MYOCARDIAL INFARCTION Nursing Management

Myocardial infarction (MI) is caused by marked reduction/loss of blood flow through one or more of the coronary arteries, resulting in cardiac muscle ischemia and necrosis.

Care Setting

Inpatient acute hospital, step-down, or medical unit.

Related Concerns

Angina

Dysrhythmias

Heart failure: chronic

Psychosocial aspects of care

Thrombophlebitis: deep vein thrombosis

Client Assessment Database

Activity/Rest

May report: Weakness, fatigue, loss of sleep

Sedentary lifestyle, sporadic exercise schedule

May exhibit: Tachycardia, dyspnea with rest/activity

Circulation

May report: History of previous MI, CAD, HF, hypertension, diabetes mellitus

May exhibit: BP may be normal, increased, or decreased; postural changes may be noted from lying to sitting/standing

Pulse may be normal, full/bounding, or have a weak/thready quality with delayed capillary refill; irregularities (dysrhythmias) may be present

Heart sounds S₃/S₄ may reflect a pathologic condition (e.g., cardiac failure, decreased ventricular contractility or compliance)

Murmurs may reflect valvular insufficiency or papillary muscle dysfunction

Friction rub (suggests pericarditis)

Heart rate regular or irregular; tachycardia/bradycardia may be present

Edema: Jugular vein distention, peripheral/dependent edema, generalized edema

Color: Pallor or cyanosis/mottling of skin, nail beds, mucous membranes, and lips may be noted

Ego Integrity

May report: Denial of significance of symptoms/presence of condition

Fear of dying, feelings of impending doom

Anger at inconvenience of illness/”unnecessary” hospitalization

Worry about family, employment, finances

May exhibit: Denial, withdrawal, anxiety, lack of eye contact

Irritability, anger, combative behavior

Focus on self/pain

Elimination

May exhibit: Normal or decreased bowel sounds

Food/Fluid

May report: Nausea, loss of appetite, belching, indigestion/heartburn

May exhibit: Poor skin turgor; dry or diaphoretic skin

Vomiting

Hygiene

May report/

exhibit: Difficulty in performing self-care tasks

Neurosensory

May report: Dizziness, fainting spells in or out of bed (upright or at rest)

May exhibit: Changes in mentation

Weakness

Pain/Discomfort

May report: Note: Reports of location and intensity of pain differ between men and women.

Sudden onset of chest pain unrelieved by rest or nitroglycerin (although most pain is deep and visceral, 20% of MIs are painless)

Location: Typically, anterior chest (substernal, precordium); may radiate to arms, jaw, face; may have atypical location such as epigastrium/abdomen, elbow, jaw, back, neck, between shoulder blades, severe sore throat. Women may report pain between shoulder blades, back pain, tiredness, throat fullness

Quality: Crushing, constricting, vise-like, squeezing, heavy, steady. Women may report dull aching pain

Intensity: Usually 10 on a scale of 0–10 or “worst pain ever experienced.” Note: Pain is sometimes absent in women, postoperative clients, those with prior stroke or heart failure, diabetes mellitus or hypertension, or the elderly. Studies indicate that up to one-third of persons experiencing MI do not have typical chest pain.

Precipitating factor: May/may not be associated with activity

May exhibit: Facial grimacing, changes in body posture, may place clenched fist on midsternum when describing pain

Crying, groaning, squirming, stretching

Withdrawal, lack of eye contact

Autonomic responses: Changes in heart rate/rhythm, BP, respirations, skin color/moisture, level of consciousness

Respiration

May report: Dyspnea with/without exertion, nocturnal dyspnea

Cough with/without sputum production

History of smoking, chronic respiratory disease

May exhibit: Increased respiratory rate, shallow/labored breathing

Pallor or cyanosis

Breath sounds clear or crackles/wheezes

Sputum clear, possibly pink-tinged

Social Interaction

May report: Recent stress; e.g., work, family

Difficulty coping with recent/current stressors; e.g., money, work, family problems made worse by this illness/hospitalization

May exhibit: Difficulty resting quietly, overemotional responses (intense anger, fear)

Withdrawal from family

Teaching/Learning

May report: Family history of heart disease/MI, diabetes, stroke, hypertension, peripheral vascular disease

Use of tobacco

Use/misuse cardiac medications, OTC preparations

Use of vitamins/herbal supplemetns (e.g., vitamin E, gensing, garlic, ginkgo, hawthorn, bromelain)

Discharge plan

considerations: May require assistance with food preparation, shopping, transportation, homemaking/maintenance tasks; physical layout of home

Refer to section at end of plan for postdischarge considerations.

Diagnostic Studies

ECG: ST elevation signifying ischemia; peaked upright or inverted T wave indicating injury; development of Q waves signifying prolonged ischemia or necrosis.

Blood tests:

Cardiac enzymes and isoenzymes: CPK-MB (isoenzyme in cardiac muscle): Elevates within 4–8 hours, peaks in 12–20 hours, returns to normal in 48–72 hours.

Troponins: Troponin I (cTnI) and troponin T (cTnT): Levels are elevated at 4–6 hours, peak at 14–18 hours, and return to baseline over 6–7 days. These enzymes have increased specificity for necrosis and are therefore useful in diagnosing postoperative MI when MB-CPK may be elevated related to skeletal trauma.

Myoglobin: A heme protein of small molecular weight that is more rapidly released from damaged muscle tissue with elevation within 2 hr after an acute MI, and peak levels occurring in 3–15 hours.

Electrolytes: Imbalances of sodium and potassium can alter conduction and compromise contractility.

WBC: Leukocytosis (10,000–20,000) usually appears on the second day after MI due to the inflammatory process.

Chemistry profiles: May be abnormal depending on acute/chronic abnormal organ function/perfusion.

ABGs/pulse oximetry: May indicate hypoxia or acute/chronic lung disease processes.

Lipids (total lipids, HDL, LDL, VLDL, total cholesterol, triglycerides, and phospholipids): Elevations may reflect arteriosclerosis as a cause for coronary narrowing or spasm.

Coronary angiography:  In hospitals with catheterization lab facilities, coronary angiography has become the gold standard for the assessment and treatment of myocardial infarction. Visualizes narrowing/occlusion of coronary arteries and is usually done in conjunction with measurements of chamber pressures and assessment of left ventricular function (ejection fraction). Procedure is not usually done in acute phase of MI unless angioplasty with/without stenting, or emergency heart surgery is imminent.

Chest x-ray: May be normal or show an enlarged cardiac shadow suggestive of HF or ventricular aneurysm.

Two-dimensional echocardiogram: May be done to determine dimensions of chambers, septal/ventricular wall motion, ejection fraction (blood flow), and valve configuration/function.

Nuclear imaging studies:

Persantine or thallium: Evaluates myocardial blood flow and status of myocardial cells; e.g., location/extent of acute/previous MI.

Cardiac blood imaging/MUGA: Evaluates specific and general ventricular performance, regional wall motion, and ejection fraction.

Technetium: Accumulates in ischemic cells, outlining necrotic area(s).

Digital subtraction angiography (DSA): Technique used to visualize status of arterial bypass grafts and to detect peripheral artery disease.

MRI: Allows visualization of blood flow, cardiac chambers/intraventricular septum, valves, vascular lesions, plaque formations, areas of necrosis/infarction, and blood clots.

Exercise stress test: Determines cardiovascular response to activity (often done in conjunction with thallium imaging in the recovery phase).

Nursing Priorities

1. Relieve pain, anxiety.

2. Reduce myocardial workload.

3. Prevent/detect and assist in treatment of life-threatening dysrhythmias or complications.

4. Promote cardiac health, self-care.

Discharge Goals

1. Chest pain absent/controlled.

2. Heart rate/rhythm sufficient to sustain adequate cardiac output/tissue perfusion.

3. Achievement of activity level sufficient for basic self-care.

4. Anxiety reduced/managed.

5. Disease process, treatment plan, and prognosis understood.

6. Plan in place to meet needs after discharge.

 

NURSING DIAGNOSIS: acute Pain

May be related to

Tissue ischemia (coronary artery occlusion)

Possibly evidenced by

Reports of chest pain with/without radiation

Facial grimacing

Restlessness, changes in level of consciousness

Changes in pulse, BP

DESIRED OUTCOMES/EVALUATION CRITERIA—CLIENT WILL:

Pain Level (NOC)

Verbalize relief/control of chest pain within appropriate time frame for administered medications.

Display reduced tension, relaxed manner, ease of movement.

Pain Control (NOC)

Demonstrate use of relaxation techniques

ACTIONS/INTERVENTIONS Pain Management (NIC) Independent Monitor/document characteristics of pain, noting verbal reports, nonverbal cues (e.g., moaning, crying, restlessness, diaphoresis, clutching chest, rapid breathing), and hemodynamic response (BP/heart rate changes). Obtain full description of pain from client including location, intensity (0–10), duration, characteristics (dull/crushing), and radiation. Assist client to quantify pain by comparing it to other experiences. Review history of previous angina, anginal equivalent, or MI pain. Discuss family history if pertinent. Instruct client to report pain immediately. Provide quiet environment, calm activities, and comfort measures (e.g., dry/wrinkle-free linens, backrub). Approach client calmly and confidently.

RATIONALE Variation of appearance and behavior of clients in pain may present a challenge in assessment (e.g., men and women consistently present differently; or an individual may present differently from one episode to another). However, most clients with an acute MI appear ill, distracted, and focused on pain. Verbal history and deeper investigation of precipitating factors should be postponed until pain is relieved. Respirations may be increased as a result of pain and associated anxiety; release of stress-induced catecholamines increases heart rate and BP. Pain is a subjective experience and must be described by client. Provides baseline for comparison to aid in determining effectiveness of therapy, resolution/progression of problem. May differentiate current pain from preexisting patterns, as well as identify complications such as extension of infarction, pulmonary embolus, or pericarditis. Delay in reporting pain hinders pain relief/may necessitate increased dosage of medication to achieve relief. In addition, severe pain may induce shock by stimulating the sympathetic nervous system, thereby creating further damage and interfering with diagnostics and relief of pain. Decreases external stimuli, which may aggravate anxiety and cardiac strain, limit coping abilities and adjustment to current situation.

Assist/instruct in relaxation techniques; e.g., deep/slow breathing, distraction behaviors, visualization, guided imagery. Check vital signs before and after administration of narcotic medication. Collaborative Administer supplemental oxygen by means of nasal cannula or face mask, as indicated. Administer medications as indicated: Aspirin (ASA); Antianginals; e.g., nitroglycerin (Nitro-Bid, Nitrostat, Nitro-Dur), isosorbide dinitrate (Isordil), mononitrate (Imdur); β-Blockers; e.g., atenolol (Tenormin), pindolol (Visken), propranolol (Inderal), nadolol (Corgard), metoprolol (Lopressor); Analgesics; e.g., morphine sulfate.

Helpful in decreasing perception of/ response to pain. Provides a sense of having some control over the situation, increase in positive attitude. Hypotension/respiratory depression can occur as a result of narcotic administration. These problems may increase myocardial damage in presence of ventricular insufficiency.   Increases amount of oxygen available for myocardial uptake and thereby may relieve discomfort associated with tissue ischemia. Aspirin is the mainline medication to be given first to all acute MI clients. ASA possesses anti-inflammatory, analgesic, and anitplatelet qualities that assist in the stabilization of plaque while decreasing clotting potential. Nitrates are useful for pain control by coronary vasodilating effects, which increase coronary blood flow and myocardial perfusion. Peripheral vasodilation effects reduce the volume of blood returning to the heart (preload), thereby decreasing myocardial workload and oxygen demand. Important second-line agents for pain control through effect of blocking sympathetic stimulation, thereby reducing heart rate, systolic BP, and myocardial oxygen demand. May be given alone or with nitrates. Note: β-blockers may be contraindicated if myocardial contractility is severely impaired because negative inotropic properties can further reduce contractility. Although intravenous (IV) morphine is the usual drug of choice, other injectable narcotics may be used in acute-phase/recurrent chest pain unrelieved by nitroglycerin to reduce severe pain, provide sedation, and decrease myocardial workload. IM injections should be avoided, if possible, because they can alter the CPK diagnostic indicator and are not well absorbed in underperfused tissue.

 

NURSING DIAGNOSIS: Activity Intolerance

May be related to

Imbalance between myocardial oxygen supply and demand

Presence of ischemia/necrotic myocardial tissues

Cardiac depressant effects of certain drugs (beta-blockers, antidysrhythmics)

Possibly evidenced by

Alterations in heart rate and BP with activity

Development of dysrhythmias

Changes in skin color/moisture

Exertional angina

Generalized weakness

DESIRED OUTCOMES/EVALUATION CRITERIA—CLIENT WILL:

Activity Tolerance (NOC)

Demonstrate measurable/progressive increase in tolerance for activity with heart rate/rhythm and BP within client’s normal limits and skin warm, pink, dry.

Report absence of angina with activity.

ACTIONS/INTERVENTIONS Energy Management (NIC) Independent Record/document heart rate and rhythm and BP changes before, during, and after activity as indicated. Correlate with reports of chest pain/shortness of breath. (Refer to ND: risk for decreased Cardiac Output.) Encourage rest (bed/chair) initially. Thereafter, limit activity on basis of pain/ adverse cardiac response. Provide nonstress diversional activities. Instruct client to avoid increasing abdominal pressure; e.g., straining during defecation. Explain pattern of graded increase of activity level; e.g., getting up to commode or sitting in chair, progressive ambulation, and resting after meals. Review signs/symptoms reflecting intolerance of present activity level or requiring notification of nurse/physician. Collaborative Refer to cardiac rehabilitation program.

RATIONALE Trends determine client’s response to activity and may indicate myocardial oxygen deprivation that may require decrease in activity level/return to bedrest, changes in medication regimen, or use of supplemental oxygen. Reduces myocardial workload/oxygen consumption, reducing risk of complications (e.g., extension of MI). Note: American Heart Association/American College of Cardiology guidelines (1996) suggest that clients with cardiac conditions should not be kept in bed longer than 24 hours. Clients with uncomplicated MI are encouraged to engage in mild activity out of bed, including short walks 12 hours after incident. Activities that require holding the breath and bearing down (Valsalva’s maneuver) can result in bradycardia (temporarily reduced cardiac output) and rebound tachycardia with elevated BP. Progressive activity provides a controlled demand on the heart, increasing strength and preventing overexertion. Palpitations, pulse irregularities, development of chest pain, or dyspnea may indicate need for changes in exercise regimen or medication. Provides continued support/additional supervision and participation in recovery and wellness process.

NURSING DIAGNOSIS: Anxiety [specify level]/Fear

May be related to

Threat to or change in health and socioeconomic status

Threat of loss/death

Unconscious conflict about essential values, beliefs, and goals of life

Interpersonal transmission/contagion

Possibly evidenced by

Fearful attitude

Apprehension, increased tension, restlessness, facial tension

Uncertainty, feelings of inadequacy

Somatic complaints/sympathetic stimulation

Focus on self, expressions of concern about current and future events

Fight (e.g., belligerent attitude) or flight behavior

DESIRED OUTCOMES/EVALUATION CRITERIA—CLIENT WILL:

Anxiety Self-Control/Fear Self-Control (NOC)

Recognize feelings.

Identify causes, contributing factors.

Verbalize reduction of anxiety or fear.

Demonstrate positive problem-solving skills.

Identify/use resources appropriately.

ACTIONS/INTERVENTIONS Anxiety Reduction (NIC) Independent Identify and acknowledge client’s perception of threat/situation. Encourage expressions of, and do not deny feelings of, anger, grief, sadness, fear. Note presence of hostility, withdrawal, and/or denial (inappropriate affect or refusal to comply with medical regimen). Maintain confident manner (without false reassurance). Observe for verbal/nonverbal signs of anxiety, and stay with client. Intervene if client displays destructive behavior.

RATIONALE Coping with the pain and emotional trauma of an MI is difficult. Client may fear death and/or be anxious about immediate environment. Ongoing anxiety (related to concerns about impact of heart attack on future lifestyle, matters left unattended/unresolved, and effects of illness on family) may be present in varying degrees for some time and may be manifested by symptoms of depression. Research into survival rates between type A and type B individuals and the impact of denial has been ambiguous; however, studies show some correlation between degree/expression of anger or hostility and an increased risk for MI. Client and SO can be affected by the anxiety/uneasiness displayed by health team members. Honest explanations can alleviate anxiety. Client may not express concern directly, but words/actions may convey sense of agitation, aggression, and hostility. Intervention can help client regain control of own behavior.

 

Accept but do not reinforce use of denial. Avoid confrontations. Orient client/SO to routine procedures and expected activities. Promote participation when possible. Answer all questions factually. Provide consistent information; repeat as indicated. Encourage client/SO to communicate with one another, sharing questions and concerns. Provide privacy for client and SO. Provide rest periods/uninterrupted sleep time, quiet surroundings, with client controlling type, amount of external stimuli. Support normality of grieving process, including time necessary for resolution. Encourage independence, self-care, and decision making within accepted treatment plan. Encourage discussion about postdischarge expectations. Collaborative Administer antianxiety/hypnotics as indicated; e.g., alprazolam (Xanax), diazepam (Valium), lorazepam (Ativan), flurazepam (Dalmane).

Denial can be beneficial in decreasing anxiety but can postpone dealing with the reality of the current situation. Confrontation can promote anger and increase use of denial, reducing cooperation and possibly impeding recovery. Predictability and information can decrease anxiety for client. Accurate information about the situation reduces fear, strengthens nurse-client relationship, and assists client/SO to deal realistically with situation. Attention span may be short, and repetition of information helps with retention. Sharing information elicits support/comfort and can relieve tension of unexpressed worries. Allows needed time for personal expression of feelings; may enhance mutual support and promote more adaptive behaviors. Conserves energy and enhances coping abilities. Can provide reassurance that feelings are normal response to situation/perceived changes. Increased independence from staff promotes self-confidence and reduces feelings of abandonment that can accompany transfer from coronary unit/discharge from hospital. Helps client/SO identify realistic goals, thereby reducing risk of discouragement in face of the reality of limitations of condition/pace of recuperation.   Promotes relaxation/rest and reduces feelings of anxiety.

NURSING DIAGNOSIS: risk for decreased Cardiac Output

Risk factors may include

Changes in rate, rhythm, electrical conduction

Reduced preload/increased SVR

Infarcted/dyskinetic muscle, structural defects; e.g., ventricular aneurysm,

septal defects

Possibly evidenced by

[Not applicable; presence of signs and symptoms establishes actual diagnosis.]

DESIRED OUTCOMES/EVALUATION CRITERIA—CLIENT WILL:

Cardiac Pump Effectiveness (NOC)

Maintain hemodynamic stability; e.g., BP, cardiac output within normal range, adequate urinary output, decreased frequency/absence of dysrhythmias.

Report decreased episodes of dyspnea, angina.

Demonstrate an increase in activity tolerance.

ACTIONS/INTERVENTIONS Cardiac Care: Acute (NIC) Independent Auscultate BP. Compare both arms and obtain lying, sitting, and standing pressures when able. Evaluate quality and equality of pulses, as indicated. Auscultate heart sounds: Note development of S3, S4; Presence of murmurs/rubs. Auscultate breath sounds.

RATIONALE Hypotension may occur related to ventricular dysfunction, hypoperfusion of the myocardium, and vagal stimulation. However, hypertension is also a common phenomenon, possibly related to pain, anxiety, catecholamine release, and/or preexisting vascular problems. Orthostatic (postural) hypotension may be associated with complications of infarct; e.g., HF. Decreased cardiac output results in diminished weak/thready pulses. Irregularities suggest dysrhythmias, which may require further evaluation/monitoring. S3 is usually associated with HF, but it may also be noted with the mitral insufficiency (regurgitation) and left ventricular overload that can accompany severe infarction. S4 may be associated with myocardial ischemia, ventricular stiffening, and pulmonary or systemic hypertension. Indicates disturbances of normal blood flow within the heart; e.g., incompetent valve, septal defect, or vibration of papillary muscle/chordae tendineae (complication of MI). Presence of rub with an infarction is also associated with inflammation; e.g., pericardial effusion and pericarditis. Crackles reflecting pulmonary congestion may develop because of depressed myocardial function.

Monitor heart rate and rhythm. Document dysrhythmias via telemetry. Note response to activity and promote rest appropriately. (Refer to ND: Activity Intolerance.) Provide small/easily digested meals. Limit caffeine intake; e.g., coffee, chocolate, cola as indicated. Have emergency equipment/medications available. Collaborative Administer supplemental oxygen, as indicated. Measure cardiac output and other functional parameters as appropriate. Maintain IV/Hep-Lock access as indicated. Review serial ECGs. Review chest x-ray. Monitor laboratory data; e.g., cardiac enzymes, ABGs, electrolytes.

Heart rate and rhythm respond to medication, activity, and developing complications. Dysrhythmias (especially premature ventricular contractions or progressive heart blocks) can compromise cardiac function or increase ischemic damage. Acute or chronic atrial flutter/fibrillation may be seen with coronary artery or valvular involvement and may or may not be pathologic. Overexertion increases oxygen consumption/demand and can compromise myocardial function. Large meals may increase myocardial workload and cause vagal stimulation, resulting in bradycardia/ectopic beats. Caffeine is a direct cardiac stimulant that can increase heart rate but may not be a problem for everyone (e.g., some clients with regular daily caffeine intake). Sudden coronary occlusion, lethal dysrhythmias, extension of infarct, and unrelenting pain are situations that may precipitate cardiac arrest, requiring immediate life-saving therapies/transfer to critical/coronary care unit (CCU). Increases amount of oxygen available for myocardial uptake, reducing ischemia and resultant cellular irritation/dysrhythmias. Cardiac index, preload/afterload, contractility, and cardiac work can be measured noninvasively with thoracic electrical bioimpedance (TEB) technique. Useful in evaluating response to therapeutic interventions and identifying need for more aggressive/emergency care. Patent line is important for administration of emergency drugs in presence of persistent lethal dysrhythmias or chest pain. Provides information regarding progression/resolution of infarction, status of ventricular function, electrolyte balance, and effects of drug therapies. May reflect pulmonary edema related to ventricular dysfunction. Enzymes monitor resolution/extension of infarction. Presence of hypoxia indicates need for supplemental oxygen. Electrolyte imbalance; e.g., hypokalemia/hyperkalemia, adversely affects cardiac rhythm/contractility.

Administer antidysrhythmic drugs as indicated. (Refer to CP: Dysrhythmias.) Assist with insertion/maintain pacemaker/automatic internal cardiac defibrillator (AICD) when used.

Dysrhythmias are usually treated symptomatically. Early inclusion of ACE inhibitor therapy (especially in presence of large anterior MI, ventricular aneurysm, or HF) enhances ventricular output, increases survival, and may slow progression of HF. Note: Use of routine lidocaine is no longer recommended. Pacing may be a temporary support measure during acute phase or may be needed permanently if infarction severely damages conduction system, impairing systolic function. Use of AICD is currently advocated in client who has had ventricular fibrillation or tachycardia resulting in arrest. Strong supporting data document the benefits of ICDs for the primary prevention of sudden cardiac death.

NURSING DIAGNOSIS: ineffective Tissue Perfusion

Risk factors may include

Reduction/interruption of blood flow; e.g., vasoconstriction, hypovolemia/shunting, and thromboembolic formation

Possibly evidenced by

[Not applicable; presence of signs and symptoms establishes an actual diagnosis.]

DESIRED OUTCOMES/EVALUATION CRITERIA—CLIENT WILL:

Cardiac Pump Effectiveness (NOC)

Demonstrate adequate perfusion as individually appropriate; e.g., skin warm and dry, peripheral pulses present/strong, vital signs within client’s normal range, client alert/oriented, balanced I&O, absence of edema, free of pain/discomfort

ACTIONS/INTERVENTIONS Hemodynamic Regulation (NIC) Independent Investigate sudden changes or continued alterations in mentation; e.g., anxiety, confusion, lethargy, stupor. Inspect for pallor, cyanosis, mottling, cool/clammy skin. Note strength of peripheral pulse.

RATIONALE Cerebral perfusion is directly related to cardiac output and is also influenced by electrolyte/acid-base variations, hypoxia, and systemic emboli. Systemic vasoconstriction resulting from diminished cardiac output may be evidenced by decreased skin perfusion and diminished pulses. (Refer to ND: risk for decreased Cardiac Output, p. 000.)

 

 

Monitor respirations, note work of breathing. Monitor intake, note changes in urine output. Record urine specific gravity as indicated. Assess GI function, noting anorexia, decreased/absent bowel sounds, nausea/vomiting, abdominal distention, constipation. Circulatory Care: Venous Insufficiency (NIC) Encourage active/passive leg exercises, avoidance of isometric exercises. Assess for pain in lower extremity/ Homans’ sign, erythema, edema. Instruct client in application/periodic removal of antiembolic hose when used. Collaborative Monitor laboratory data; e.g., ABGs, BUN, creatinine, electrolytes, coagulation studies (PT, aPTT, clotting times). Administer medications as indicated:Antiplatelet agents; e.g., aspirin, abciximab (ReoPro), clopidogrel (Plavix); eptifibatide (Integrilin);Anticoagulants; e.g., heparin/enoxaparin (Lovenox); Cimetidine (Tagamet), ranitidine (Zantac), antacids.

Cardiac pump failure and/or ischemic pain may precipitate respiratory distress; however, sudden/continued dyspnea may indicate thromboembolic pulmonary complications. Decreased intake/persistent nausea may result in reduced circulating volume, which negatively affects perfusion and organ function. Specific gravity measurements reflect hydration status and renal function. Reduced blood flow to mesentery can produce GI dysfunction; e.g., loss of peristalsis. Problems may be potentiated/aggravated by use of analgesics, decreased activity, and dietary changes. Enhances venous return, reduces venous stasis, and decreases risk of thrombophlebitis; however, isometric exercises can adversely affect cardiac output by increasing myocardial work and oxygen consumption. Indicators of deep vein thrombosis (DVT), although calf pain is not always present. Limits venous stasis, improves venous return, and reduces risk of thrombophlebitis in client who is limited in activity. Indicators of organ perfusion/function. Abnormalities in coagulation may occur as a result of therapeutic measures (e.g., heparin/Coumadin use and some cardiac drugs).   Reduces mortality in MI clients, and is taken daily. Aspirin also reduces coronary reocclusion after percutaneous transluminal coronary angioplasty (PTCA). IV antiplatelet drugs (e.g., ReoPro, Integrilin) are used as adjuncts to PTCA to decrease complication of platelet clumping within stent when placed. Low-dose heparin is given during PTCA and may be given prophylactically in high-risk clients (e.g., atrial fibrillation, obesity, ventricular aneurysm, or history of thrombophlebitis) to reduce risk of thrombophlebitis or mural thrombus formation. May occasionally be used to reduce or neutralize gastric acid, preventing discomfort and gastric irritation, especially in presence of reduced mucosal circulation.

Assist with reperfusion therapy: Administer thrombolytic agents; e.g., alteplase (Activase, rt-PA), reteplase (Retavase), streptokinase (Streptase), anistreplase (Eminase), urokinase, (Abbokinase). Prepare for procedures; e.g., balloon coronary angioplasty (PTCA), with/without intracoronary stents. Transfer to critical care or step-down unit.

Thrombolytic therapy is the treatment of choice if angioplasty is not immediately (within 90 minutes) available. The goal is to restore pefusion to the myocardium. Angioplasty is used to open blocked coronary arteries, and immediately restore myocardial perfusion. The mechanism includes a combination of vessel stretching and plaque compression and/or removal of thrombotic material. Intracoronary stents may be placed at the time of PTCA to provide structural support within the coronary artery . Drug-eluting (drug-coated) stents may be used to decrease risk of restenosis/improve long-term patency. Depending on client’s condition/heart damage, other chronic health conditions, telemetry or more intensive monitoring and aggressive interventions may be necessary to promote optimum outcome.

NURSING DIAGNOSIS: risk for excess Fluid Volume

Risk factors may include

Decreased organ perfusion (renal)

Increased sodium/water retention

Increased hydrostatic pressure or decreased plasma proteins (sequestering of fluid in interstitial space/tissues)

Possibly evidenced by

[Not applicable; presence of signs and symptoms establishes an actual diagnosis.]

DESIRED OUTCOMES/EVALUATION CRITERIA—CLIENT WILL:

Fluid Balance (NOC)

Maintain fluid balance as evidenced by BP within client’s normal limits.

Be free of peripheral/venous distention and dependent edema, with lungs clear and weight stable.

ACTIONS/INTERVENTIONS Fluid Management (NIC) Independent Auscultate breath sounds for presence of crackles. Note JVD, development of dependent edema.

RATIONALE May indicate pulmonary edema secondary to cardiac decompensation. Suggests developing congestive failure/fluid volume excess.

Measure I&O, noting decrease in output, concentrated appearance. Calculate fluid balance. Weigh daily. Maintain total fluid intake at 2000 mL/24 hour within cardiovascular tolerance.  Collaborative Provide low-sodium, low caffeine diet/beverages. Administer diuretics; e.g., furosemide (Lasix), spironolactone with hydrochlorothiazide (Aldactazide), hydralazine (Apresoline). Monitor potassium as indicated.

Decreased cardiac output results in impaired kidney perfusion, sodium/water retention, and reduced urine output. Sudden changes in weight reflect alterations in fluid balance. Meets normal adult body fluid requirements, but may require alteration/restriction in presence of cardiac decompensation. Sodium enhances fluid retention and should therefore be restricted during active MI phase and/or if heart failure is present. Caffiene may cause vasospasm. May be necessary to correct fluid overload. Drug choice is usually dependent on acute/chronic nature of symptoms. Hypokalemia can limit effectiveness of therapy and can occur with use of potassium-depleting diuretics.

NURSING DIAGNOSIS: deficient Knowledge [Learning Need] regarding cause/treatment of condition, self-care, and discharge needs

May be related to

Lack of information/misunderstanding of medical condition/therapy needs

Unfamiliarity with information resources

Lack of recall

Possibly evidenced by

Questions; statement of misconception

Failure to improve on previous regimen

Development of preventable complications

DESIRED OUTCOMES/EVALUATION CRITERIA—CLIENT WILL:

Knowledge: Cardiac Disease Management (NOC)

Verbalize understanding of condition, potential complications, individual risk factors, and function of pacemaker (if used).

Relate signs of pacemaker failure.

Verbalize understanding of therapeutic regimen.

List desired action and possible adverse side effects of medications.

Cardiac Disease Self-Management (NOC)

Correctly perform necessary procedures and explain reasons for actions.

ACTIONS/INTERVENTIONS Teaching: Individual (NIC) Independent Assess client/SO level of knowledge and ability/desire to learn. Be alert to signs of avoidance; e.g., changing subject away from information being presented or extremes of behavior (withdrawal/euphoria). Present information in varied learning formats; e.g., programmed books, audiovisual tapes, question-and-answer sessions, group activities. Cardiac Care: Rehabilitation (NIC) Reinforce explanations of risk factors, dietary/activity restrictions, medications, and symptoms requiring immediate medical attention. Discuss use of herbals (e.g., gensing, garlic, ginkgo, hawthorn, bromelain) as indicated. Encourage identification/reduction of individual risk factors; e.g., smoking/alcohol consumption, obesity. Warn against isometric activity, Valsalva’s maneuver, and activities requiring arms positioned above head. Review programmed increases in levels of activity. Educate client regarding gradual resumption of activities; e.g., walking, work, recreational and sexual activity. Provide guidelines for gradually increasing activity and instruction regarding target heart rate and pulse taking, as appropriate. Identify alternative activities for “bad weather” days, such as measured walking in house or shopping mall. Review signs/symptoms requiring reduction in activity and notification of healthcare provider. Differentiate between increased heart rate that normally occurs during various activities and worsening signs of cardiac stress (e.g., chest pain, dyspnea, palpitations, increased heart rate lasting more than 15 min after cessation of activity, excessive fatigue the following day).

RATIONALE   Necessary for creation of individual instruction plan. Reinforces expectation that this will be a “learning experience.” Verbalization identifies misunderstandings and allows for clarification. Natural defense mechanisms, such as anger or denial of significance of situation, can block learning, affecting client’s response and ability to assimilate information. Changing to a less formal/structured style may be more effective until client/SO is ready to accept/deal with current situation. Using multiple learning methods enhances retention of material. Provides opportunity for client to retain information and to assume control/participate in rehabilitation program. Use of supplements/herbal remedies can result in alterations in blood clotting, especially when anticoagulant therapy; e.g., Plavix or ASA, is prescribed. Other herbals (e.g., hawthorn) can increase the effect of certain cardiac medications. These behaviors/chemicals have direct adverse effects on cardiovascular function and may impede recovery, increase risk for complications. These activities greatly increase cardiac workload and myocardial oxygen consumption and may adversely affect myocardial contractility/output. Gradual increase in activity increases strength and prevents overexertion, may enhance collateral circulation, and promotes return to normal lifestyle. Note: Sexual activity can be safely resumed once client can accomplish activity equivalent to climbing two flights of stairs without adverse cardiac effects. Provides for continuing daily activity program. Pulse elevations beyond established limits, development of chest pain, or dyspnea may require changes in exercise and medication regimen.

Stress importance of follow-up care, and identify community resources/support groups; e.g., cardiac rehabilitation programs, “coronary clubs,” smoking cessation clinics. Emphasize importance of contacting physician if chest pain, change in anginal pattern, or other symptoms recur. Stress importance of reporting development of fever in association with diffuse/atypical chest pain (pleural, pericardial) and joint pain. Encourage client/SO to share concerns/feelings. Discuss signs of pathologic depression versus transient feelings frequently associated with major life events. Recommend seeking professional help if depressed feelings persist.

Reinforces that this is an ongoing/continuing health problem for which support/assistance is available after discharge. Note: After discharge, client can encounter limitations in physical functioning and often incur difficulty with emotional, social, and role functioning requiring ongoing support. Timely evaluation/intervention may prevent complications. Post-MI complication of pericardial inflammation (Dressler’s syndrome) requires further medical evaluation and intervention. Depressed clients have a greater risk of dying 6–18 months following a heart attack. Timely intervention may be beneficial. Note: Selective serotonin reuptake inhibitors (SSRIs), e.g., paroxetine (Paxil), have been found to be as effective as tricyclic antidepressants but with significantly fewer adverse cardiac complications.

POTENTIAL CONSIDERATIONS following discharge from care setting (dependent on client’s age, physical condition/presence of complications, personal resources, and life responsibilities)

Activity Intolerance —imbalance between myocardial oxygen supply/demand.

anticipatory Grieving—perceived loss of general well-being, required changes in lifestyle, confronting mortality.

decisional Conflict (treatment)—multiple/divergent sources of information, perceived threat to value system, support system deficit.

interrupted Family Processes—situational transition and crisis.

impaired Home Management—altered ability to perform tasks, inadequate support systems, reluctance to request assistance.