MI Nursing Diagnosis: A Comprehensive Guide for Healthcare Professionals

Introduction

Acute myocardial infarction (MI), commonly known as a heart attack, remains a leading cause of mortality and morbidity worldwide. It’s a critical condition characterized by irreversible damage to the heart muscle due to interrupted blood supply, most often from a blockage in a coronary artery. Globally, MI affects millions, with significant mortality rates reported annually, particularly in developed nations. MI is broadly classified into ST-segment elevation MI (STEMI) and non-ST-segment elevation MI (NSTEMI), with unstable angina sharing similarities to NSTEMI but distinguished by the absence of elevated cardiac markers.¹, ², ³

The consequences of MI extend beyond immediate tissue damage, often leading to impaired heart function, both systolic and diastolic, and increasing the risk of life-threatening arrhythmias. Prompt reperfusion of the heart to restore blood flow is paramount. Outcomes are significantly improved when treatment is initiated within six hours of symptom onset. Therefore, early recognition and swift intervention are critical in managing acute MI and improving patient prognosis.

Diagnosis of MI is typically confirmed when at least two of the following criteria are present:

Clinical symptoms indicative of myocardial ischemia.
New ST-segment changes on an electrocardiogram (ECG) or the presence of a new left bundle branch block (LBBB).
Development of pathological Q waves on the ECG.
Imaging evidence revealing new regional wall motion abnormalities.
Identification of an intracoronary thrombus during autopsy or angiography.

Nursing Diagnoses for Myocardial Infarction

In the context of acute myocardial infarction, several key nursing diagnoses are crucial for guiding patient care. These diagnoses address the immediate physiological and psychological challenges patients face. Understanding and prioritizing these diagnoses is essential for nurses to deliver effective and comprehensive care. The primary nursing diagnoses associated with MI include:

Acute Pain: Related to myocardial ischemia and tissue injury. Chest pain is the hallmark symptom of MI, resulting from the heart muscle’s deprivation of oxygen.
Activity Intolerance: Related to decreased cardiac output and imbalance between oxygen supply and demand. The damaged heart muscle’s reduced pumping efficiency limits the body’s ability to meet the demands of physical activity.
Fear/Anxiety: Related to the life-threatening nature of the event and uncertainty about the future. The sudden onset of MI and its potential complications can evoke significant emotional distress in patients.
Risk for Decreased Cardiac Output: Related to altered contractility, rhythm disturbances, and structural damage to the myocardium. MI directly impacts the heart’s ability to pump blood effectively, leading to potential hemodynamic instability.
Risk for Ineffective Tissue Perfusion: Related to reduced cardiac output and compromised blood flow to vital organs and peripheral tissues. The heart’s diminished pumping capacity can impair oxygen delivery throughout the body.
Risk for Excess Fluid Volume: Related to heart failure and compensatory mechanisms. Impaired cardiac function can lead to fluid retention, increasing the workload on the heart and potentially causing pulmonary edema.
Deficient Knowledge: Related to lack of information regarding the disease process, treatment plan, and lifestyle modifications necessary for recovery and prevention of future events. Patients need comprehensive education to understand their condition and actively participate in their care and rehabilitation.

Causes of Myocardial Infarction

The fundamental cause of acute myocardial infarction is a significant reduction in coronary blood flow. This disruption in blood supply leads to a critical mismatch between myocardial oxygen supply and demand, resulting in myocardial ischemia. This decreased coronary blood flow is often multifactorial.

Atherosclerosis is the most common underlying cause, where the rupture of atherosclerotic plaques triggers thrombus formation, acutely obstructing coronary arteries. However, other etiologies contribute to myocardial ischemia, including coronary artery embolism (accounting for nearly 3% of cases), cocaine-induced vasospasm, coronary artery dissection, and spontaneous coronary vasospasm.⁴, ⁵

Risk Factors for Myocardial Infarction

Atherosclerosis plays a dominant role in the majority of acute myocardial infarction cases, with approximately 70% of fatal events linked to plaque-related occlusions. Consequently, risk factors for atherosclerotic disease are crucial considerations in MI prevention. Modifiable risk factors are responsible for a significant majority of MI cases—around 90% in men and 94% in women. These modifiable factors include:

Cigarette smoking
Physical inactivity
Hypertension
Obesity
Elevated total cholesterol, LDL cholesterol, and triglyceride levels

Non-modifiable risk factors, while not directly controllable, are also important to acknowledge and include:

Age
Sex
Family history of cardiovascular disease⁶, ⁷

Assessment of Myocardial Infarction

Patient history and physical examination are vital, although findings can be variable when assessing for acute myocardial infarction. History taking should focus on the characteristics of chest pain: onset, quality, location, radiation, and associated symptoms. Research suggests that diaphoresis (sweating) and pain radiating to both arms are strong indicators of MI in men. Other associated symptoms may include:

Lightheadedness
Anxiety
Cough
Choking sensation
Diaphoresis
Wheezing
Irregular heart rate or palpitations

The physical exam should prioritize vital signs and general appearance, noting diaphoresis, as well as respiratory and cardiovascular findings. Key physical exam findings may include:

Heart Rate: May reveal tachycardia, atrial fibrillation, or ventricular arrhythmias.
Pulses: Unequal pulses may suggest aortic dissection, a critical differential diagnosis.
Blood Pressure: Typically elevated initially, but hypotension can occur in cases of cardiogenic shock.
Respirations: Tachypnea is common.
Temperature: Fever is not uncommon, especially in later stages.
Neck Veins: Jugular venous distension may indicate right ventricular failure.
Cardiac Auscultation: May reveal lateral displacement of the apical impulse, soft S1 sound, palpable S4 gallop, or a new mitral regurgitation murmur. A loud holosystolic murmur radiating to the sternum could suggest ventricular septal rupture.
Lungs: Wheezing and rales (crackles) may be present if pulmonary edema has developed.
Extremities: May exhibit edema, cyanosis, and feel cold to the touch due to poor perfusion.

Image: Gross pathology specimen showing myocardial infarction. The infarcted area is visible in the left ventricle and interventricular septum. Left ventricular hypertrophy is also noted.

Evaluation and Diagnostic Testing for Myocardial Infarction

Prompt and rapid ECG testing is crucial for all patients presenting with chest pain or symptoms suggestive of MI. It’s important to note that women, the elderly, and patients with diabetes may present with atypical symptoms. Women may experience abdominal pain or dizziness, and some may not have chest pain at all. Elderly patients more commonly present with shortness of breath as their primary symptom. Any of these presentations should prompt immediate ECG evaluation.⁸, ⁹, ¹⁰

While ECG is highly specific for MI (95% to 97%), its sensitivity is lower (approximately 30%). Using right-sided and posterior ECG leads, as well as repeating ECGs, can improve sensitivity. Early ischemic changes may manifest as peaked T-waves, known as “hyperacute T waves,” which often precede ST-segment elevation. ST-segment elevations greater than 2 mm in two contiguous leads (inferior leads II, III, aVF; septal leads V1, V2; anterior leads V3, V4; lateral leads I, aVL, V5, V6) are highly indicative of ST-elevation myocardial infarction (STEMI). Reciprocal ST depressions may also be observed in anatomically opposite regions of the myocardium.

ECG diagnosis of STEMI can be challenging, especially in patients with pre-existing left bundle branch block (LBBB) or pacemakers. The Sgarbosa criteria have been developed to aid in STEMI diagnosis in these complex cases. Isolated ST-segment elevation in lead aVR in the appropriate clinical context may suggest left main coronary artery occlusion, a particularly dangerous condition. Wellens’ syndrome, characterized by deeply biphasic T waves in leads V2 and V3, is often predictive of critical proximal left anterior descending artery occlusion and a high risk of extensive anterior wall MI.

Patients with myocardial infarction may not always present with ST-segment elevation on ECG. For patients with typical chest pain but without ST-segment elevation, NSTEMI should be considered. Subtle ECG changes, such as ST-segment depressions and T-wave inversions, may be present. Serial ECGs can be valuable in detecting dynamic changes over time. In some NSTEMI cases, the initial ECG may be normal or show only non-specific changes.

Clinical decision-making tools, such as the HEART score, can assist clinicians in risk stratification and determining the need for further testing in patients with suspected NSTEMI. Given the limited sensitivity of ECG for STEMI, cardiac troponin assays are routinely used in patients with suspected MI. The HEART score incorporates clinical suspicion, patient risk factors, ECG findings, and troponin levels to categorize patients into different risk levels.

Laboratory Features:

Cardiac Troponins: Highly specific markers of myocardial injury and the primary laboratory test for MI diagnosis.
Complete Blood Count (CBC): To assess overall hematologic status.
Lipid Profile: To evaluate for underlying hyperlipidemia, a major risk factor.
Renal Function Tests: To assess kidney function, important for medication management and overall prognosis.
Metabolic Panel: To assess electrolytes, glucose, and other metabolic parameters.

Image: Infographic detailing myocardial infarction warning signs specifically in women. Highlights atypical symptoms that women may experience during a heart attack.

Medical Management of Myocardial Infarction

Immediate medical management of both STEMI and NSTEMI includes:

Aspirin: Chewable aspirin (160-325 mg) should be administered immediately to all patients to inhibit platelet aggregation.
Intravenous Access: Establishment of IV access is crucial for medication administration.
Oxygen Supplementation: Oxygen should be administered if oxygen saturation is below 91%.
Pain Management: Opioids, such as morphine, may be used for pain relief. Sublingual nitroglycerin can also be administered if blood pressure is adequate, to promote vasodilation and reduce chest pain.¹¹, ¹², ¹³

STEMI Treatment:

The primary goal in STEMI is immediate reperfusion therapy.

Percutaneous Coronary Intervention (PCI): Emergent PCI is the preferred reperfusion strategy. Ideally, it should be performed within 90 minutes of STEMI diagnosis. Prior to PCI, patients should receive dual antiplatelet therapy (aspirin and a P2Y12 inhibitor like ticagrelor) and intravenous heparin infusion. Glycoprotein IIb/IIIa inhibitors or direct thrombin inhibitors may also be administered during PCI.
Fibrinolytic Therapy: If PCI cannot be performed within 90 minutes of diagnosis, intravenous thrombolytic agents should be administered to dissolve the clot and restore blood flow. Thrombolysis is most effective when administered within the first few hours of symptom onset.

NSTEMI Treatment:

Management of NSTEMI depends on the patient’s clinical stability and risk stratification.

Medical Management: Stable, asymptomatic NSTEMI patients may be initially managed medically with antiplatelet agents (aspirin and P2Y12 inhibitors) and anticoagulants.
PCI: PCI may be performed within 48 hours of admission for patients with NSTEMI, particularly those at higher risk. Early PCI has been shown to improve in-hospital mortality and reduce length of stay. Emergent PCI is indicated for NSTEMI patients with refractory ischemia or hemodynamic or electrical instability.

Discharge Medications:

Prior to discharge after acute MI, patients are typically prescribed a combination of medications, including:

Aspirin
High-dose statin (to lower cholesterol)
Beta-blocker (to reduce heart rate and blood pressure)
ACE-inhibitor or ARB (especially for patients with heart failure or reduced ejection fraction)

PCI, if indicated, should ideally be performed within 12 hours of symptom onset. Fibrinolytic therapy, if chosen, should be administered within 120 minutes. Parenteral anticoagulation, in addition to antiplatelet therapy, is recommended for all MI patients.

Image: 12-lead ECG showing Pardee waves, indicative of acute myocardial infarction. ST-segment elevation is evident in inferior leads II, III, and aVF, with reciprocal ST depression in anterolateral leads.

Nursing Management of Myocardial Infarction

Nursing care is integral to the management of patients with acute myocardial infarction. Key nursing interventions include:

Daily ECG: Obtain a 12-lead ECG daily and with any significant change in patient condition.
IV Access: Ensure two large-bore IV lines are patent for medication and fluid administration.
Cardiac Enzyme Monitoring: Monitor serial cardiac enzyme levels (troponins) to assess myocardial damage.
Initiate MI Treatment Protocols: Promptly implement medical orders for acute MI management, including medications and reperfusion strategies.
Pain Management: Administer prescribed analgesics, such as morphine, for chest pain.
Nitroglycerin Administration: Administer nitroglycerin as ordered, typically 0.4 mg sublingually, monitoring blood pressure closely.
Oxygen Therapy: Provide supplemental oxygen if pulse oximetry is less than 94% on room air.
Cardiology Consultation: Ensure timely consultation with a cardiologist.
Vital Signs and Hemodynamic Monitoring: Monitor vital signs frequently, including heart rate, blood pressure, respiratory rate, and oxygen saturation. Monitor daily weights and urine output to assess fluid balance.
Anticoagulation Administration: Administer heparin or other anticoagulants as ordered, particularly for STEMI patients.
Post-Cardiac Catheterization Care: For patients undergoing cardiac catheterization, meticulously check the groin or radial artery access site for hematoma formation and assess distal pulses in the affected limb.

When To Seek Immediate Medical Help

Patients should be educated to seek immediate medical attention if they experience any of the following:

Hypotension (low blood pressure)
Nausea and vomiting
Persistent or worsening chest pain
Loss of distal leg pulses (may indicate emboli or severe hypotension)
Sudden change in mental status
Continuing oxygen desaturation (shortness of breath, low oxygen levels)
Tachycardia or new onset arrhythmias
Sudden onset of a loud heart murmur (may indicate new mitral regurgitation or ventricular rupture)

Outcome Identification for MI Patients

Expected outcomes of nursing care for patients with MI include:

Improved breathing pattern and respiratory function
Relief of chest pain and discomfort
Improved tissue perfusion and hemodynamic stability
Regaining functional abilities to pre-MI baseline

Monitoring for Myocardial Infarction

Continuous monitoring is essential in patients with MI. Key parameters to monitor include:

ECG monitoring for rhythm disturbances and ST-segment changes
Serial cardiac enzyme levels (troponins)
Oxygen saturation via pulse oximetry
Vital signs (heart rate, blood pressure, respiratory rate)
Intensity and characteristics of chest pain
Peripheral pulses, particularly in the legs
Auscultation of the chest for rales (crackles) and new heart murmurs

Coordination of Care for Myocardial Infarction

Management of acute myocardial infarction requires a collaborative interprofessional team approach. This team typically includes:

Cardiologist
Cardiac surgeon
Interventional cardiologist
Intensivist (critical care physician)
Cardiac rehabilitation specialist
Critical care or cardiology nurses
Physical therapists
Pharmacist
Nurse practitioner
Social worker
Primary care provider

Given that a significant number of patients with MI die before reaching the hospital, public education regarding symptoms of MI and the importance of immediate emergency medical services activation is crucial.

Nurses and pharmacists play key roles in patient education regarding nitroglycerin use and when to seek emergency help (call 911 or local emergency number if chest pain is not relieved after three doses of nitroglycerin).

At hospital triage, nurses must promptly communicate with the interprofessional team to expedite reperfusion therapy. The cardiologist will determine the most appropriate reperfusion strategy (thrombolysis or PCI) based on symptom duration and contraindications. All MI patients require intensive care unit (ICU) monitoring. Nurses must be vigilant in monitoring for potentially life-threatening complications and communicate any abnormal clinical signs or laboratory results to the team immediately. Premature discharge should be avoided as complications can arise up to a week post-MI.

Post-stabilization, comprehensive patient education is essential, focusing on risk factor modification for coronary artery disease. Social workers should be involved to facilitate home care arrangements, cardiac rehabilitation enrollment, and access to necessary support services. Pharmacists provide medication reconciliation, education on proper medication dosing, and potential side effects.

Upon discharge, patients should be enrolled in a cardiac rehabilitation program and receive guidance on adopting a heart-healthy lifestyle, including:

Dietary modifications (low-salt, low-fat, high-fiber diet)
Smoking cessation
Alcohol abstinence or moderation
Weight management
Regular physical activity
Blood pressure and blood glucose control
Lipid management
Medication adherence¹⁴, ¹⁵, ¹⁶

Pharmacist involvement in medication review and patient education is crucial for medication compliance. [^{Level 5}]

Outcomes of Myocardial Infarction:

Despite advancements in treatment, acute myocardial infarction continues to have a high out-of-hospital mortality rate. Data indicates that a substantial proportion of patients die before reaching the hospital, and a significant percentage die upon arrival. In-hospital mortality and readmission rates remain considerable. Overall prognosis is influenced by factors such as ejection fraction, age, and comorbidities. Patients who do not undergo revascularization have poorer outcomes compared to those who do. The best prognosis is associated with early and successful reperfusion and preserved left ventricular function.¹⁷, ¹⁸, ¹⁹ [^{Level 2}]

Image: Icon representing medical imaging. This icon is a placeholder indicating the potential for imaging findings in the diagnosis or context of myocardial infarction.

Health Teaching and Health Promotion for MI Prevention

Health education and promotion are crucial for preventing future cardiac events. Key areas to emphasize include:

Adopting a heart-healthy, low-salt diet
Maintaining medication compliance
Achieving and maintaining a healthy body weight
Engaging in regular physical activity and enrolling in cardiac rehabilitation programs
Controlling blood pressure, blood glucose, and lipid levels
Smoking cessation
Regular follow-up with healthcare providers

Risk Management for Myocardial Infarction

Effective risk management strategies include:

Educating patients to never disregard chest pain and to seek prompt medical attention.
Ensuring timely referral to a cardiologist for patients with abnormal vital signs or concerning symptoms.
Prompt consultation with a physician for any abnormal laboratory parameters.

Discharge Planning for Myocardial Infarction Patients

Comprehensive discharge planning is essential for a smooth transition to home and continued recovery. Key components include:

Reinforcing the importance of a heart-healthy diet.
Encouraging ambulation and gradual increase in physical activity.
Ensuring patient understanding of and adherence to prescribed medications.
Scheduling follow-up appointments with healthcare providers as recommended.
Reinforcing smoking cessation and avoidance of tobacco products.

Evidence-Based Issues in Myocardial Infarction Care

Evidence consistently demonstrates that earlier treatment of MI leads to improved prognosis. Nurses play a vital role in early recognition of MI symptoms and signs and initiating timely interventions. Reducing modifiable risk factors is paramount for improving patient outcomes and preventing recurrent events.

Review Questions (Self-Assessment)

(Note: Review questions would typically follow here in an educational article, but are omitted as per instructions.)

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Disclosures:

Oren Mechanic, Michael Gavin, Shamai Grossman, and Kim Ziegler declare no relevant financial relationships with ineligible companies.