and emotional support helps reduce anxiety, facilitate coping, and improve the patient’s overall well-being.
Monitor vital signs and symptoms: Regularly assess and monitor vital signs, including blood pressure, heart rate, respiratory rate, and oxygen saturation. Monitor for symptoms such as chest pain, shortness of breath, or changes in mentation. Rationale: Timely detection of abnormal vital signs or symptoms enables prompt intervention and the prevention of complications.
Promote lifestyle modifications: Educate patients on lifestyle modifications, such as smoking cessation, adopting a heart-healthy diet, engaging in regular exercise, and managing stress. Rationale: These interventions help reduce risk factors, improve cardiac function, and promote long-term recovery.
Facilitate patient and family education: Provide comprehensive education regarding the diagnosis, treatment, medications, and self-care measures. Teach patients about the signs and symptoms of worsening conditions and when to seek medical assistance. Rationale: Education empowers patients and their families to actively participate in their care and promotes adherence to treatment plans.
Collaborate with the healthcare team: Work collaboratively with the healthcare team to coordinate care, facilitate consultations, and ensure a multidisciplinary approach to patient management. Rationale: Effective collaboration improves communication, enhances the quality of care, and promotes positive patient outcomes.
More Nursing Diagnosis for Myocardial Infarction
Acute Pain
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
Risk for Decreased Cardiac Output
Nursing Diagnosis: Risk for Decreased Cardiac Output related to lack of blood supply to the heart secondary to myocardial infarction
Activity Intolerance
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
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.
Anxiety
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.
Risk for Excess Fluid Volume
Nursing Diagnosis: Risk for Excess Fluid Volume due to diminished renal perfusion secondary to myocardial infarction.
Nursing Test Questions for Myocardial Infarction
Question 1: Which of the following is the most common cause of myocardial infarction?
A) Atrial fibrillation
B) Coronary artery spasm
C) Pulmonary embolism
D) Atherosclerosis
Answer: D) Atherosclerosis Rationale: Atherosclerosis is the most common cause of myocardial infarction. It is characterized by the buildup of plaque within the coronary arteries, leading to reduced blood flow and oxygen supply to the heart muscle.
Question 2: Which laboratory test is the most specific and sensitive marker for myocardial infarction?
A) Creatine kinase (CK)
B) Troponin
C) Myoglobin
D) C-reactive protein (CRP)
Answer: B) Troponin Rationale: Troponin is the most specific and sensitive marker for myocardial infarction. Elevated troponin levels indicate myocardial damage, as troponin is released into the bloodstream when heart muscle cells are injured.
Question 3: Which medication is commonly administered to reduce myocardial oxygen demand in patients with myocardial infarction?
A) Heparin
B) Furosemide
C) Nitroglycerin
D) Alteplase
Answer: C) Nitroglycerin Rationale: Nitroglycerin is commonly administered to reduce myocardial oxygen demand by dilating coronary arteries and improving blood flow to the heart. It also helps relieve chest pain (angina) associated with myocardial infarction.
Question 4: During the acute phase of myocardial infarction, what position should the nurse encourage the patient to assume?
A) High Fowler’s position
B) Supine position with elevated legs
C) Left lateral position
D) Semi-Fowler’s position with the head of the bed elevated 30 degrees
Answer: A) High Fowler’s position Rationale: During the acute phase of myocardial infarction, the nurse should encourage the patient to assume a High Fowler’s position. This position helps improve oxygenation, reduces venous return, and minimizes the workload on the heart.
Question 5: Which complication is a potential risk for patients with myocardial infarction within the first 24-48 hours?
A) Heart failure
B) Ventricular fibrillation
C) Pulmonary embolism
D) Cardiogenic shock
Answer: B) Ventricular fibrillation Rationale: Ventricular fibrillation is a potential complication that can occur within the first 24-48 hours after a myocardial infarction. Prompt recognition and treatment are essential, as ventricular fibrillation can lead to cardiac arrest if not managed quickly.
Nursing References
Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.
Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier.
Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2020). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier.
Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.
Best Nursing Books and Resources
These are the nursing books and resources that we recommend.
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The Nursing Diagnosis Handbook E-Book: An Evidence-Based Guide to Planning Care
This is an excellent reference for nurses and nursing students. While it is a great resource for writing nursing care plans and nursing diagnoses, it also helps guide the nurse to match the nursing diagnosis to the patient assessment and diagnosis.
This handbook has been updated with NANDA-I approved Nursing Diagnoses that incorporates NOC and NIC taxonomies and evidenced based nursing interventions and much more.
NANDA International Nursing Diagnoses: Definitions & Classification, 2021-2023
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Nursing Care Plans: Nursing Diagnosis and Intervention
It contains more than 200 care plans that adhere to the newest evidence-based recommendations.
Additionally, it distinguishes between nursing and collaborative approaches and highlights QSEN competencies.
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