Myocardial Infarction Nursing Care Plan Diagnosis: A Comprehensive Guide

Myocardial infarction (MI), commonly known as a heart attack, is a critical condition requiring immediate and comprehensive nursing care. It occurs when blood flow to the heart muscle is severely reduced or completely blocked, typically due to a blockage in the coronary arteries. This blockage, often caused by coronary artery disease, deprives the heart muscle of oxygen, leading to ischemia and potential irreversible damage. In emergency situations, prompt recognition and intervention are crucial to minimize cardiac tissue damage and improve patient outcomes.

Myocardial ischemia arises from an imbalance between myocardial oxygen supply and demand. While coronary artery disease is the primary culprit, other factors can contribute to MI, including:

• Vasospasm: Sudden constriction of a coronary artery, restricting blood flow.
• Blood clots: Formation of thrombi that obstruct coronary arteries.
• Electrolyte imbalances: Disruptions in electrolyte levels that can affect heart function.
• Trauma to the coronary arteries: Physical injury leading to arterial damage and blockage.

Prolonged oxygen deprivation in the heart manifests as chest pain or discomfort, often described as pressure, squeezing, or tightness. This pain can radiate to the neck, jaw, shoulder, or arm. Diagnostic evaluations, including laboratory tests and electrocardiogram (ECG) changes, are essential to confirm myocardial damage and guide immediate nursing interventions.

Alt text: ECG tracing demonstrating ST-segment elevation, a key indicator of STEMI during myocardial infarction.

STEMI vs. NSTEMI: Understanding the Difference for Nursing Care

Myocardial infarction is broadly classified into two main types: ST-elevation myocardial infarction (STEMI) and non-ST-elevation myocardial infarction (NSTEMI). This differentiation is critical because it guides immediate treatment strategies.

STEMI: Characterized by a complete blockage of a coronary artery, STEMI causes significant and specific changes in the heart’s electrical activity, readily visible on an ECG as ST-segment elevation. This indicates a more extensive and acute myocardial injury requiring immediate reperfusion therapy to restore blood flow.

NSTEMI: In contrast, NSTEMI involves a partial blockage of a coronary artery. The ECG in NSTEMI may not show ST-segment elevation but might exhibit other changes like ST-segment depression or T-wave inversion. Although less dramatic on ECG, NSTEMI still signifies myocardial damage and requires prompt medical and nursing management. Patients experiencing NSTEMI also present with typical heart attack symptoms, necessitating urgent assessment and intervention.

Understanding the distinction between STEMI and NSTEMI is crucial for nurses to anticipate the appropriate treatment pathway and provide tailored care.

The Nursing Process for Myocardial Infarction: A Step-by-Step Approach

In managing myocardial infarction, nurses utilize the nursing process – a systematic approach to patient care encompassing assessment, diagnosis, planning, implementation, and evaluation. For MI patients, this process is initiated immediately upon arrival in the emergency department to ensure timely and effective interventions.

The primary goals of nursing care in the acute phase of MI are to:

• Reduce ischemia: Restore blood flow to the heart muscle to minimize damage.
• Relieve pain: Manage chest pain and discomfort effectively.
• Prevent complications: Address potential circulatory collapse and shock.
• Provide emotional support: Alleviate anxiety and fear associated with the event.

Initial emergency interventions often follow the MONA regimen (Morphine, Oxygen, Nitrates, Aspirin), although the specific sequence and application may vary based on the patient’s condition and evolving protocols. Continuous cardiac monitoring is essential, and intravenous (IV) access is established for fluid and medication administration. Further diagnostic tests and procedures, such as cardiac catheterization or coronary artery bypass graft (CABG) surgery, may be necessary depending on the severity and type of MI.

Beyond the acute phase, nursing care extends to patient education and rehabilitation. Nurses play a vital role in educating patients about medication adherence, dietary modifications, weight management, and lifestyle changes to mitigate future cardiac events. Cardiac rehabilitation programs are often recommended to support ongoing recovery and improve long-term outcomes.

Comprehensive Nursing Assessment for Myocardial Infarction

The nursing assessment is the cornerstone of effective care for patients with myocardial infarction. It involves a thorough collection of subjective and objective data to understand the patient’s condition comprehensively.

Review of Health History: Gathering Subjective Data

Obtaining a detailed health history is crucial in identifying potential myocardial infarction. This involves exploring the patient’s symptoms, risk factors, and past medical history.

1. Document General Symptoms: Patients may present with a range of symptoms, not always classic chest pain. Inquire about:

• Pain: Chest, back, shoulder, or jaw pain, noting location, intensity, character, and radiation.
• Palpitations: Awareness of rapid or irregular heartbeats.
• Dyspnea: Shortness of breath at rest or during exertion.
• Fatigue: Unusual or excessive tiredness.
• Diaphoresis: Sweating, often profuse and cold.
• Nausea: Feeling sick to the stomach.
• Syncope: Fainting or loss of consciousness.
• Dizziness: Lightheadedness or vertigo.

2. Detailed Chest Pain Assessment: If chest pain is reported, further characterization is essential:

• Description: Tightness, squeezing, heaviness, burning, or pressure.
• Location and Radiation: Pain in the arm, shoulder, or jaw.
• Provocation and Palliation: Pain during exertion or at rest, triggers like stress or emotions, relieving factors.
• Duration: Intermittent or persistent pain, pain lasting longer than 20 minutes.
• Intensity: Using a pain scale (0-10).
• Associated Symptoms: Nausea, vomiting, diaphoresis, dyspnea.

3. Identify Risk Factors: Assessing risk factors helps determine the likelihood of MI and guides preventive strategies. Differentiate between non-modifiable and modifiable risk factors:

Non-modifiable Risk Factors:

• Age and Gender: Men over 45 and women over 50 or post-menopausal are at higher risk.
• Family History: First-degree relatives with premature heart disease (before age 55) increase risk.
• Race/Ethnicity: Certain ethnicities, like Black individuals, have a higher incidence of MI.

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 Mellitus/Insulin Resistance: Diabetes damages blood vessels and increases blood viscosity.
• Tobacco Use: Smoking and second-hand smoke are major contributors to MI.
• Obesity: Excess weight increases blood pressure and cardiac workload.
• Physical Inactivity: Lack of exercise promotes arterial stiffness and poor cardiovascular health.
• Unhealthy Diet: High intake of saturated and trans fats promotes atherosclerosis.
• Stress: Chronic stress elevates heart rate and blood pressure.
• Excessive Alcohol Use: Heavy alcohol consumption damages heart muscle and affects lipid levels.
• Inadequate Sleep: Lack of sleep can lead to sustained elevated blood pressure.

4. Medication Review: Certain medications can increase cardiac risk. Document all current medications, including:

• Anthracyclines: Chemotherapy drugs with potential cardiotoxicity.
• Antipsychotic Drugs: Some antipsychotics can affect heart rhythm and blood pressure.
• NSAIDs (Nonsteroidal Anti-inflammatory Drugs): Increase risk of cardiovascular events in some individuals.
• Type 2 Diabetes Medications (Thiazolidinediones and Rosiglitazone): Linked to increased cardiovascular risk.
• Recreational and Street Drugs: Amphetamines, cocaine, anabolic steroids, and nicotine are potent cardiac stressors.

5. Assess Emotional Factors: Anginophobia, the fear of chest pain, can mimic MI symptoms. Evaluate for:

• Anxiety Disorders: Underlying anxiety can trigger panic attacks resembling MI.
• Anginophobia Symptoms: Fear of choking, chest tightness, leading to tachycardia, tachypnea, hypertension, and diaphoresis.
• Mental Health History: Assess for pre-existing anxiety or panic disorders.

Physical Assessment: Objective Data Collection

The physical assessment provides crucial objective data about the patient’s current physiological status.

1. Prioritize ABCs (Airway, Breathing, Circulation): In suspected MI, immediately assess and stabilize ABCs. Initiate CPR if necessary.

2. Systemic Assessment: Conduct a focused physical exam, including:

• Neck: Jugular vein distention (JVD) indicating fluid overload or heart failure.
• Central Nervous System (CNS): Assess mental status, noting anxiety, restlessness, impending doom, syncope, dizziness, lightheadedness, and confusion.
• Cardiovascular System: Auscultate heart sounds for murmurs or extra sounds. Check for carotid bruits. Assess for arrhythmias and blood pressure abnormalities. Palpate peripheral pulses for rate, rhythm, and quality.
• Circulatory System: Assess for palpitations and thready or weak pulses indicating reduced cardiac output.
• Respiratory System: Observe respiratory rate and effort, noting dyspnea at rest or exertion, and auscultate breath sounds.
• Gastrointestinal System: Inquire about nausea and vomiting.
• Musculoskeletal System: Assess for pain in the neck, arm, back, jaw, or upper extremities, and note fatigue.
• Integumentary System: Observe skin color for cyanosis or pallor. Assess temperature and moisture, noting diaphoresis.

3. Calculate ASCVD Risk Score: Use risk calculators to estimate the patient’s 10-year risk of atherosclerotic cardiovascular disease (ASCVD). Factors include:

• Age, Gender, Race, Blood Pressure, Cholesterol Levels (Total and HDL), Diabetes status, Smoking History, Medications for hypertension and hyperlipidemia.

This score helps stratify risk and guide preventive and treatment strategies.

Diagnostic Procedures: Confirming Myocardial Infarction

Diagnostic tests are essential to confirm the diagnosis of myocardial infarction and assess the extent of cardiac damage.

1. Electrocardiogram (ECG) Interpretation: Obtain and review ECG results immediately, ideally within 10 minutes of arrival. ECG findings in MI may include:

• Pathological Q waves: Indicate previous myocardial infarction.
• ST-segment elevation (STEMI): Classic sign of acute, complete coronary artery occlusion.
• ST-segment depression or T-wave inversion (NSTEMI): Suggests myocardial ischemia and partial occlusion.

2. Troponin Levels Monitoring: Cardiac troponins (Troponin I or T) are highly sensitive and specific biomarkers for myocardial damage.

• Elevated Troponin: Indicates myocardial injury. Levels rise 4-9 hours after damage, peak at 12-24 hours, and remain elevated for 1-2 weeks.
• Serial Troponin Measurements: Repeat measurements are crucial to track the trend and confirm MI diagnosis, especially in NSTEMI.

3. Echocardiogram (ECHO): Echocardiography is a valuable tool to assess heart function and structure.

• Initial ECHO: Recommended within 24-48 hours of suspected MI to evaluate wall motion abnormalities, ejection fraction, and valve function.
• Follow-up ECHO: A second ECHO within three months provides a baseline assessment of post-infarction cardiac function.

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

• Cardiac CT Scan: Identifies coronary artery disease and plaque buildup.
• CT Coronary Angiogram: Uses contrast dye to visualize coronary arteries in detail, assessing for blockages and stenosis.

Alt text: Illustration depicting a cardiac catheterization procedure, a vital intervention for diagnosing and treating myocardial infarction by visualizing and opening blocked coronary arteries.

Nursing Interventions for Myocardial Infarction: Restoring Cardiac Health

Nursing interventions are crucial for managing myocardial infarction, focusing on restoring blood flow, relieving pain, managing symptoms, and facilitating rehabilitation.

Restore Blood Perfusion: Re-establishing Coronary Flow

Timely reperfusion is paramount in limiting myocardial damage. Nursing interventions focus on facilitating and supporting reperfusion therapies.

1. Reperfusion Therapy Assistance:

• Primary Percutaneous Coronary Intervention (PCI): Prepare patient for urgent PCI, the preferred reperfusion strategy for STEMI, aiming for door-to-balloon time within 90 minutes.
• Fibrinolytic Therapy: If PCI is not immediately available (within 120 minutes), prepare for fibrinolytic therapy (“clot busters”) administration, especially in STEMI.

2. Facilitate Artery Unblocking Procedures:

• Coronary Angioplasty and Stent Placement: Prepare patient pre- and post-procedure care for angioplasty and stent placement to open blocked arteries and maintain patency.
• Coronary Artery Bypass Graft (CABG) Surgery: For patients with complex blockages, prepare for CABG surgery to create new pathways for blood flow around blocked arteries.

3. Ischemia Reduction:

• Dual Antiplatelet Therapy (DAPT): Administer prescribed DAPT (e.g., aspirin and clopidogrel) for patients undergoing PCI to prevent stent thrombosis and recurrent events.
• Anticoagulation: Administer anticoagulants like bivalirudin, enoxaparin, or unfractionated heparin as ordered to prevent clot formation and propagation.

4. Blood Thinning Agents Administration:

• Anticoagulants (e.g., heparin, warfarin): Administer cautiously, monitoring coagulation studies (PT/INR, aPTT) and observing for bleeding complications.
• Antiplatelets (e.g., aspirin, clopidogrel): Administer as prescribed to prevent platelet aggregation and thrombus formation.

5. Thrombolytic Administration:

• “Clot Busters” (e.g., tPA, streptokinase): Administer thrombolytics promptly in eligible STEMI patients when PCI is delayed. Closely monitor for bleeding, a major complication of thrombolytic therapy.

Relieve the Pain: Managing Anginal Discomfort

Pain management is a priority in MI. Anginal pain is often severe and distressing, requiring prompt and effective intervention.

1. Pain Relief Administration:

• Opioid Analgesics (e.g., Morphine): Administer intravenous opioids like morphine as prescribed for pain relief. Monitor respiratory rate, blood pressure, and level of consciousness.
• Nitroglycerin: Administer sublingual or intravenous nitroglycerin to promote vasodilation and reduce chest pain. Monitor blood pressure closely for hypotension.

2. Supplemental Oxygen Therapy:

• Oxygen Administration: Administer supplemental oxygen to maintain oxygen saturation above 90%, improving myocardial oxygenation and reducing ischemic pain.

3. Vasodilation Promotion:

• Nitroglycerin Infusion: Administer IV nitroglycerin as ordered, titrating dose to alleviate chest pain and manage blood pressure. Monitor for headache and hypotension.

Manage the Symptoms: Stabilizing Vital Functions

Managing symptoms associated with MI is crucial for preventing complications and supporting patient comfort.

1. Blood Pressure Management:

• Antihypertensive Therapy: Collaborate with the healthcare provider to establish blood pressure goals.
• Blood Pressure Monitoring: Frequently monitor blood pressure and heart rate.

2. Maintain Blood Pressure within Acceptable Limits:

• Beta-blockers (e.g., metoprolol, atenolol): Administer to reduce heart rate, blood pressure, and myocardial contractility, decreasing myocardial oxygen demand. Contraindicated in suspected coronary vasospasm.
• ACE Inhibitors (e.g., lisinopril, enalapril): Administer to patients with systolic left ventricular dysfunction, heart failure, hypertension, or diabetes to reduce afterload and improve cardiac remodeling.
• Intravenous Nitrates: Administer IV nitrates for symptom relief and ST-segment depression in NSTEMI. Titrate dose carefully, monitoring blood pressure and for headache.

3. Lipid Lowering Therapy:

• Statin Medications (e.g., atorvastatin, rosuvastatin): Administer statins to lower LDL cholesterol, stabilize atherosclerotic plaques, and reduce the risk of recurrent events.

4. Blood Glucose Control:

• Glucose Monitoring: Regularly monitor blood glucose levels, as hyperglycemia is common in acute MI due to stress response.
• Glucose-Lowering Treatments: Administer insulin or oral hypoglycemic agents as ordered to maintain blood glucose within target range.

Cardiac Rehabilitation: Promoting Recovery and Long-Term Health

Cardiac rehabilitation is a crucial component of post-MI care, focusing on restoring physical function, reducing risk factors, and improving quality of life.

1. Cardiac Rehabilitation Plan Adherence:

• Encourage Participation: Strongly encourage patient participation in cardiac rehabilitation programs, especially after MI and surgical procedures.

2. Prevent Complications and Readmissions:

• Rehabilitation Benefits Education: Educate patients on the benefits of cardiac rehabilitation in reducing complications and hospital readmissions.

3. Continued Rehabilitation Post-Discharge:

• Outpatient Rehabilitation: Facilitate transition to outpatient cardiac rehabilitation programs (home-based or center-based) for continued recovery.

4. Educate on Rehabilitation Benefits:

• Improved Outcomes: Educate patients on the benefits of cardiac rehabilitation, including improved exercise capacity, weight management, lipid profile, psychological well-being, and overall quality of life.

Prevent MI Complications: Lifestyle Modifications and Ongoing Care

Preventing complications and recurrent MI is a long-term goal, requiring patient education and lifestyle modifications.

1. Encourage Regular Exercise:

• Gradual Exercise Progression: Advise patients to gradually increase exercise, starting with 15-20 minutes sessions and progressing as tolerated, under healthcare provider guidance.

2. Promote Healthy Weight Maintenance:

• Weight Management Counseling: Provide counseling on healthy weight management through diet and exercise to reduce cardiac workload and blood pressure.

3. Patient Education and Teach-Back:

• Medication and Treatment Education: Educate patients about medication regimens, follow-up appointments, and necessary lab/diagnostic tests. Use teach-back method to ensure understanding.

4. Stress Management Techniques:

• Stress Reduction Strategies: Educate patients on stress reduction techniques like yoga, relaxation exercises, guided imagery, deep breathing, and meditation.

5. Control Underlying Conditions:

• Comorbidity Management: Emphasize the importance of managing underlying conditions like diabetes, hyperlipidemia, and hypertension to prevent complications and recurrent MI.

6. Lifestyle Change Support:

• Healthy Lifestyle Counseling: Provide comprehensive counseling on adopting a heart-healthy lifestyle, including:
  • Regular exercise and physical activity.
  • Heart-healthy and balanced diet.
  • Smoking cessation.
  • Stress and anxiety management.
  • Limiting alcohol consumption.

7. Emphasize Regular Follow-Up Visits:

• Scheduled Follow-up: Stress the importance of regular follow-up appointments (e.g., 3-6 weeks post-discharge for STEMI, outpatient follow-up for NSTEMI and revascularized patients).

8. CPR Training for Caregivers:

• CPR Education: Encourage caregivers and family members to undergo CPR training to respond effectively in emergencies.

9. Action Plan for Attack Symptoms:

• Emergency Response Education: Educate patients on recognizing MI symptoms (chest pain, dyspnea) and the need to immediately take nitroglycerin or aspirin and seek medical attention.

10. Address Questions About Sexual Activity:

• Resuming Sexual Activity Guidance: Provide reassurance and guidance on resuming sexual activity once the patient feels capable of physical exertion, usually after cardiac rehabilitation.

11. Medical Alert Identification:

• Medical Alert Recommendation: Recommend wearing a medical alert bracelet or necklace to inform emergency responders about cardiac history.

Myocardial Infarction Nursing Care Plans: Addressing Key Nursing Diagnoses

Nursing care plans provide structured guidance for managing specific patient needs based on nursing diagnoses. For myocardial infarction, common nursing diagnoses and associated care plans include:

Acute Pain

Nursing Diagnosis: Acute Pain related to myocardial ischemia secondary to blockage of coronary arteries.

Related Factors:

• Blockage of coronary arteries.
• Reduced oxygenated blood flow to the myocardium.

Evidenced By:

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

Expected Outcomes:

• Patient verbalizes pain relief or controlled pain.
• Patient rates chest pain lower on pain scale compared to baseline.
• Patient appears relaxed and rests comfortably.
• Patient performs daily activities without significant pain.

Assessments:

1. Differentiate Angina from MI Pain: Assess characteristics of chest pain to distinguish angina from MI. MI pain is often:

   • Sudden onset, often in early morning.
   • Crushing substernal pain.
   • Radiating to jaw, back, left arm.
   • Lasting ≥ 30 minutes.
   • Unrelieved by rest or nitroglycerin in some cases.

2. Pain Characteristics Assessment: Detailed pain assessment including onset, precipitating factors (activity, emotion), relieving factors, quality, radiation, severity, and timing.

3. ECG During Chest Pain: Obtain ECG during chest pain to assess for ischemic changes.

Interventions:

1. Nitroglycerin Administration: Administer nitroglycerin sublingually or via buccal route for chest pain relief as per protocol.

2. Oxygen Administration: Provide supplemental oxygen to improve myocardial oxygenation.

3. Morphine Administration: Administer morphine intravenously for pain relief and to reduce myocardial oxygen demand.

4. Pain Control Effectiveness Evaluation: Regularly evaluate the effectiveness of pain management interventions and adjust as needed.

Anxiety

Nursing Diagnosis: Anxiety related to perceived threat of death and health status changes secondary to myocardial infarction.

Related Factors:

• Threat of death.
• Perceived threat to health status.
• Change in role functioning.
• Lifestyle modifications.

Evidenced By:

• Increased tension and restlessness.
• Fearful attitude and apprehension.
• Expressed concerns and uncertainty.
• Dyspnea and palpitations.
• Increased heart rate and respiratory rate.

Expected Outcomes:

• Patient verbalizes causes of anxiety.
• Patient expresses understanding of necessary post-MI lifestyle changes.
• Patient implements effective coping mechanisms.
• Patient demonstrates reduced anxiety, evidenced by stable vital signs and calm demeanor.

Assessments:

1. Anxiety Observation: Monitor for signs of anxiety, recognizing it as a common psychological response post-MI with prognostic implications.

2. Subjective and Objective Anxiety Cues: Assess for verbal and nonverbal cues of anxiety, even subtle signs like chest guarding without verbal pain complaint.

3. Coping Mechanisms Assessment: Evaluate patient’s usual coping strategies and their effectiveness in managing current anxiety.

Interventions:

1. Acknowledge Patient’s Anxiety: Validate patient’s feelings and encourage verbalization of anxieties without judgment.

2. Information and Education: Provide clear and honest information about tests, procedures, and treatment plans to reduce anxiety. Allow time for questions and provide accurate answers.

3. Patient Involvement in Care Planning: Involve patient in care decisions to promote autonomy and reduce anxiety associated with loss of control.

4. Stress Management Promotion: Implement stress management techniques to reduce anxiety and prevent post-traumatic stress disorder (PTSD) post-MI.

5. Anxiety Reduction Techniques Education: Teach anxiety reduction techniques such as relaxation exercises, deep breathing, mindfulness, and encourage use of supportive resources.

Decreased Cardiac Output

Nursing Diagnosis: Decreased Cardiac Output related to altered contractility secondary to myocardial infarction.

Related Factors:

• Changes in heart rate and electrical conduction.
• Reduced preload.
• Reduced cardiovascular blood flow.
• Rupture of atherosclerotic plaque.
• Occluded coronary artery.
• Altered muscle contractility.

Evidenced By:

• Sudden, persistent chest pain unrelieved by rest and medication.
• Shortness of breath.
• Nausea and vomiting.
• Anxiety and restlessness.
• Cool, pale, moist skin.
• Tachycardia or bradycardia.
• Tachypnea.
• Fatigue and dizziness.
• Confusion and altered mental status.
• Dysrhythmias.
• Hypotension.

Expected Outcomes:

• Patient maintains blood pressure within acceptable limits.
• Patient demonstrates absence or reduction of dyspnea, angina, and dysrhythmias.
• Patient verbalizes understanding of MI and its management.
• Patient participates in activities that reduce cardiac workload.

Assessments:

1. Risk and Causative Factors: Assess medical history for conditions predisposing to decreased cardiac output (e.g., atherosclerosis, heart failure).

2. Angina vs. MI Differentiation: Differentiate stable angina from MI. MI pain is unrelated to activity, prolonged, and unrelieved by rest or usual angina medications.

3. Blood Pressure Monitoring: Closely monitor blood pressure, reporting systolic BP < 100 mmHg or a drop of ≥ 25 mmHg from baseline, as this can indicate cardiogenic shock.

4. ECG Monitoring: Obtain ECG to detect STEMI, NSTEMI, and dysrhythmias.

5. Signs of Poor Cardiac Output: Assess for clinical signs of decreased cardiac output such as cool, clammy skin, weak pulses, reduced urine output, altered mental status, and peripheral vasoconstriction.

6. Cardiac Enzymes Monitoring: Monitor cardiac enzyme levels (troponin, CK-MB) to assess myocardial damage.

Interventions:

1. Oxygen Administration: Administer supplemental oxygen to enhance oxygen delivery to heart and tissues.

2. Thrombolytic Therapy Administration: If indicated and PCI is not immediately available, administer thrombolytic therapy promptly within symptom onset window. Monitor for bleeding.

3. Beta-blocker Administration: Administer beta-blockers to reduce myocardial workload and improve perfusion.

4. IV Access Establishment: Ensure patent IV access for medication and fluid administration.

5. Prepare for Cardiac Catheterization: Prepare patient for possible urgent cardiac catheterization for diagnosis and intervention (PCI).

6. Bed Rest and Activity Restrictions: Promote bed rest to reduce cardiac workload, especially post-catheterization, advise against heavy lifting and strenuous activity.

7. Cardiac Rehabilitation Referral: Refer patient to cardiac rehabilitation for comprehensive recovery and risk factor modification.

Ineffective Tissue Perfusion (Cardiopulmonary)

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

Related Factors:

• Atherosclerotic plaque formation.
• Narrowed and obstructed coronary arteries.
• Rupture of unstable plaque.
• Vasospasm of coronary arteries.
• Ineffective cardiac muscle contraction.
• Conditions compromising blood supply.
• Increased cardiac workload.

Evidenced By:

• Diminished peripheral pulses.
• Increased central venous pressure (CVP).
• Tachycardia and dysrhythmias.
• Decreased oxygen saturation.
• Angina and dyspnea.
• Change in level of consciousness and restlessness.
• Fatigue and exertional dyspnea or chest pain.
• Cold, clammy skin and pallor.
• Prolonged capillary refill time.

Expected Outcomes:

• Patient achieves palpable peripheral pulses and capillary refill within normal limits.
• Patient exhibits warm, dry skin without pallor or cyanosis.
• Patient demonstrates alert and oriented level of consciousness.

Assessments:

1. ECG Monitoring: Obtain ECG immediately to assess for ischemic changes and guide interventions.

2. Cardiovascular Status Assessment: Assess for signs of impaired tissue perfusion due to coronary artery blockage and reduced cardiac output.

3. Peripheral Perfusion Assessment: Assess skin color, temperature, capillary refill, and peripheral pulses to evaluate tissue perfusion status.

Interventions:

1. CPR Initiation: If cardiac arrest occurs, initiate CPR immediately and call for emergency assistance.

2. Reperfusion Treatment Initiation: Facilitate prompt reperfusion therapy (PCI or fibrinolysis) for STEMI patients within recommended timeframes.

3. Surgical Procedure Preparation: Prepare patient for potential PCI or CABG as indicated.

4. Fibrinolytic Administration (if indicated): Administer fibrinolytics promptly if PCI is not immediately accessible, monitoring for bleeding.

5. Aspirin Administration: Administer aspirin immediately upon suspicion of MI to inhibit platelet aggregation.

6. Cardiac Rehabilitation Referral: Refer patient to cardiac rehabilitation for long-term management and risk reduction.

Risk for Unstable Blood Pressure

Nursing Diagnosis: Risk for Unstable Blood Pressure related to myocardial ischemia and altered cardiac function secondary to myocardial infarction.

Related Factors:

• Ineffective heart muscle contraction.
• Myocardial ischemia.
• Constricted and obstructed arteries.
• Rupture of unstable plaque.
• Coronary artery spasm.
• Underlying cardiac conditions.
• Increased cardiac workload.

Evidenced By:

Risk diagnosis, therefore no “as evidenced by” criteria. Focus is on risk factors and preventive interventions.

Expected Outcomes:

• Patient maintains blood pressure within normal limits.
• Patient performs activities without significant blood pressure fluctuations.
• Patient adheres to medication regimen to manage blood pressure.

Assessments:

1. Blood Pressure Monitoring: Regularly monitor blood pressure, noting trends and significant fluctuations.

2. Cardiovascular Status Assessment: Assess for signs of cardiac complications (arrhythmias, heart failure, cardiogenic shock) that can affect blood pressure stability.

3. Signs and Symptoms Assessment: Monitor for symptoms associated with unstable blood pressure (headache, chest pain, dizziness, altered mental status, diaphoresis).

4. Risk Factors Identification: Identify patient-specific risk factors contributing to unstable blood pressure (e.g., pre-existing hypertension, medications, comorbidities).

5. Chest Pain Assessment: Assess chest pain characteristics, as pain and associated sympathetic response can contribute to blood pressure instability.

Interventions:

1. Blood Pressure Stabilization: Administer medications as prescribed (beta-blockers, ACE inhibitors, calcium channel blockers) to stabilize blood pressure.

2. Vasodilator Administration: Administer vasodilators (e.g., nitrates) as prescribed to reduce blood pressure and improve coronary blood flow.

3. Fluid Overload Management: If heart failure or fluid overload contributes to hypertension, administer diuretics as ordered to reduce fluid volume.

4. Patient Education on Blood Pressure Management: Educate patient about the importance of blood pressure control, medication adherence, and lifestyle modifications.

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