Myocardial infarction (MI), commonly known as a heart attack, occurs when there is inadequate perfusion to the myocardium due to a blockage in blood and oxygen supply to the heart. This condition, known as myocardial ischemia, is frequently caused by coronary artery disease.
In emergency situations, oxygen deprivation leads to ischemia, or reduced blood flow. An imbalance between myocardial oxygen supply and demand can result in MI, potentially causing cardiac death.
Besides coronary artery disease, other factors can trigger MI, including:
- Vasospasm (sudden narrowing of a coronary artery)
- Blood clots
- Electrolyte imbalances
- Trauma to the coronary arteries
Prolonged oxygen deprivation to the heart can manifest as chest pressure or discomfort, the most prevalent symptom. This pain might radiate to the neck, jaw, shoulder, or arm. Diagnostic evaluations, laboratory findings, and ECG alterations can confirm heart damage.
STEMI vs. NSTEMI
Unlike ST-elevation myocardial infarction (STEMI), non-ST-elevation myocardial infarction (NSTEMI) does not present with specific changes in the heart’s electrical activity on an ECG. In NSTEMI, the coronary artery is partially blocked, and the ST segment isn’t elevated, although heart attack symptoms can still be present.
Nursing Process for Myocardial Infarction
Nurses play a crucial role in immediately assessing patients to differentiate between chest pain (angina) and myocardial infarction (MI), as MIs require immediate intervention to preserve cardiac tissue. Prompt action in the emergency room for acute MI patients focuses on reducing ischemia, alleviating pain, and preventing circulatory collapse and shock. The MONA regimen (morphine, oxygen, nitrates, and aspirin) is typically initiated. Continuous cardiac monitoring and IV access for fluid and emergency medication administration are established. Further procedures like cardiac catheterization or CABG may be necessary.
Post-MI, nurses are vital in patient education and encouragement regarding medication adherence, dietary and weight management, and lifestyle modifications to mitigate risk factors. Cardiac rehabilitation programs are often recommended for ongoing recovery after hospital discharge.
Nursing Assessment for Myocardial Infarction
The initial step in nursing care is a thorough nursing assessment, encompassing physical, psychosocial, emotional, and diagnostic data collection. This section will outline subjective and objective data pertinent to myocardial infarction, crucial for formulating an effective Nursing Diagnosis Nursing Care Plan For Myocardial Infarction.
Review of Health History
1. Identify General Symptoms. Patients may report various general symptoms:
- Chest, back, shoulder, or jaw pain
- Palpitations
- Shortness of breath (dyspnea) at rest and during exertion
- Fatigue
- Sweating
- Nausea
- Fainting (syncope)
- Dizziness
2. Detailed Chest Pain Interview. Elicit detailed descriptions of chest pain:
- Chest tightness, squeezing, heaviness, or burning sensations
- Arm or shoulder pain
- Pain during exertion or at rest
- Jaw or abdominal pain during exertion or at rest
- Intermittent or persistent pain
- Pain lasting over 20 minutes
- Pain during physical activity
- Pain triggered by stress or emotions
3. Risk Factor Identification.
Non-modifiable risk factors:
- Gender and Age: MI is more common in men over 45 and women over 50 or post-menopause.
- Family History: A family history of ischemic heart disease in a first-degree relative before age 55 increases MI risk.
- Race/Ethnicity: Black individuals face twice the MI risk compared to non-Black individuals.
Modifiable risk factors:
- Hypertension: Uncontrolled high blood pressure stiffens arteries, reducing oxygenated blood flow to the heart.
- Hyperlipidemia/Hypercholesterolemia: Elevated LDL or decreased HDL cholesterol levels increase MI risk.
- Diabetes or Insulin Resistance: Diabetes or insulin resistance leads to hardened arteries and viscous blood due to high glucose levels.
- Tobacco Use: Smoking and secondhand smoke are strongly linked to MI.
- Obesity: Obese individuals have higher blood pressure due to increased blood volume needed to oxygenate the body, increasing heart strain.
- Physical Inactivity: Lack of activity can lead to rigid arteries, increasing MI risk.
- Diet: Diets high in trans and saturated fats contribute to arterial cholesterol buildup.
- Stress: Extreme stress increases heart rate and blood flow, potentially constricting arteries already narrowed by plaques.
- Alcohol Use: Heavy alcohol consumption affects lipids, platelets, and heart function, increasing heart damage and sudden cardiac death risk.
- Lack of Sleep: Insufficient sleep leads to prolonged elevated blood pressure.
4. Medication Review. Certain medications can constrict heart blood vessels, increasing heart workload:
- Anthracyclines
- Antipsychotic drugs
- Nonsteroidal anti-inflammatory drugs
- Type 2 diabetes medications (thiazolidinediones and rosiglitazone)
- Recreational and street drugs:
- Amphetamines and amphetamine-like substances
- Anabolic steroids
- Cocaine and crack
- Nicotine
5. Emotional Factors Assessment. Anginophobia, the fear of chest pain, can trigger panic attacks mimicking MI symptoms, such as tachycardia, tachypnea, hypertension, and diaphoresis, often rooted in underlying anxiety disorders requiring mental health support.
Physical Assessment for Myocardial Infarction
1. Prioritize ABCs. In suspected MI cases, immediate action is crucial: call emergency services or go to the ER, prioritizing Airway, Breathing, and Circulation. Initiate CPR if no pulse is detected.
2. Systemic Assessment:
- Neck: Check for jugular vein distention.
- CNS: Assess for anxiety, impending doom feeling, syncope, dizziness, lightheadedness, and mental status changes.
- Cardiovascular: Evaluate chest pain, murmurs, carotid artery bruits, arrhythmias, and blood pressure abnormalities.
- Circulatory: Note palpitations and thready pulse.
- Respiratory: Assess for dyspnea at rest or during exertion.
- Gastrointestinal: Check for nausea and vomiting.
- Musculoskeletal: Evaluate neck, arm, back, jaw, and upper extremity pain, and fatigue.
- Integumentary: Observe for cyanosis, pale skin, and excessive sweating.
3. ASCVD Risk Calculation. Calculate the patient’s atherosclerotic cardiovascular disease (ASCVD) risk score, aiming for a low score (<7.5%). Factors include:
- Age
- Gender
- Race
- Blood pressure
- Cholesterol levels
- Medications
- Diabetes status
- Smoking history
Diagnostic Procedures for Myocardial Infarction
1. ECG Interpretation. An ECG should be performed within 10 minutes of ER arrival. MI indications include:
- Pathological Q waves (greater than 25% of the QRS complex height).
- ST-segment elevation in STEMI.
- ST-segment depression or no consistent ST elevation in NSTEMI.
- Troponin elevation indicating cardiac muscle degeneration in both STEMI and NSTEMI.
2. Troponin Level Monitoring. Cardiac troponins (Troponin I or T) are highly sensitive biomarkers for myocardial ischemia. Levels elevate 4-9 hours post-damage, peak at 12-24 hours, and remain elevated for 1-2 weeks.
3. Echocardiogram. An echocardiogram is essential for diagnosing acute MI, ideally within 24-48 hours, with a follow-up echo within three months to establish a post-infarction baseline.
4. Further Investigations.
- Cardiac CT scans can accurately identify coronary heart disease causing MI.
- CT coronary angiograms use IV dye for detailed heart images.
Nursing Interventions for Myocardial Infarction
Nursing interventions and care are paramount for patient recovery, forming a critical part of the nursing diagnosis nursing care plan for myocardial infarction.
Restore Blood Perfusion
1. Reperfusion Therapy Assistance. Primary percutaneous coronary intervention (PCI) and fibrinolytic therapy are crucial for rapidly restoring blood flow to the ischemic myocardium and limiting infarct size.
2. Blocked Artery Management.
- Coronary Angioplasty and Stent Placement: Balloon stents widen narrowed arteries, maintaining artery patency.
- Coronary Artery Bypass Graft (CABG): Creates a bypass around blocked arteries using a second blood vessel.
3. Ischemia Reduction. Dual antiplatelet therapy (DAPT) is recommended for PCI patients. Anticoagulants like bivalirudin, enoxaparin, and unfractionated heparin are commonly used.
4. Blood Thinners Administration. Administer blood thinners cautiously as prescribed to prevent blood clot formation.
- Anticoagulants prolong blood clot formation time.
- Antiplatelets (e.g., aspirin) prevent platelet aggregation.
5. Clot Dissolution. Thrombolytics and fibrinolytics are “clot busters” that dissolve clots obstructing heart blood flow. Early administration minimizes heart damage and enhances survival chances.
Relieve Pain
1. Pain Relief Administration. Intravenous opioids like morphine are frequently used analgesics. Morphine reduces blood pressure, heart rate, and venous return, decreasing myocardial oxygen demand.
2. Supplemental Oxygen Administration. Oxygen increases cardiac tissue oxygenation and reduces ischemic pain, improving cardiac function and reducing infarct size.
3. Vasodilation Promotion. Nitroglycerin remains a first-line treatment for acute MI, inducing vasodilation and improving myocardial blood flow, primarily relieving chest pain.
Manage Symptoms
1. Blood Pressure Goal Setting. Antihypertensive therapy aims to manage blood pressure to prevent severe MI complications. Healthcare providers set individual blood pressure targets.
2. Blood Pressure Maintenance. Medications to manage high blood pressure in MI patients include:
- Beta-blockers: Reduce heart rate, blood pressure, and myocardial contractility, lowering myocardial oxygen demand. Avoid in suspected coronary vasospasm.
- ACE inhibitors: Used for patients with systolic left ventricular dysfunction, heart failure, hypertension, or diabetes.
- Intravenous nitrates: Effective for symptom relief and ST-segment depression regression in NSTEMI, superior to sublingual nitrates, titrated until symptom resolution or adverse effects appear.
3. Lipid Lowering. Statins are recommended to lower LDL cholesterol, stabilizing atherosclerotic plaques and preventing vessel blockage.
4. Blood Glucose Stabilization. Stress from acute MI can cause hyperglycemia. Glucose-lowering treatments are beneficial, regardless of diabetic status, to normalize blood sugar levels.
Cardiac Rehabilitation
1. Rehabilitation Plan Adherence. Cardiac rehab is crucial, particularly post-surgical procedures, reducing mortality risk after MI or bypass surgery.
2. Complication and Readmission Prevention. Cardiac rehabilitation aids recovery, reducing complications and hospital readmission rates.
3. Continued Rehabilitation Post-Discharge. Rehabilitation continues at home or in community facilities for about three months, tailored to individual needs.
4. Benefit Education. Cardiac rehab improves exercise capacity, BMI, lipid profiles, psychological well-being, and quality of life post-MI.
Prevent MI Complications
1. Regular Exercise Encouragement. Gradually increase exercise to 15-20 minutes, 4-6 weeks post-MI, as tolerated and advised by healthcare providers.
2. Healthy Weight Maintenance Promotion. Maintaining a healthy weight reduces blood pressure and MI risk.
3. Teach-back Method for MI Treatments. Patient education enhances medication and treatment adherence. Use teach-back methods to confirm understanding of medication regimens and follow-up care.
4. Stress Avoidance. Stress management techniques like yoga, relaxation, guided imagery, deep breathing, and meditation are vital.
5. Underlying Condition Control. Manage conditions like diabetes, hyperlipidemia, and hypertension to prevent complications and recurrent MI.
6. Lifestyle Change Assistance. Promote healthy lifestyle changes:
- Regular exercise and physical activity
- Heart-healthy diet
- Smoking cessation
- Stress and anxiety management
- Limited alcohol consumption
7. Regular Follow-up Emphasis. Recommend follow-up visits 3-6 weeks post-discharge for STEMI patients and outpatient follow-up for low-risk NSTEMI and revascularized patients.
8. CPR Training Encouragement. Encourage CPR training for caregivers and family members to improve emergency response.
9. Action Plan for Attack Symptoms. Advise patients on when to seek immediate medical attention and use nitroglycerin or aspirin for symptoms like chest pain and dyspnea.
10. Information on Sex After MI. Reassure patients that sexual activity is rarely an MI trigger and can resume when they feel physically capable.
11. Medical Alert Recommendation. Suggest medical alert bracelets or IDs to inform emergency responders about heart attack risk.
Nursing Care Plans for Myocardial Infarction
Nursing care plans, based on identified nursing diagnoses, prioritize assessments and interventions for both short and long-term care goals in myocardial infarction. Examples include:
Acute Pain Nursing Care Plan
Acute pain related to MI is caused by inadequate blood flow to the heart, manifesting as chest pain/discomfort.
Nursing Diagnosis: Acute Pain
Related to:
- Blockage of coronary arteries
- Reduced oxygen-rich blood flow to the heart
As evidenced by:
- Verbal reports of chest pain, pressure, or tightness
- Chest clutching
- Restlessness
- Labored breathing and dyspnea
- Diaphoresis
- Vital sign changes
Expected outcomes:
- Patient will report pain relief or control.
- Patient’s pain rating will decrease from baseline.
- Patient will appear relaxed and rested.
- Patient will perform daily activities without assistance.
Assessments:
1. Differentiate angina from MI chest pain. MI pain characteristics:
- Sudden onset, often in the early morning
- Crushing substernal pain
- Radiating pain to jaw, back, left arm
- Lasting 30+ minutes
- Not relieved by rest or nitroglycerin
2. Pain Characteristic Assessment. Detail symptom onset, triggers (activity, emotion), and pain relief measures taken.
3. ECG during Pain. Obtain ECG during chest pain episodes for rapid assessment.
Interventions:
1. Nitroglycerin Administration. Administer sublingual nitroglycerin for initial chest pain.
2. Oxygen Administration. Provide supplemental oxygen to improve heart function.
3. Morphine Administration. Administer morphine to reduce cardiac oxygen demand, blood pressure, heart rate, and anxiety.
4. Pain Control Effectiveness Evaluation. Regularly assess pain management effectiveness.
Anxiety Nursing Care Plan
Anxiety associated with MI can be due to sympathetic nervous system activation or be a contributing factor to MI.
Nursing Diagnosis: Anxiety
Related to:
- Perceived threat of death
- Threat to health status
- Role function changes
- Lifestyle modifications
As evidenced by:
- Increased tension
- Fearful attitude
- Apprehension
- Expressed concerns or uncertainty
- Restlessness
- Dyspnea
Expected outcomes:
- Patient will verbalize anxiety causes.
- Patient will understand necessary post-MI changes.
- Patient will use effective coping mechanisms.
- Patient will show reduced anxiety signs (stable vital signs, calm demeanor).
Assessments:
1. Observe Anxiety Levels. Recognize anxiety as a common and prognostic psychological symptom post-MI.
2. Subjective and Objective Anxiety Cues. Be alert to anxiety signs, even without chest pain complaints.
3. Coping Mechanism Assessment. Evaluate patient’s coping strategies for long-term recovery and adaptation.
Interventions:
1. Validate Patient Anxiety. Acknowledge and validate patient’s feelings, encouraging verbalization and offering support.
2. Provide Information and Answer Questions. Clearly explain tests, procedures, and interventions, allowing time for questions and honest answers.
3. Involve Patient in Care Planning. Include patients in care decisions to enhance autonomy and coping during treatment and recovery.
4. Stress Management. Implement stress management techniques to reduce PTSD risk and improve quality of life.
5. Teach Anxiety Reduction Techniques. Collaboratively identify and teach anxiety-reducing methods like exercise, journaling, breathing exercises, music, and medications.
Decreased Cardiac Output Nursing Care Plan
Decreased cardiac output in MI results from heart muscle damage, potentially leading to cardiogenic shock and death.
Nursing Diagnosis: Decreased Cardiac Output
Related to:
- Heart rate and electrical conduction changes
- Reduced preload and cardiovascular blood flow
- Atherosclerotic plaque rupture
- Occluded artery
- Altered muscle contractility
As evidenced by:
- Persistent chest pain unrelieved by rest and medication
- Shortness of breath
- Nausea and vomiting
- Anxiety
- Cool, pale, moist skin
- Tachycardia and tachypnea
- Fatigue and dizziness
- Confusion
- Dysrhythmia
Expected outcomes:
- Patient will maintain blood pressure within provider-set limits.
- Patient will exhibit reduced or absent dyspnea, angina, and dysrhythmias.
- Patient will understand MI and its management.
- Patient will participate in activities reducing heart workload.
Assessments:
1. Risk and Causative Factor Assessment. Review medical history for atherosclerosis, clots, heart failure, and other risk factors.
2. Angina vs. MI Differentiation. Differentiate stable angina from MI based on pain characteristics and relief factors.
3. Blood Pressure Monitoring. Closely monitor blood pressure, reporting systolic BP <100 mmHg or a 25 mmHg drop to prevent cardiogenic shock.
4. ECG Monitoring. Obtain ECG for early MI diagnosis and dysrhythmia detection.
5. Poor Cardiac Output Signs. Assess for cool skin, weak pulses, decreased urine output, altered mental status, and peripheral vasoconstriction.
6. Cardiac Enzyme Assessment. Monitor cardiac enzymes (myoglobin, troponin, creatine kinase), especially troponins for MI specificity.
Interventions:
1. Oxygen Administration. Administer oxygen to enhance heart and tissue perfusion.
2. Thrombolytic Therapy. Administer thrombolytics within 6 hours of symptom onset if PCI is not immediately available; monitor for bleeding.
3. Beta-blocker Administration. Administer beta-blockers to reduce myocardial workload and improve perfusion.
4. IV Access Establishment. Establish IV access for medication, fluids, and blood product administration.
5. Cardiac Catheterization Preparation. Prepare for potential urgent cardiac catheterization to assess blockages and place stents.
6. Bed Rest and Activity Restriction. Encourage bed rest to reduce heart workload and restrict activity post-catheterization.
7. Cardiac Rehabilitation Encouragement. Recommend cardiac rehabilitation for diet, exercise, and recovery education.
Ineffective Tissue Perfusion Nursing Care Plan
Ineffective tissue perfusion in MI is due to blocked oxygenated blood flow to tissues and organs.
Nursing Diagnosis: Ineffective Tissue Perfusion
Related to:
- Plaque formation and narrowed/obstructed arteries
- Unstable plaque rupture and vasospasm
- Ineffective cardiac muscle contraction
- Conditions compromising blood supply
- Increased heart workload
As evidenced by:
- Diminished peripheral pulses
- Increased CVP
- Tachycardia and dysrhythmias
- Decreased oxygen saturation
- Angina and dyspnea
- Altered consciousness level
- Restlessness and fatigue
- Exertional symptoms
- Cold, clammy skin and pallor
- Prolonged capillary refill
- Edema and claudication
- Numbness and altered sensation
- Poor wound healing
Expected outcomes:
- Patient will achieve normal pulses and capillary refill.
- Patient will exhibit warm skin without pallor or cyanosis.
- Patient will maintain alert and coherent consciousness.
Assessments:
1. ECG Assessment. Obtain ECG within 10 minutes of admission to assess heart electrical activity and detect MI signs.
2. Cardiovascular Status Assessment. Evaluate for coronary artery blockage and resulting ischemia, cardiac output, and tissue perfusion.
3. Peripheral Circulation Assessment. Assess skin color, capillary refill, and pulses to detect perfusion issues.
Interventions:
1. CPR Initiation. Start CPR if MI is suspected and no pulse is detected.
2. Reperfusion Treatment Initiation. Initiate reperfusion therapy for prolonged ST-segment elevation and ischemia symptoms within 12 hours.
3. Surgical Procedure Consideration. Prepare for PCI within 120 minutes of ECG diagnosis.
4. Fibrinolytic Administration. Administer fibrinolytics within 10 minutes of STEMI diagnosis if PCI is not immediately feasible.
5. Aspirin Administration. Administer aspirin immediately in suspected MI to maintain blood flow.
6. Cardiac Rehabilitation Referral. Refer to cardiac rehab for long-term recovery and secondary prevention.
Risk for Unstable Blood Pressure Nursing Care Plan
Risk for unstable blood pressure in MI arises from blood pressure instability, leading to insufficient blood flow and oxygenation.
Nursing Diagnosis: Risk for Unstable Blood Pressure
Related to:
- Ineffective heart muscle contraction
- Ischemia and constricted/obstructed arteries
- Unstable plaque rupture and coronary artery spasm
- Underlying cardiac conditions
- Increased workload exertion
As evidenced by:
Risk diagnosis is not evidenced by signs and symptoms. Interventions are preventative.
Expected outcomes:
- Patient will maintain blood pressure within normal limits.
- Patient will perform activities without BP fluctuations.
- Patient will adhere to BP-controlling medication regimen.
Assessments:
1. Blood Pressure Monitoring. Monitor BP for instability due to oxygen deprivation in MI.
2. Cardiovascular Status Assessment. Assess for MI complications related to cardiac muscle injury.
3. Signs and Symptoms Assessment. Monitor for headache, chest pain, mental status changes, diaphoresis, and dizziness related to BP changes.
4. Risk Factor Identification. Assess for combined risk factors increasing MI likelihood.
5. Chest Pain Assessment. Evaluate chest pain and associated sympathetic stimulation affecting BP.
Interventions:
1. Blood Pressure Stabilization. Use beta-blockers, ACE inhibitors, and calcium channel blockers to stabilize BP.
2. Vasodilator Administration. Administer vasodilators to achieve BP goals (<140/90 mmHg).
3. Fluid Overload Relief. Administer diuretics if heart failure or fluid overload contributes to hypertension.
4. Patient Education. Educate on the importance of BP monitoring and adherence to treatment, highlighting hypertension as a “silent killer.”
References
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