Nursing Process: The Patient With Myocardial Infarction

NURSING PROCESS: THE PATIENT WITH MYOCARDIAL INFARCTION

Assessment

One of the most important aspects of care of the patient with an MI is the assessment. It establishes the baseline for the patient so that any deviations may be identified, systematically identifies the patient’s needs, and helps determine the priority of those needs. Systematic assessment includes a careful history, particularly as it relates to symptoms: chest pain or discomfort, difficulty breathing (dyspnea), palpitations, unusual fatigue, faintness (syncope), or sweating (diaphoresis). Each symptom must be evaluated with re-gard to time, duration, the factors that precipitate the symptom and relieve it, and comparison with previous symptoms. A precise and complete physical assessment is critical to detect complica-tions and any change in patient status. Chart 28-6 identifies im-portant assessments and possible findings.

Intravenous sites are examined frequently. At least one and possibly two intravenous lines are placed for any patient with ACS to ensure that access is available for administering emergency med-ications. Medications are administered intravenously to achieve rapid onset and to allow for timely adjustment. Intramuscular medications are avoided because of unpredictable absorption, de-layed effect, and the risk of causing elevated serum enzyme levels by injuring muscle cells with an injection. After the patient’s con-dition stabilizes, the intravenous line may be changed into a saline lock to maintain intravenous access.

Diagnosis

NURSING DIAGNOSES

Based on the clinical manifestations, history, and diagnostic assessment data, the patient’s major nursing diagnoses may include:

·      Ineffective cardiopulmonary tissue perfusion related to re-duced coronary blood flow from coronary thrombus and atherosclerotic plaque

·      Potential impaired gas exchange related to fluid overload from left ventricular dysfunction

·       Potential altered peripheral tissue perfusion related to de-creased cardiac output from left ventricular dysfunction

·      Anxiety related to fear of death

·        Deficient knowledge about post-MI self-care

COLLABORATIVE PROBLEMS/ POTENTIAL COMPLICATIONS

Based on the assessment data, potential complications that may develop include the following:

·      Acute pulmonary edema

·       Heart failure

·       Cardiogenic shock

·       Dysrhythmias and cardiac arrest

·       Pericardial effusion and cardiac tamponade

·       Myocardial rupture

Planning and Goals

The major goals of the patient include relief of pain or ischemic signs and symptoms (eg, ST-segment changes), prevention of further myocardial damage, absence of respiratory dysfunction, maintenance or attainment of adequate tissue perfusion by de-creasing the heart’s workload, reduced anxiety, adherence to the self-care program, and absence or early recognition of complica-tions.

Nursing Interventions

RELIEVING PAIN AND OTHER SIGNS AND SYMPTOMS OF ISCHEMIA

Balancing the cardiac oxygen supply with its oxygen demand (eg, as evidenced by the relief of chest pain) is the top priority for the patient with an acute MI. Although medication therapy is re-quired to accomplish this goal, nursing interventions are also im-portant. Collaboration among the patient, nurse, and physician is critical in assessing the patient’s response to therapy and in al-tering the interventions accordingly.

The accepted method for relieving symptoms associated with MI is revascularization with thrombolytic therapy or emergent PCI for patients who present to the health care facility immedi-ately and who have no major contraindications. These therapies are important because, in addition to relieving symptoms, they aid in minimizing or avoiding permanent injury to the myo-cardium. With or without revascularization, administration of as-pirin, intravenous beta-blocker, and nitroglycerin is indicated. Use of a GPIIb/IIIa agent or heparin may also be indicated. The nurse administers morphine for relief of pain and other symp-toms, anxiety, and reduction of preload.

Oxygen should be administered along with medication therapy to assist with relief of symptoms. Administration of oxygen even in low doses raises the circulating level of oxygen to reduce pain asso-ciated with low levels of myocardial oxygen. The route of admin-istration, usually by nasal cannula, and the oxygen flow rate are documented. A flow rate of 2 to 4 L/min is usually adequate to maintain oxygen saturation levels of 96% to 100% if no other dis-ease is present.

Vital signs are assessed frequently as long as the patient is expe-riencing pain and other signs or symptoms of acute ischemia. Phys-ical rest in bed with the backrest elevated or in a cardiac chair helps to decrease chest discomfort and dyspnea. Elevation of the head is beneficial for the following reasons:

·      Tidal volume improves because of reduced pressure from abdominal contents on the diaphragm and better lung ex-pansion and gas exchange.

·      Drainage of the upper lung lobes improves.

·        Venous return to the heart (preload) decreases, which re-duces the work of the heart.

IMPROVING RESPIRATORY FUNCTION

Regular and careful assessment of respiratory function can help the nurse detect early signs of pulmonary complications. Scrupu-lous attention to fluid volume status prevents overloading the heart and lungs. Encouraging the patient to breathe deeply and change position frequently helps keep fluid from pooling in the bases of the lungs.

PROMOTING ADEQUATE TISSUE PERFUSION

Limiting the patient to bed or chair rest during the initial phase of treatment is particularly helpful in reducing myocardial oxygen consumption (mVO₂). This limitation should remain until the patient is pain-free and hemodynamically stable. Checking skin temperature and peripheral pulses frequently is important to ensure adequate tissue perfusion. Oxygen may be administered to enrich the supply of circulating oxygen.

REDUCING ANXIETY

Alleviating anxiety and fears is an important nursing function to reduce the sympathetic stress response. Decreased sympa-thetic stimulation decreases the workload of the heart, which may relieve pain and other signs and symptoms of ischemia.

Developing a trusting and caring relationship with the patient is critical in reducing anxiety. Providing information to the pa-tient and family in an honest and supportive manner invites the patient to be a partner in care and greatly assists in developing a positive relationship. Ensuring a quiet environment, preventing interruptions that disturb sleep, using a caring and appropriate touch, teaching the patient the relaxation response, using humor and assisting the patient to laugh, and providing the appropriate prayer book and assisting the patient to pray if consistent with the patient’s beliefs are other nursing interventions that can be used to reduce anxiety. Frequent opportunities are provided for the pa-tient to privately share concerns and fears. An atmosphere of ac-ceptance helps the patient to know that these concerns and fears are both realistic and normal. Music therapy, in which the patient listens to selected music for a predetermined duration and at a set time, has been found to be an effective method for reducing anx-iety and managing stress (Chlan & Tracy, 1999; Evans, 2002). Pet therapy, in which animals are brought to the patient, appears to provide emotional support and reduce anxiety. Administrative and infectious control practitioners are usually involved in devel-oping standards for the animals, animal handlers, and patients who are eligible for pet therapy.

MONITORING AND MANAGING POTENTIAL COMPLICATIONS

Complications that can occur after acute MI are caused by the dam-age that occurs to the myocardium and to the conduction system as a result of the reduced coronary blood flow. Because these com-plications can be lethal, close monitoring for and early identifica-tion of the signs and symptoms is critical.

The nurse monitors the patient closely for changes in cardiac rate and rhythm, heart sounds, blood pressure, chest pain, respi-ratory status, urinary output, skin color and temperature, senso-rium, ECG changes, and laboratory values. Any changes in the patient’s condition are reported promptly to the physician, and emergency measures are instituted when necessary.

PROMOTING HOME AND COMMUNITY-BASED CARE

Teaching Patients Self-Care

The most effective way to increase the probability the patient will implement a self-care regimen after discharge is to identify the priorities as perceived by the patient, provide adequate education about heart-healthy living, and facilitate the patient’s involve-ment in a cardiac rehabilitation program. Working with patients in developing plans to meet their specific needs further enhances the potential for an effective treatment plan (Chart 28-8).

Evaluation

EXPECTED PATIENT OUTCOMES

Expected patient outcomes may include the following:

·        Relief of angina

·        No signs of respiratory difficulties

·        Adequate tissue perfusion

·        Decreased anxiety

·        Adherence to a self-care program

·        Absence of  complications