Myocardial Infarction Chest Pain: Nursing Diagnosis and Comprehensive Care Plan

Myocardial infarction (MI), commonly known as a heart attack, is a critical medical emergency demanding immediate and effective intervention. It occurs when blood flow to the heart muscle is severely reduced or blocked, most often due to a buildup of plaque (cholesterol and other substances) in the coronary arteries. This blockage deprives the heart muscle of oxygen, leading to myocardial ischemia and potential irreversible damage or death of heart tissue. Coronary artery disease is the primary underlying cause of most myocardial infarctions.

In situations where oxygen supply to the heart is compromised, ischemia rapidly develops as cells are deprived of oxygen. An imbalance between myocardial oxygen supply and demand can swiftly lead to myocardial infarction and cardiac tissue death.

Besides coronary artery disease, other factors can precipitate a myocardial infarction, including:

• Vasospasm: Sudden constriction or narrowing of a coronary artery, restricting blood flow.
• Blood clots: Formation of thrombi that obstruct coronary arteries.
• Electrolyte imbalances: Disruptions in essential electrolytes can affect heart function and blood flow.
• Trauma to the coronary arteries: Physical injury to these vessels can impede blood supply.

Prolonged oxygen deprivation to the heart manifests most commonly as chest pain or discomfort, often described as pressure, tightness, or squeezing. This pain, a hallmark symptom of myocardial infarction, may radiate to the neck, jaw, shoulder, or arm. Diagnostic evaluations, including laboratory tests and electrocardiogram (ECG) changes, are crucial in confirming heart damage.

In this article, we will delve into the critical aspects of myocardial infarction, with a specific focus on chest pain, nursing diagnoses, and the comprehensive care plan essential for effective patient management.

STEMI vs. NSTEMI: Understanding the Difference

Myocardial infarctions are broadly categorized into two main types based on ECG findings: ST-elevation myocardial infarction (STEMI) and non-ST-elevation myocardial infarction (NSTEMI). The distinction is crucial for guiding immediate treatment strategies.

NSTEMI: Unlike STEMI, NSTEMI does not present with ST-segment elevation on an ECG. In NSTEMI, the coronary artery is typically partially blocked, leading to significant but not complete obstruction. Despite the absence of ST-segment elevation, patients experiencing NSTEMI still exhibit symptoms of a heart attack and require prompt medical attention.

STEMI: STEMI is characterized by a complete blockage of a coronary artery, resulting in ST-segment elevation on the ECG. This indicates a more extensive and acute myocardial injury requiring immediate reperfusion therapy to restore blood flow and minimize heart muscle damage.

ECG showing ST-segment elevation, a key indicator of STEMI myocardial infarction, highlighting the need for rapid intervention to restore blood flow.

The Nursing Process for Myocardial Infarction with Chest Pain

In emergency settings, nurses play a pivotal role in the rapid assessment and management of patients presenting with chest pain, differentiating between angina and myocardial infarction. Given the potentially life-threatening nature of MI, immediate interventions are paramount to preserve cardiac tissue and improve patient outcomes.

Upon arrival in the emergency room, the initial steps for a patient suspected of acute myocardial infarction are focused on:

• Reducing ischemia: Interventions to improve blood flow to the heart muscle.
• Relieving chest pain: Prompt pain management to alleviate discomfort and reduce myocardial oxygen demand.
• Preventing circulatory collapse and shock: Measures to stabilize hemodynamics and prevent life-threatening complications.

The MONA regimen (Morphine, Oxygen, Nitrates, Aspirin) is often initiated in the acute phase. Continuous cardiac monitoring is essential, and intravenous (IV) access is established for fluid and medication administration. Depending on the patient’s condition and diagnostic findings, further interventions such as cardiac catheterization or coronary artery bypass graft (CABG) surgery may be necessary.

Post-acute phase, nursing care shifts to patient education and rehabilitation. Nurses are crucial in educating patients about medication adherence, dietary modifications, weight management, and lifestyle changes to mitigate future cardiac events. Cardiac rehabilitation programs are frequently recommended to support ongoing recovery and improve long-term cardiovascular health.

Comprehensive Nursing Assessment for Myocardial Infarction

The cornerstone of effective nursing care is a thorough nursing assessment. This involves gathering comprehensive data encompassing physical, psychosocial, emotional, and diagnostic aspects. In the context of myocardial infarction, a detailed assessment is essential to guide appropriate interventions and develop an individualized care plan.

Review of Health History: Subjective Data Collection

Obtaining a detailed health history is crucial in identifying potential myocardial infarction and guiding subsequent care. Key areas to explore include:

1. General Symptom Review: Patients may present with a variety of symptoms beyond chest pain. It is important to inquire about:

• Chest, back, shoulder, or jaw pain: Characterize the onset, duration, location, and intensity.
• Palpitations: Awareness of rapid or irregular heartbeats.
• Shortness of breath (dyspnea): Assess occurrence at rest or during exertion.
• Fatigue: Unexplained or excessive tiredness.
• Sweating (diaphoresis): Sudden onset of profuse sweating.
• Nausea and vomiting: Gastrointestinal distress accompanying chest pain.
• Fainting (syncope) or dizziness: Episodes of lightheadedness or loss of consciousness.

2. Detailed Chest Pain Assessment: Given the significance of chest pain in myocardial infarction, a thorough characterization is vital. Explore the following aspects:

• Description: Ask the patient to describe the pain – tightness, squeezing, heaviness, burning.
• Radiation: Determine if pain radiates to the arm, shoulder, or jaw.
• Provocation and Palliation: Note if pain is related to exertion or rest, and if any factors relieve it.
• Duration: How long does the pain last? Is it intermittent or persistent? Pain lasting more than 20 minutes is concerning.
• Aggravating factors: Identify triggers such as physical activity, stress, or emotions.

3. Risk Factor Identification: Understanding the patient’s risk profile is essential for both diagnosis and long-term management. Assess for both non-modifiable and modifiable risk factors:

Non-modifiable Risk Factors:

• Gender and Age: Men over 45 and women over 50 or post-menopausal are at increased risk.
• Family history: Ischemic heart disease in a first-degree relative before age 55 increases risk.
• Race/ethnicity: Black individuals have a higher incidence of myocardial infarction compared to non-Black individuals.

Modifiable Risk Factors:

• Hypertension: Uncontrolled high blood pressure strains the heart and arteries.
• Hyperlipidemia/Hypercholesterolemia: Elevated LDL cholesterol and low HDL cholesterol contribute to plaque formation.
• Diabetes or Insulin Resistance: These conditions damage blood vessels and increase blood viscosity.
• Tobacco Use: Smoking and secondhand smoke are strongly linked to myocardial infarction.
• Obesity: Excess weight increases blood pressure and cardiovascular strain.
• Physical Inactivity: Lack of exercise contributes to arterial rigidity and poor cardiovascular health.
• Diet: High intake of trans and saturated fats promotes cholesterol buildup in arteries.
• Stress: Chronic stress can elevate heart rate and blood pressure, exacerbating arterial plaque issues.
• Alcohol Use: Heavy alcohol consumption can damage the heart and increase sudden cardiac death risk.
• Lack of Sleep: Insufficient sleep can lead to sustained elevated blood pressure.

4. Medication History Review: Certain medications can have cardiovascular side effects, either increasing risk or mimicking MI symptoms. Review the patient’s medication list for:

• Anthracyclines (chemotherapy drugs)
• Antipsychotic drugs
• Nonsteroidal anti-inflammatory drugs (NSAIDs)
• Type 2 diabetes medications (thiazolidinediones and rosiglitazone)
• Recreational and street drugs: Amphetamines, anabolic steroids, cocaine, nicotine.

5. Emotional and Psychological Factors: Anginophobia, the fear of chest pain, can trigger panic attacks that mimic myocardial infarction symptoms. Assess for:

• History of anxiety disorders or panic attacks.
• Irrational fear of chest pain or choking.
• Symptoms like tachycardia, tachypnea, hypertension, and diaphoresis in relation to anxiety.

Physical Assessment: Objective Data Collection

The physical assessment in suspected myocardial infarction is focused on rapid stabilization and identification of key clinical signs.

1. Prioritize ABCs (Airway, Breathing, Circulation): In any suspected MI, immediate assessment and stabilization of airway, breathing, and circulation are paramount. If the patient is unresponsive and pulseless, initiate CPR immediately and call for emergency medical services.

2. Systemic Assessment: A systematic approach is crucial to identify objective signs of myocardial infarction:

• Neck: Assess for jugular vein distention (JVD), which can indicate heart failure.
• Central Nervous System (CNS): Note anxiety, feelings of impending doom, syncope, dizziness, lightheadedness, or changes in mental status, which can reflect reduced cerebral perfusion.
• Cardiovascular:
  • Chest pain: Observe patient’s behavior and verbal reports.
  • Auscultate heart sounds: Listen for murmurs or abnormal heart sounds.
  • Auscultate carotid arteries: Check for bruits, which may indicate carotid artery disease.
  • Assess for arrhythmias: Irregular heart rhythms.
  • Measure blood pressure: Note for hypertension or hypotension.
• Circulatory: Assess for palpitations and thready pulse, indicative of poor cardiac output.
• Respiratory: Evaluate for dyspnea at rest or exertion, reflecting pulmonary congestion or reduced oxygenation.
• Gastrointestinal: Note nausea and vomiting, common autonomic responses to MI.
• Musculoskeletal: Inquire about neck, arm, back, jaw, or upper extremity pain, and fatigue, as referred pain from cardiac ischemia.
• Integumentary: Observe skin color for cyanosis or pallor, and assess for diaphoresis, signs of poor perfusion and sympathetic response.

3. ASCVD Risk Score Calculation: Calculating the patient’s Atherosclerotic Cardiovascular Disease (ASCVD) risk score can provide a quantitative estimate of their 10-year risk of cardiovascular events. Factors included in the ASCVD risk calculator are:

• Age
• Gender
• Race
• Blood pressure
• Cholesterol levels (total and HDL)
• Medication use for hypertension or cholesterol
• Diabetes status
• Smoking history

A low ASCVD risk score is desirable (score <7.5%).

The ASCVD risk score calculator helps assess a patient’s 10-year risk of atherosclerotic cardiovascular disease, crucial for risk stratification in myocardial infarction assessment.

Diagnostic Procedures for Myocardial Infarction

Diagnostic procedures are essential to confirm myocardial infarction, assess the extent of cardiac damage, and guide treatment strategies.

1. Electrocardiogram (ECG) Interpretation: An ECG is a critical initial diagnostic test, ideally performed within 10 minutes of arrival for patients with suspected MI. ECG findings in MI may include:

• Pathological Q waves: Indicate previous myocardial infarction. They are wider and deeper than normal Q waves.
• ST-segment elevation (STEMI): Indicates acute, ongoing injury and complete artery blockage.
• ST-segment depression (NSTEMI): Suggests ischemia or subendocardial injury, often with partial artery blockage.
• T-wave inversions: Can indicate ischemia.

2. Troponin Level Monitoring: Cardiac troponins (Troponin I or T) are highly specific biomarkers for myocardial damage. Elevated troponin levels in the blood confirm myocardial infarction.

• Troponin levels rise 4-9 hours after myocardial injury, peak at 12-24 hours, and remain elevated for 1-2 weeks.
• Serial troponin measurements are typically performed to track the progression of myocardial damage.

3. Echocardiogram (Echo): An echocardiogram is an ultrasound of the heart, providing valuable information about:

• Wall motion abnormalities: Areas of the heart muscle that are not contracting normally, indicating ischemia or infarction.
• Ejection fraction: The percentage of blood pumped out of the left ventricle with each beat, a measure of heart function.
• Overall cardiac structure and function.
• Recommended within 24-48 hours of suspected MI and repeated within three months for baseline assessment.

4. Advanced Imaging: In some cases, further imaging may be necessary:

• Cardiac CT scan: Provides detailed images of coronary arteries to detect blockages.
• CT coronary angiogram: Uses contrast dye to visualize coronary arteries in detail, assessing for stenosis or occlusion.

Nursing Interventions for Myocardial Infarction Chest Pain

Nursing interventions for myocardial infarction are aimed at restoring blood flow, relieving chest pain, managing symptoms, facilitating cardiac rehabilitation, and preventing complications.

Restoring Blood Perfusion: Time is Muscle

Prompt restoration of blood flow to the ischemic myocardium is critical to minimize myocardial damage and improve patient outcomes.

1. Reperfusion Therapy: Primary percutaneous coronary intervention (PCI) and fibrinolytic therapy are the two main reperfusion strategies.

• Primary PCI: A catheter is inserted, typically through the femoral or radial artery, and guided to the blocked coronary artery. A balloon-tipped catheter is inflated to open the artery, and a stent is usually placed to maintain patency. PCI is the preferred method when available and timely.
• Fibrinolytic therapy: “Clot-busting” medications are administered intravenously to dissolve thrombi and restore blood flow. This is considered when PCI is not immediately accessible, particularly in settings where transfer to a PCI-capable center would delay treatment significantly.

2. Coronary Angioplasty and Stent Placement: During PCI, these procedures are performed to mechanically open blocked arteries.

• Coronary angioplasty: Balloon inflation within the narrowed artery compresses plaque and widens the vessel lumen.
• Stent placement: A mesh tube (stent) is deployed in the artery to provide structural support and prevent restenosis (re-narrowing).

3. Coronary Artery Bypass Graft (CABG) Surgery: CABG is a surgical procedure to bypass blocked coronary arteries.

• A healthy blood vessel (often from the leg, arm, or chest) is grafted to circumvent the blockage, creating a new pathway for blood flow to the heart muscle.
• CABG may be indicated for patients with multi-vessel disease, left main coronary artery stenosis, or when PCI is not feasible or successful.

4. Dual Antiplatelet Therapy (DAPT): DAPT is crucial post-PCI to prevent stent thrombosis and recurrent events.

• Typically involves aspirin and a P2Y12 inhibitor (e.g., clopidogrel, ticagrelor, prasugrel).
• Duration of DAPT varies based on stent type and patient risk factors, usually 6-12 months or longer.

5. Anticoagulation: Anticoagulants are used to prevent thrombus formation and propagation.

• Medications like heparin (unfractionated or low-molecular-weight), bivalirudin, or fondaparinux are commonly used, especially during PCI and in the acute phase of MI.

6. Thrombolytic or Fibrinolytic Agents: These medications are used to dissolve existing blood clots in the coronary arteries.

• Examples include tissue plasminogen activator (tPA), streptokinase, and reteplase.
• Most effective when administered early after symptom onset (ideally within 3 hours, up to 12 hours in some cases).

Relieving Chest Pain: Prioritizing Patient Comfort

Effective pain management is essential not only for patient comfort but also for reducing myocardial oxygen demand and improving hemodynamic stability.

1. Opioid Analgesics: Intravenous opioids, such as morphine, are frequently used for chest pain relief in MI.

• Morphine reduces pain, anxiety, and myocardial oxygen demand by decreasing preload and afterload.
• Monitor for side effects such as respiratory depression, hypotension, and nausea.

2. Supplemental Oxygen: Administering supplemental oxygen aims to increase oxygen delivery to the ischemic myocardium.

• Typically initiated at 2-4 L/min via nasal cannula, titrated to maintain oxygen saturation >90%.
• High-flow oxygen may be needed in patients with respiratory distress or hypoxemia.

3. Vasodilators: Nitroglycerin: Nitroglycerin is a cornerstone medication for managing chest pain in MI.

• Nitroglycerin causes vasodilation, reducing preload and afterload, and improves coronary blood flow.
• Administered sublingually, intravenously, or topically.
• Monitor blood pressure closely due to potential for hypotension.

Managing Symptoms and Hemodynamic Stability

Maintaining hemodynamic stability and managing related symptoms are crucial aspects of nursing care in myocardial infarction.

1. Blood Pressure Management: Target blood pressure goals are individualized.

• Antihypertensive Medications:
  • Beta-blockers: Reduce heart rate, blood pressure, and myocardial contractility, decreasing myocardial oxygen demand. Contraindicated in acute coronary vasospasm.
  • ACE inhibitors: Beneficial in patients with left ventricular dysfunction, heart failure, hypertension, or diabetes.
  • Intravenous nitrates: Effective for symptom relief and ST-segment depression in NSTEMI.

2. Lipid Lowering Therapy: Statins are initiated early in MI to lower LDL cholesterol and stabilize atherosclerotic plaques.

• High-intensity statin therapy is generally recommended regardless of baseline cholesterol levels.

3. Blood Glucose Control: Hyperglycemia is common in acute MI, even in non-diabetic patients, due to stress response.

• Maintain blood glucose levels within target range (often 140-180 mg/dL in acute setting).
• Insulin therapy may be needed to achieve glycemic control.

Cardiac Rehabilitation: Long-Term Recovery and Prevention

Cardiac rehabilitation is a comprehensive program designed to improve cardiovascular health, functional capacity, and quality of life after myocardial infarction.

1. Phase II Cardiac Rehabilitation: Typically starts after hospital discharge and continues for several weeks to months. Components include:

• Exercise training: Supervised exercise program tailored to individual needs and functional capacity.
• Patient education: Information on heart-healthy lifestyle, risk factor modification, medications, and symptom recognition.
• Psychosocial support: Addressing emotional and psychological aspects of recovery.

2. Benefits of Cardiac Rehabilitation:

• Reduced mortality and morbidity post-MI.
• Improved exercise tolerance and functional capacity.
• Enhanced risk factor management (smoking cessation, lipid control, blood pressure management).
• Improved psychological well-being and quality of life.
• Reduced hospital readmissions.

Preventing Myocardial Infarction Complications

Preventive strategies are essential to minimize complications and reduce the risk of recurrent cardiac events.

1. Lifestyle Modifications: Emphasize and educate patients on the importance of:

• Regular exercise: Aim for at least 150 minutes of moderate-intensity or 75 minutes of vigorous-intensity aerobic activity per week.
• Heart-healthy diet: Low in saturated and trans fats, cholesterol, and sodium; rich in fruits, vegetables, and whole grains.
• Weight management: Achieve and maintain a healthy weight.
• Smoking cessation: Complete avoidance of tobacco products.
• Stress management: Techniques such as yoga, meditation, deep breathing, and relaxation exercises.
• Moderate alcohol consumption: If consumed, limit to one drink per day for women and two for men.
• Adequate sleep: Aim for 7-9 hours of quality sleep per night.

2. Medication Adherence: Reinforce the importance of taking prescribed medications as directed, including:

• Antiplatelets
• Beta-blockers
• ACE inhibitors or ARBs
• Statins

3. Regular Follow-Up and Monitoring: Schedule and emphasize the importance of regular follow-up appointments with healthcare providers.

• Recommended follow-up within 3-6 weeks post-discharge for STEMI and NSTEMI patients.
• Ongoing monitoring of blood pressure, lipids, blood glucose, and renal function.

4. CPR Training for Family and Caregivers: Encourage CPR training for family members and caregivers to be prepared for emergencies.

5. Patient Education on Symptom Recognition and Action Plan: Educate patients on recognizing symptoms of myocardial infarction recurrence (chest pain, dyspnea) and the importance of seeking immediate medical attention.

• Advise patients to take nitroglycerin or aspirin if symptoms develop and call emergency services promptly.

6. Addressing Sexual Activity Concerns: Provide guidance on resuming sexual activity safely.

• Sexual activity is generally safe once the patient can tolerate moderate physical activity without symptoms.
• Advise patients to discuss any concerns with their healthcare provider.

7. Medical Alert Identification: Recommend wearing a medical alert bracelet or necklace to inform emergency responders of cardiac history.

Myocardial Infarction Nursing Care Plans: Addressing Key Diagnoses

Nursing care plans provide a structured framework for addressing patient needs and prioritizing interventions. Key nursing diagnoses relevant to myocardial infarction include acute pain, anxiety, decreased cardiac output, ineffective tissue perfusion, and risk for unstable blood pressure.

Nursing Care Plan 1: Acute Pain related to Myocardial Ischemia

Nursing Diagnosis: Acute Pain related to chest pain/discomfort from inadequate blood flow to the heart.

Related Factors:

• Blockage of coronary arteries
• Reduced oxygen supply to the heart muscle

Evidenced by:

• Verbal reports of chest pain, pressure, or tightness
• Chest clutching
• Restlessness
• Labored breathing and dyspnea
• Diaphoresis
• Changes in vital signs (increased heart rate, blood pressure)

Expected Outcomes:

• Patient will report pain relief or satisfactory pain control (pain score ≤ 3/10 or as per patient’s acceptable level).
• Patient will demonstrate relaxed body language and be able to rest comfortably.
• Patient will be able to participate in daily activities as tolerated without significant pain.

Nursing Assessments:

1. Differentiate angina from myocardial infarction pain:
   • MI pain: Sudden onset, crushing substernal pain, may radiate, lasts > 30 minutes, unrelieved by rest or nitroglycerin.
   • Angina: Predictable, activity-related, relieved by rest or nitroglycerin.
2. Assess pain characteristics (PQRST): Provoking factors, Quality, Region/Radiation, Severity, Timing.
3. Obtain ECG during chest pain episode: Rule out or confirm MI based on ECG changes.

Nursing Interventions:

1. Administer nitroglycerin: Sublingual or IV as ordered to dilate coronary arteries and relieve chest pain.
2. Administer supplemental oxygen: Improve myocardial oxygenation, reduce ischemic pain.
3. Administer opioid analgesics (e.g., morphine): Reduce pain, anxiety, and myocardial oxygen demand.
4. Continuously evaluate pain relief measures: Assess pain intensity and effectiveness of interventions regularly.

Nursing Care Plan 2: Anxiety related to Myocardial Infarction

Nursing Diagnosis: Anxiety related to perceived threat to health status, fear of death, and lifestyle changes.

Related Factors:

• Threat of death or serious health complications
• Uncertainty about prognosis and future
• Lifestyle modifications required post-MI

Evidenced by:

• Increased tension and restlessness
• Fearful expressions and apprehension
• Verbalization of concerns and uncertainty
• Dyspnea and palpitations
• Elevated vital signs (heart rate, blood pressure, respiratory rate)

Expected Outcomes:

• Patient will verbalize feelings and concerns related to anxiety.
• Patient will demonstrate reduced anxiety levels (calm demeanor, stable vital signs).
• Patient will identify and utilize effective coping mechanisms to manage anxiety.
• Patient will actively participate in the care plan and express understanding of necessary lifestyle changes.

Nursing Assessments:

1. Observe for signs of anxiety: Restlessness, agitation, verbal expressions of fear, physical manifestations.
2. Assess subjective and objective anxiety cues: Patient’s reports, body language, vital sign changes.
3. Evaluate patient’s coping mechanisms: Identify current coping strategies and their effectiveness.

Nursing Interventions:

1. Acknowledge and validate patient’s anxiety: Encourage verbalization of feelings, provide reassurance and support.
2. Provide clear and accurate information: Explain procedures, treatments, and prognosis to reduce uncertainty.
3. Involve patient in care planning: Promote a sense of control and autonomy.
4. Teach stress-reduction techniques: Deep breathing exercises, relaxation techniques, guided imagery.
5. Consider referral for mental health support: If anxiety is severe or persistent, consider psychological counseling.

Nursing Care Plan 3: Decreased Cardiac Output related to Myocardial Infarction

Nursing Diagnosis: Decreased Cardiac Output related to altered contractility, changes in heart rate/rhythm, and structural damage from myocardial infarction.

Related Factors:

• Loss of viable heart muscle
• Altered heart rate and rhythm (arrhythmias)
• Reduced preload or increased afterload
• Mechanical complications (e.g., ventricular rupture)

Evidenced by:

• Persistent chest pain unrelieved by rest and medication
• Shortness of breath, orthopnea
• Nausea and vomiting
• Anxiety and restlessness
• Cool, pale, moist skin
• Tachycardia or bradycardia, arrhythmias
• Hypotension
• Fatigue and dizziness
• Confusion or altered mental status
• Decreased urine output

Expected Outcomes:

• Patient will maintain blood pressure and heart rate within acceptable parameters.
• Patient will demonstrate improved cardiac output as evidenced by reduced dyspnea, angina, and arrhythmias.
• Patient will verbalize understanding of MI and management strategies.
• Patient will participate in activities that reduce cardiac workload.

Nursing Assessments:

1. Identify risk factors for decreased cardiac output: Pre-existing heart conditions, extent of MI, complications.
2. Differentiate angina from MI: As described in Acute Pain care plan.
3. Closely monitor blood pressure: Report hypotension (SBP < 90 mmHg or significant drop).
4. Obtain ECG: Identify arrhythmias, ST-segment changes.
5. Assess for signs of poor cardiac output: Peripheral perfusion, mental status, urine output.
6. Monitor cardiac enzymes (troponin): Assess extent of myocardial damage.

Nursing Interventions:

1. Administer supplemental oxygen: Improve oxygen delivery to myocardium and tissues.
2. Administer medications as ordered:
   • Thrombolytics or PCI for reperfusion.
   • Beta-blockers to reduce heart rate and contractility.
   • ACE inhibitors to reduce afterload.
   • Diuretics to manage fluid overload.
3. Establish IV access: For medication and fluid administration.
4. Prepare for possible cardiac catheterization: For diagnostic and interventional purposes.
5. Promote bed rest and activity restrictions: Reduce cardiac workload.
6. Encourage cardiac rehabilitation: For long-term recovery and improved cardiac function.

Nursing Care Plan 4: Ineffective Tissue Perfusion related to Myocardial Infarction

Nursing Diagnosis: Ineffective Tissue Perfusion (cardiac, peripheral) related to interruption of arterial blood flow secondary to myocardial infarction.

Related Factors:

• Coronary artery obstruction (plaque, thrombus, vasospasm)
• Reduced cardiac output
• Hypovolemia or hypotension

Evidenced by:

• Diminished peripheral pulses
• Prolonged capillary refill time (>3 seconds)
• Cool, clammy skin; pallor or cyanosis
• Angina, dyspnea
• Changes in level of consciousness, restlessness
• Fatigue and weakness
• Edema
• Reports of claudication or numbness

Expected Outcomes:

• Patient will demonstrate adequate tissue perfusion evidenced by palpable peripheral pulses and capillary refill < 3 seconds.
• Patient will exhibit warm, dry skin with normal color.
• Patient will maintain alert and oriented level of consciousness.
• Patient will report reduction or absence of angina and claudication.

Nursing Assessments:

1. Obtain ECG: Assess for evidence of myocardial ischemia and infarction.
2. Assess cardiovascular status: Monitor heart rate, rhythm, blood pressure, heart sounds.
3. Evaluate peripheral perfusion: Assess skin color, temperature, capillary refill, peripheral pulses.

Nursing Interventions:

1. Initiate CPR if indicated: For cardiac arrest.
2. Facilitate reperfusion therapy: PCI or fibrinolysis.
3. Administer aspirin: Antiplatelet effect to improve blood flow.
4. Manage pain and anxiety: Reduce sympathetic nervous system activation and vasoconstriction.
5. Refer to cardiac rehabilitation: Promote long-term cardiovascular health.

Nursing Care Plan 5: Risk for Unstable Blood Pressure related to Myocardial Infarction

Nursing Diagnosis: Risk for Unstable Blood Pressure related to myocardial ischemia, altered cardiac function, and compensatory mechanisms.

Related Factors:

• Ineffective myocardial contraction
• Ischemia and pain
• Vasoconstriction
• Underlying cardiac conditions
• Increased cardiac workload

Evidenced by:
Risk Diagnosis – No Evidencing Signs/Symptoms, Focus on Risk Factors

Expected Outcomes:

• Patient will maintain blood pressure within prescribed parameters (e.g., systolic 100-140 mmHg, diastolic 60-90 mmHg).
• Patient will demonstrate stable blood pressure during activities and rest.
• Patient will adhere to medication regimen to manage blood pressure.
• Patient will verbalize understanding of factors that influence blood pressure and strategies for management.

Nursing Assessments:

1. Continuously monitor blood pressure: Assess for hypotension and hypertension.
2. Assess cardiovascular status: Evaluate heart rate, rhythm, ECG, signs of heart failure.
3. Identify risk factors: Pre-existing hypertension, heart failure, medications, fluid imbalance.
4. Assess chest pain: Pain can contribute to blood pressure instability.

Nursing Interventions:

1. Administer antihypertensive medications as prescribed: Beta-blockers, ACE inhibitors, calcium channel blockers, diuretics.
2. Administer vasodilators as prescribed: Nitrates for angina and blood pressure control.
3. Manage fluid balance: Administer diuretics for fluid overload, monitor hydration status.
4. Provide patient education: Explain medications, lifestyle modifications, and importance of blood pressure monitoring.

These comprehensive nursing care plans provide a framework for managing patients experiencing myocardial infarction with chest pain. They highlight the critical role of nurses in assessment, intervention, and education to improve patient outcomes and promote long-term cardiovascular health.

References

1. American College of Cardiology. (2015, September 21). Is sexual activity safe after MI? Retrieved March 2023, from https://www.acc.org/latest-in-cardiology/articles/2015/09/21/16/25/is-sexual-activity-safe-after-mi
2. Cleveland Clinic. (2021, December 28). NSTEMI: Causes, symptoms, diagnosis, treatment & outlook. Retrieved March 2023, from https://my.clevelandclinic.org/health/diseases/22233-nstemi-heart-attack#diagnosis-and-tests
3. Cleveland Clinic. (2022, October 30). Heart attack: What is it, causes, symptoms & treatment. Retrieved March 2023, from https://my.clevelandclinic.org/health/diseases/16818-heart-attack-myocardial-infarction#diagnosis-and-tests
4. Dewit, S. C., Stromberg, H., & Dallred, C. (2017). Care of Patients With Diabetes and Hypoglycemia. In Medical-surgical nursing: Concepts & practice (3rd ed., pp. 811-817). Elsevier Health Sciences.
5. Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nurse’s pocket guide: Diagnoses, interventions, and rationales (15th ed.). F A Davis Company.
6. Harding, M. M., Kwong, J., Roberts, D., Reinisch, C., & Hagler, D. (2020). Lewis’s medical-surgical nursing – 2-Volume set: Assessment and management of clinical problems (11th ed., pp. 2697-2729). Mosby.
7. Hinkle, J. L., & Cheever, K. H. (2018). Management of Patients With Coronary Vascular Disorders. In Brunner and Suddarth’s textbook of medical-surgical nursing (13th ed., pp. 1567-1575). Wolters Kluwer India Pvt.
8. Ignatavicius, MS, RN, CNE, ANEF, D. D., Workman, PhD, RN, FAAN, M. L., Rebar, PhD, MBA, RN, COI, C. R., & Heimgartner, MSN, RN, COI, N. M. (2018). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care (9th ed., pp. 1386-1388). Elsevier.
9. Johns Hopkins Medicine. (n.d.). Heart attack. Johns Hopkins Medicine, based in Baltimore, Maryland. Retrieved February 2023, from https://www.hopkinsmedicine.org/health/conditions-and-diseases/heart-attack
10. Mayo Clinic. (2022, May 21). Heart attack – Symptoms and causes. Retrieved March 2023, from https://www.mayoclinic.org/diseases-conditions/heart-attack/symptoms-causes/syc-20373106
11. National Center for Biotechnology Information. (2022, August 8). Myocardial infarction – StatPearls – NCBI bookshelf. Retrieved March 2023, from https://www.ncbi.nlm.nih.gov/books/NBK537076/
12. Ojha, N., & Dhamoon, A. S. (2022, May 11). Myocardial infarction – StatPearls – NCBI bookshelf. National Center for Biotechnology Information. https://www.ncbi.nlm.nih.gov/books/NBK537076/
13. Silvestri, L. A., Silvestri, A. E., & Grimm, J. (2022). Saunders comprehensive review for the NCLEX-RN examination (9th ed.). Elsevier Inc.
14. Winchester Hospital. (n.d.). Drugs that may lead to heart damage. Retrieved March 2023, from https://www.winchesterhospital.org/health-library/article?id=31675