Nursing Care Plan Myocardial Infarction

CARE SETTING

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

RELATED CONCERNS

1. Angina
2. Dysrhythmias
3. Heart failure: chronic
4. Psychosocial aspects of care
5. Thrombophlebitis: deep vein thrombosis
6. Patient Assessment Database

ACTIVITY/REST

May report: 

1. Weakness, fatigue, loss of sleep
2. Sedentary lifestyle, sporadic exercise schedule

May exhibit: 
Tachycardia, dyspnea with rest/activity

CIRCULATION

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


May exhibit: 

1. BP may be normal, increased, or decreased; postural changes may be noted from lying to sitting/standing
2. Pulse may be normal, full/bounding, or have a weak/thready quality with delayed capillary refill; irregularities (dysrhythmias) may be present
3. Heart sounds S3/S4 may reflect a pathological condition (e.g., cardiac failure, decreased ventricular contractility or compliance)
4. Murmurs may reflect valvular insufficiency or papillary muscle dysfunction
5. Friction rub (suggests pericarditis)
6. Heart rate regular or irregular; tachycardia/bradycardia may be present
7. Edema: Jugular vein distention, peripheral/dependent edema, generalized edema
8. Color: Pallor or cyanosis/mottling of skin, nailbeds, mucous membranes, and lips may be noted

EGO INTEGRITY

May report: 

1. Denial of significance of symptoms/presence of condition
2. Fear of dying, feelings of impending doom
3. Anger at inconvenience of illness/”unnecessary” hospitalization
4. Worry about family, job, finances

May exhibit: 

1. Denial, withdrawal, anxiety, lack of eye contact
2. Irritability, anger, combative behavior
3. Focus on self/pain

ELIMINATION

May exhibit: 
Normal or decreased bowel sounds

FOOD/FLUID

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

May exhibit: 
Poor skin turgor; dry or diaphoretic skin
Vomiting

HYGIENE

May report/exhibit: 
Difficulty in performing self-care tasks

NEUROSENSORY

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


May exhibit: 
Changes in mentation
Weakness

PAIN/DISCOMFORT

1. May report: Sudden onset of chest pain unrelieved by rest or nitroglycerin (although most pain is deep and visceral, 20% of MIs are painless)
2. 
   
3. Location: Typically anterior chest (substernal, precordium); may radiate to arms, jaw, face;
4. may have atypical location such as epigastrium/abdomen; elbow, jaw, back, neck, between shoulder blades, severe sore throat; throat fullness (females)
5. 
   
6. Quality: Crushing, constricting, viselike, squeezing, heavy, steady
7. 
   
8. Intensity: Usually 10 on a scale of 0–10 or “worst pain ever experienced.” Note: Pain is sometimes absent in females, postoperative patients, those with prior stroke or heart failure, diabetes mellitus or hypertension, or the elderly. Studies indicate that up to one-third of persons experiencing MI do not have typical chest pain.
9. 
   
10. Precipitating factor: May/may not be associated with activity

May exhibit: 

1. Facial grimacing, changes in body posture, may place clenched fist on midsternum when describing pain
2. Crying, groaning, squirming, stretching
3. Withdrawal, lack of eye contact
4. Autonomic responses: Changes in heart rate/rhythm, BP, respirations, skin color/moisture, level of consciousness

RESPIRATION

May report: 

1. Dyspnea with/without exertion, nocturnal dyspnea
2. Cough with/without sputum production
3. History of smoking, chronic respiratory disease

May exhibit: 

1. Increased respiratory rate, shallow/labored breathing
2. Pallor or cyanosis
3. Breath sounds clear or crackles/wheezes
4. Sputum clear, pink-tinged

SOCIAL INTERACTION

May report: 

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

May exhibit: 

1. Difficulty resting quietly, overemotional responses (intense anger, fear)
2. Withdrawal from family

TEACHING/LEARNING

May report: 

1. Family history of heart disease/MI, diabetes, stroke, hypertension, peripheral vascular disease
2. Use of tobacco
3. Discharge plan
4. DRG projected length of inpatient stay: 4.9–7.0 days (2–4 days/critical care unit [CCU])
5. May require assistance with food preparation, shopping, transportation, homemaking/maintenance tasks; physical layout of home

DIAGNOSTIC STUDIES

1. ECG: ST elevation signifying ischemia; peaked upright or inverted T wave indicating injury; development of Q waves signifying prolonged ischemia or necrosis.
2. Cardiac enzymes and isoenzymes: CPK-MB (isoenzyme in cardiac muscle): Elevates within 4–8 hr, peaks in 12–20 hr, returns to normal in 48–72 hr.
3. LDH: Elevates within 8–24 hr, peaks within 72–144 hr, and may take as long as 14 days to return to normal. An LDH1 greater than LDH2 (flipped ratio) helps confirm/diagnose MI if not detected in acute phase.
4. Troponins: Troponin I (cTnI) and troponin T (cTnT): Levels are elevated at 4–6 hr, peak at 14–18 hr, and return to baseline over 6–7 days. These enzymes have increased specificity for necrosis and are therefore useful in diagnosing postoperative MI when MB-CPK may be elevated related to skeletal trauma.
5. Myoglobin: A heme protein of small molecular weight that is more rapidly released from damaged muscle tissue with elevation within 2 hr after an acute MI, and peak levels occurring in 3–15 hr.
6. Electrolytes: Imbalances of sodium and potassium can alter conduction and compromise contractility.
7. WBC: Leukocytosis (10,000–20,000) usually appears on the second day after MI because of the inflammatory process.
8. ESR: Rises on second or third day after MI, indicating inflammatory response.
9. Chemistry profiles: May be abnormal, depending on acute/chronic abnormal organ function/perfusion.
10. ABGs/pulse oximetry: May indicate hypoxia or acute/chronic lung disease processes.
11. Lipids (total lipids, HDL, LDL, VLDL, total cholesterol, triglycerides, phospholipids): Elevations may reflect arteriosclerosis as a cause for coronary narrowing or spasm.
12. Chest x-ray: May be normal or show an enlarged cardiac shadow suggestive of HF or ventricular aneurysm.
13. Two-dimensional echocardiogram: May be done to determine dimensions of chambers, septal/ventricular wall motion, ejection fraction (blood flow), and valve configuration/function.
14. Nuclear imaging studies: Persantine or Thallium: Evaluates myocardial blood flow and status of myocardial cells, e.g., location/extent of acute/previous MI.
15. Cardiac blood imaging/MUGA: Evaluates specific and general ventricular performance, regional wall motion, and ejection fraction.
16. Technetium: Accumulates in ischemic cells, outlining necrotic area(s).
17. Coronary angiography: Visualizes narrowing/occlusion of coronary arteries and is usually done in conjunction with measurements of chamber pressures and assessment of left ventricular function (ejection fraction). Procedure is not usually done in acute phase of MI unless angioplasty or emergency heart surgery is imminent.
18. Digital subtraction angiography (DSA): Technique used to visualize status of arterial bypass grafts and to detect peripheral artery disease.
19. Magnetic resonance imaging (MRI): Allows visualization of blood flow, cardiac chambers/intraventricular septum, valves, vascular lesions, plaque formations, areas of necrosis/infarction, and blood clots.
20. Exercise stress test: Determines cardiovascular response to activity (often done in conjunction with thallium imaging in the recovery phase).

NURSING PRIORITIES

1. Relieve pain, anxiety.
2. Reduce myocardial workload.
3. Prevent/detect and assist in treatment of life-threatening dysrhythmias or complications.
4. Promote cardiac health, self-care.

DISCHARGE GOALS

1. Chest pain absent/controlled.
2. Heart rate/rhythm sufficient to sustain adequate cardiac output/tissue perfusion.
3. Achievement of activity level sufficient for basic self-care.
4. Anxiety reduced/managed.
5. Disease process, treatment plan, and prognosis understood.
6. Plan in place to meet needs after discharge.