Myocardial infarction (MI) is a critical emergency that requires
timely management to save heart muscle and limit damage that may evolve over
several hours. Blood flow is abruptly decreased or stopped through the coronary
arteries and results in ischemia and necrosis to the myocardium if not treated.
Many people die prior to receiving medical care due to the denial that anything
may be wrong and postponement of seeking medical care. Cardiac dysrhythmias,
mainly ventricular fibrillation, is usually the cause of death in these
individuals. An MI is diagnosed based on type of chest pain,
electrocardiographic changes, and increase of cardiac enzymes, such as CK,
SGOT, and LDH. Precordial pain is similar to but usually more intense and
prolonged than anginal pain, and in the instance of MI, the chest pain is usually
constant and not relieved with nitroglycerin or rest.
Atherosclerosis of the arteries is usually the most common finding
in patients. Atherosclerosis and arteriosclerosis are used interchangeably when
discussing the fatty plaques that adhere to the inner layer of the arteries.
The continuous build up of these plaques, as well as the potential for hemorrhage
at the intimal layer may result in alterations of the blood flow through the
coronary arteries and abnormalities in platelet aggregation may contribute to
changes in coronary perfusion. Infarction may occur without coronary artery
dis- ease or occlusion, and if the patient has developed an adequate collateral
circulation, coronary occlu- sion may occur without infarction.
MI is usually a disease involving the left ventricle but the
damage may extend to other areas, such as the atria or right ventricle. A right ventricular myocardial
infarction usually has high right ventricular filling pressures and often has
severe tricuspid regurgitation. Transmural infarcts involve the entire
thickness of the myocardium and are characterized by Q waves on the
electrocardiogram. Nontransmural infarcts are characterized by S-T segment and
T wave changes. Subendocardial infarcts usually involve the inner portion of
the myocardium where wall tension is highest and the blood flow is most vul-
nerable to circulatory problems. Occlusion of the right coronary artery will result
in an inferior infarction that may also include posterior portions of the
heart. Occlusion of the left main artery, known as “the widow maker,” usually
results in death due to the extensive damage. Occlusion of the left anterior
descending artery results in an anterior infarction and may include some
inferior parts of the heart, and occlusion of the circumflex artery results in
a lateral infarction.
Precipitating factors that preclude MI include heredity, age,
gender, presence of hypertension, presence of diabetes mellitus, cigarette
smoking, hyperlipidemia, obesity, sedentary lifestyles, and stress.
The main goals in treating myocardial infarction are to increase
blood flow to the coronary arteries and thus decrease infarction size, increase
oxygen supply and decrease oxygen demand to prevent myocardial death or injury,
and control or correct dysrhythmias .
MEDICAL CARE
Oxygen: to increase available oxygen supply
Analgesics: morphine is the drug of choice, given in incremental doses IV
every 5 minutes as needed; IM injections are avoided because they can raise the
enzyme levels and do not act as quickly
Thrombolytic agents: Streptokinase, Urokinase, or Tissue Plasminogen Activator (tPa)
given either intracoronary or intravenously to activate the body’s own
fibrinolytic system to dissolve the clot and resume coronary blood perfusion
Cardiac glycosides: digitalis to increase force and strength of ventricular
contractions and to decrease the conduction and rate of contractions in order
to increase cardiac output; usually not used in the acute phase
Diuretics: furosemide (Lasix) to promote excess fluid removal, to decrease
edema and pulmonary venous pressure by preventing sodium and water reabsorption
Vasodilators: hydralazine (Apresoline), nifedipine (Procardia, Adalat),
nitroglycerin (Nitropaste, Nitrodur, Nitrostat, Tridil, Nitroglycerine),
prazosin (Minipres), captopril (Capoten) used to relax venous and/or arterial
smooth muscle to decrease preload, decrease afterload, and decrease oxygen
demand
Beta-adrenergic blockers: used to decrease blood pressure, decrease elevated plasma renins,
and with non-selective blockers, may do so without related reflex tachycardias;
used to treat ventricular dysrhythmias and for the prophylaxis of angina
Aspirin: used to decrease platelet aggregation and helps with vasodilation
of peripheral vessels
Thrombolytics: used in the treatment of acute MI; acts by activating mechanisms
for conversion of plasminogen to plasmin which is able to dissolve the clot;
commonly used are streptokinase, urokinase, alteplase, or anistreplase
Heparin: used with thrombolytic protocols, and in the treatment of MI;
prevents conversion of fibrinogen to fibrin and prothrombin to thrombin by its
action on antithrombin III
Laboratory: leukocyte count, sed rate and blood glucose may be elevated;
creatinine phosphokinase (CK, CPK) will normally increase within 4-6 hours,
peak between 12-24 hours, and last 2-3 days but should not be used as sole
indicator due to possibility of elevation with other problems such as surgery
or trauma; lactate dehydrogenase (LDH) will normally increase within 8-12
hours, peak between 2-4 days, and last 10-14 days but should not be used as
sole indicator due to possi- bility of elevation with other problems such as
liver failure; serum glutamic oxaloacetic transami- nase (SGOT) is occasionally
used as an infarct indicator; isoenzymes of CPK are very specific with CPK-MB
most specific for MI, and levels will not rise with transient chest pain or in
surgi- cal procedures; a definitive level for CPK-MB is greater than or equal
to 4% of the total CDK; LDH isoenzymes, specifically LDHl is more spe- cific
for MI; if the total LDH is elevated and LDHl is most predominant, MI is
confirmed; both CPK-MB and LDHl will return to normal 72-96 hours after
elevation
Chest x-ray: shows any enlargement of the heart and pulmonary vein, presence
of pulmonary edema or pleural effusion
Electrocardiography: shows indicative changes associated with sites of acute infarcts
using Q waves, S-T segment elevation, and T wave inversion. Also reveals
changes with atrial and ventricular enlargement, rhythm and conduction
abnormalities, ischemia, electrolyte abnormalities, drug toxicity, and presence
of dysrhythmias
Echocardiography: used to study structural abnormalities and blood flow through the
heart; M-mode echocardiography measures structures with a single ultrasonic
beam that provides a narrow view of the heart; two-dimensional (2D) echocardiography
shows a two dimensional and wider look at the heart that is more useful in diagnosing
right ventricular infarcts; documents increased right ventricular size,
performance and segmental wall motion abnormalities, and blood flow through the
heart
Nuclear cardiologic
testing: MUGA (multiple gated acquisition study)
provides information that approximates ejection fractions and the analysis of
the ventricular wall motion; 99mTc (Technetium-99 pyrophosphate scan) shows
infarcted areas as increased levels of radioactivity, or “hot spots’’ that
appear 12-36 hours after infarct and remain for 4- 7 days; PET (positron
emission tomography) allows measurement of myocardial blood flow, fatty acid
and glucose metabolism, and blood volume; thallium scans can determine size and
location of damage as a “cold spot”
Magnetic resonance imaging
(MRI): provides a three dimensional view that can
detect changes in tissues before structural damage is done and is safe for
pregnant women and children Cardiac catheterization: used to assess pathophysiology
of the patient‘s cardiovascular disorder, to provide left ventricular function
information, to allow for measurement of heart pressures and cardiac output, to
evaluate stenotic lesions, and to measure blood gas content
Intra-aortic balloon pump (IABP): decreases the workload on the heart, decreases myocardial oxygen
demand, increases coronary perfusion, decreases afterload, decreases preload,
and helps to limit infarct size if quickly initiated, improves cardiac output
and tissue perfusion; used in cardiogenic shock, for support post cardiac
surgery, intractable chest pain, and in cardiac catheterizations or other
cardiovascular procedures of high-risk patients
Ventricular assist device
(VAD): used on either or both ventricles to provide
total support to the heart and circulation in order to allow recovery to the
heart; usually indicated in patients who are awaiting cardiac transplantation
or in those patients with cardiogenic shock and ventricular failure; may be
used in conjunction with IABP
Pacemakers: either temporary or permanent, used in anticipation of lethal
dysrhythmias andlor conduction problems Surgery: coronary artery bypass
grafting to reroute the coronary blood flow around the dis- eased vessel to
enable coronary perfusion
NURSING CARE PLANS
Alteration in comfort
Related to: chest pain due to decreased blood flow to myocardium, myocardial ischemia
or infarct, post procedure discomfort, chest wall pain post-surgery,
pericarditis
Defining characteristics: chest pain with or without radiation, facial grimacing, clutching
of hands or chest, restlessness, diaphoresis, changes in pulse and blood
pressure, dyspnea, dizziness
Outcome
Criteria
·
Chest pain will be relieved or controlled to
patient’s satisfaction.
INTERVENTIONS
|
RATIONALES
|
Evaluate chest pain as to type, location, severity, relief,
change with activity or rest, other symptoms concurrenrly noted, such as
pallor, diaphoresis, radiation of pain, nausea, vomiting, shortness of
breath, and vital sign changes.
|
Variations may occur with patients regarding specific complaints
and behavior. Most MI patients look acutely ill and can only focus on their
pain. Respirations may be in- creased as a result of an- xiety and pain.
Heart rate may increase due to increased catecholamines, stress, and pain,
which can also increase blood pressure.
|
Obtain description of intensity using 0-10 scale, with 0 being
no pain and 10 being the worst pain experienced.
|
Pain is a subjective experience and personal to that patient.
Intensity scales are useful to gauge improvement or deterioration as perceived
by the patient.
|
Obtain history (when possible) of previous cardiac pain and
familial history of cardiac problems.
|
This provides information that may help to differentiate current
pain from previous problems, as well as identify new problems and complications.
|
Administer oxygen by nasal cannula or mask as indicated.
|
Supplemental oxygen can increase the available oxygen and can
relieve pain associated with myocardial ischemia.
|
Administer analgesic as ordered, such as morphine
sulfate, meperidine (Demerol), or Dilaudid IV.
|
Morphine is the drug of choice to control MI pain, but other
analgesics may be used to reduce pain and reduce the workload on the heart.
IM injections should be avoided because they can alter cardiac enzymes and
are not absorbed well in tissue that is non or underperfused.
|
Administer beta-blockers as ordered (such as atenolol, pindolol,
and propranolol).
|
These drug block sympathetic stimulation, reduce heart rate and
systolic blood pressure, and thus lowers the myocardial oxygen demand. Beta
blockers should not be given in severely impaired contractility states due to
the negative inotropic properties.
|
Administer calcium channel blockers as ordered (such as verapamil, diltiazem, or nifedipine).
|
These drugs can increase coronary blood flow and collateral
circulation, reduce preload and myocardial oxygen demands, which can decrease
pain due to ischemia.
|
Maintain bedrest during pain, with position of comfort; nurse to
stay with patient during pain.
|
Reduces oxygen consumption, and demand; alleviates fear and
provides caring atmosphere.
|
Maintain relaxing environment to promote calmness.
|
Reduces competing stimuli and reduces anxiety.
|
Information, Instruction, Demonstration
INTERVENTION
|
RATIONALES
|
Instruct to notify nurse immediately of any chest pain.
|
Delay in
notification can delay pain relief and may require increased amounts of
medication in order to finally achieve relief. Pain can cause further damage
to an already injured myocardium, and may signal extension of MI, spasm, or other
complication.
|
Instruct in relaxation techniques, deep Breathing, guided
imagery, visualization, etc.
|
Helps to decrease pain and anxiety and provides distraction from
pain.
|
Instruct in nitroglycerin SL administration after
hospitalization; 1 q5 minutes up to 3 times, and if pain is
unrelieved, patient should seek emergency medical care.
|
Knowledge facilitates cooperation and compliance with medical
regimen. Pain unrelieved with NTG may be indicative of MI.
|
Instruct in activity alterations and limitations.
|
Decreases myocardial oxygen demand and workload on the heart.
|
Instruct in medication effects, side effects, contraindications,
and symptoms to report.
|
Promores knowledge and compliance with therapeutic regimen.
Alleviates fear of unknown.
|
Discharge or Maintenance Evaluation
·
Patient will report pain being absent or
controlled with medication administration.
·
Medication will be administered prior to pain
becoming severe.
·
Patient will be able to recall effects, side
effects, and contraindications of medications accurately.
·
Activity will be modified in such a way as to
prevent onset of chest pain.
Altered tissue perfussion: cardiopulmonary, cerebral, peripheral
Related to: tissue ischemia, reduction or interruption of blood flow,
vasoconstriction, hypovolemia, shunting, depressed ventricular function,
dysrhythmias, conduction defects
Defining characteristics: abnormal hemodynamic readings, dysrhythmias, decreased peripheral
pulses, cyanosis, decreased blood pressure, shortness of breath, dyspnea, cold
and clammy skin, decreased mental alertness, changes in mental status,
oliguria, anuria, sluggish capillary refill, abnormal electrolyte and digoxin
levels, hypoxia, ABG changes,
chest pain, ventilation perfusion imbalances, changes in peripheral resistance,
impaired oxygenation of myocardium, EKG changes (S-T segment, T wave, U wave),
LV enlargement, palpitations
Outcome
Criteria
·
Blood flow and perfusion to vital organs will be
preserved and circulatory function will be maximized.
·
Patient will be free of dysrhythmias.
·
Hemodynamic parameters will be within normal
limits.
INTERVENTION
|
RATIONALES
|
Monitor vital signs. Obtain hemodynamic values, noting
deviations from baseline values. for problems.
|
Provides information about the hernodynamics of the patient and
facilitates early intervention for problems.
|
Monitor EKG for disturbances in conduction and for dysrhythmias
and treat as indicated.
|
Decreased cardiac perfusion may instigate conduction abnormalities.
Ventricular fibrillation is the most common dysrhythmia following MI.
Reperfusion dysrhythmias may occur after the administration of thrombolytic
therapy.
|
Administer oxygen by nasal cannula as ordered, with rate dependent on disease
process and condition.
|
Provides oxygen necessary for tissues and organ perfusion.
|
Auscultate lungs for crackles (rales), rhonchi, or wheezes.
|
May indicate fluid overload that will further decrease tissue
perfusion.
|
Auscultate heart sounds for S3 or S4 gallop, new murmurs, presence of jugular vein distention, or
hepatojugular reflex.
|
May indicate impending or pre- sent heart failure.
|
Monitor oxygen status with ABGs, Sv02
monitoring, or with pulse oximetry.
|
Provides information about the oxygenation status of the
patient. Continuous monitoring of saturation levels provide an instant
analysis of how activity affects oxygenation and perfusion for the patient.
|
Monitor for changes in respi- ratory status, increased work of
breathing, dyspnea, etc.
|
Decreased cardiac perfusion may result in pump failure and
precipitate respiratory distress and failure.
|
Determine the presence
and character of peripheral pulses, capillary refill time, skin color and
temperature.
|
May indicate decreased perfusion resulting from impaired
coronary blood flow.
|
Discourage any non-essential activity.
|
Ambulation, exercise, transfers, and Valsalva-type maneuvers can
increase blood pressure and decrease tissue perfusion.
|
Assist patient with planned, graduated levels of activity.
|
Allows for balance between rest and activity to decrease myocar-
dial workload and oxygen demand. Gradual increases help to increase patient
tolerance to activity without pain.
|
Titrate vasoactive drugs as ordered.
|
Maintain blood pressure and heart rate at parameters set by MD
for optimal perfusion with minimal workload on heart.
|
Administer thrombolytic drugs as ordered.
|
Drugs Iyse the clot that may be occluding the coronary artery
and promote restoration of oxygen and blood flow to increase perfusion.
|
Auscultate for bowel sounds and monitor for complaints of
nausea, vomiting, anorexia, abdominal distention, abdominal pain, or
constipation.
|
Decreased perfusion to mesen- tery may result in loss or change
in peristalsis, resulting in GI use of analgesics, and change in surroundings
may contribute to changes in GI status.
|
Monitor urine output for adequate amounts, character of urine,
presence of sediment, and specific gravity.
|
Decreased perfusion to renal arteries may result in oliguria.
Dehydration secondary to nausea and vomiting may affect renal perfusion.
|
Monitor labwork such as renal or liver profiles.
|
May indicate organ dysfunction and decreased perfusion.
|
Information, Instruction, Demonstration
INTERVENTION
|
RATIONALES
|
Instruct on medications, dosage, effects, side effects, and con-
traindications.
|
Promotes compliance with regimen and knowledge base.
|
Instruct to refrain from smoking.
|
Smoking causes vasoconstriction with can decrease perfusion.
|
Instruct in dietary require- ments, menu planning, sodium
restrictions, foods to avoid.
|
Reduction of high-cholesterol and sodium foods will help to control
atherosclerosis, hyperlipidemia, fluid retention, and the effects on coronary
blood flow.
|
Discharge or Maintenance Evaluation
·
Lung fields will be clear
and free of adventitious breath sounds.
·
Extremities will be warm
and pink, with easily palpable pulses.
·
Vital signs and hemodynamic
parameters will be within normal limits for patient.
·
Oxygenation will be optimal
as evidenced by pulse oximetry greater than 90%, SvO2 greater than 75%, or normal ABGs.
·
Patient will be free of
chest pain and shortness of breath. Patient will be able to verbalize
information accurately regarding medications, diet and activity limitations.
Decreased cardiac output
Related
to: damaged myocardium, decreased con- tractility, dysrhythmias,
conduction defects, alteration in preload, alteration in afterload, vasoconstriction,
myocardial ischemia, ventricular hypertrophy
Defining characteristics: elevated blood pressure, elevated mean arterial
pressure greater than 120 mmHg, elevated systemic vascular resistance greater
than 1400 dyne-seconds/cm5, cardiac output less than 4 L/min or cardiac index
less than 2.7 L/min/m2, tachycardia, cold, pale extremities, absent or
decreased peripheral pulses, EKG changes, hypotension, S3 or S4 gallops,
decreased urinary output, diaphoresis, orthopnea, dyspnea, crackles (rales),
jugular vein distention, edema, chest pain
Outcome Criteria
·
Vital signs and hemodynamic
parameters will be
·
within normal limits for
patient, with no dysrhythmias noted.
INTERVENTION
|
RATIONALES
|
Auscultate apical pulses and monitor heart rate and rhythm.
Monitor BP in both arms.
|
Decreased contractility will be compensated by tachycardia, especially
concurrently with heart failure. Blood volume will be lowered if blood
pressure is increased resulting in increased afterload. Pulse decreases may
be noted in association with toxic levels of digoxin. Hypotension may occur
as a result of ventricular dysfunction and poor perfusion of the myocardium.
|
Monitor EKG for dysrhythmias. and treat as indicated.
|
Conduction abnormalities may occur due to ischemic myocardium
affecting the pumping efficiency of the heart.
|
Determine level of cardiac function and existing cardiac and
other conditions.
|
Additional disease states and complications may place an additional
workload on an already compromised heart.
|
Measure CO and perform other hemodynamic calculations.
|
Provides direct measurement of cardiac output function, and
calculated measurement of preload and afterload.
|
Monitor for development of new Sg or S4 gallops.
|
S3 gallops are usually associated with congestive
heart failure but can be found with mitral regurgitation and left ventricular
overload after MI. S4 gallops can be associated with myocardial
ischemia, ventricular rigidity, pulmonary hypertension, or systemic hypertension,
which can decrease cardiac output.
|
Auscultate for presence of murmurs andlor rubs.
|
Indicates disturbances of normal blood flow within the heart related
to incompetent valves, sepia1 defects, or papillary muscle/chordae tendonae
rupture post MI. Presence of a rub with an MI may be associated with
pericarditis and/ or pericardial effusions.
|
Observe lower extremities for edema, distended neck veins, cold
hands and feet, mottling, oliguria. Notify MD if urine output is < 30 cc/hr.
|
Reduced venous return to the heart can resulr in low cardiac
output; oliguria results from decreased venous return due to fluid retention.
|
Position in semi-Fowler's position.
|
Promotes easier breathing by allowing for chest expansion and
prevents pooling of blood in the pulmonary vasculature.
|
Administer cardiac glycosides, nitrates, vasodilators, diuretics,
and Antihypertensives as ordered.
|
Used in the treatment of vasoconstriction and 10 reduce heart
rate and contractility, reduces blood pressure by relaxation of venous and
arterial smooth muscle which then in turn increases cardiac output and
decreases the workload on the heart.
|
Titrate vasoactive drugs as ordered per MD parameters.
|
Maintains blood pressure and heart rate at levels to optimize
cardiac output function.
|
Weigh every day.
|
Weight gain may indicate fluid retention and possible impending
congestive failure.
|
Arrange activities so as to not overwhelm patient.
|
Avoids fatiguing patient and decreasing cardiac output further.
Balancing rest with activity minimizes energy expenditure and myocardial oxygen
demands by maintaining adequate cardiac output.
|
Avoid Valsalva type maneuvers with straining, coughing or
moving.
|
Increasing intraabdominal pressure results in an abrupt decrease
in cardiac output by preventing blood from being pumped into the thoracic
cavity and thus, less blood being pumped into the heart which then decreases
the heart rate. When the pressure is released, there is a sudden overload of blood
which then increases preload and the workload on the heart.
|
Provide small, easy to digest, meals and restrict caffeine.
|
Large meals increase the work- load on the heart by diverting
blood flow to that area. Caffeine directly stimulates the heart and increases
heart rate.
|
Have emergency equipment and medications availabIe at all times.
|
Coronary occlusion, lethal dysrhythmias, infarction extensions
or intractable pain may precipitate cardiac arrest that requires life support
and resuscitation.
|
Information, Instruction, Demonstration
INTERVENTION
|
RATIONALES
|
Instruct on medications, dose, effects, side effects, contraindications,
and avoidance of over-the-counter drugs without MD approval.
|
Promotes knowledge and compliance with regimen.
Prevents any adverse drug interactions.
|
Instruct in activity limitations. Demonstrate exercises to be
done.
|
Promotes compliance. Reduces potential for decrease in cardiac
output by lessening the workload placed on the heart.
|
Instruct to report chest pain immediately.
|
May indicate complications of decreased cardiac output.
|
Instruct patient/family regarding placement of pulmonary artery
catheter, and post procedure care.
|
Alleviates fear and promotes knowledge. Pulmonary artery
catheter necessary for direct measurement of cardiac output and for obtaining
values for other emodynamic measurements.
|
Assist with insertion and maintenance of pacemaker when needed.
|
Cardiac pacing may be necessary during the acute phase of MI or
may be necessary as a permanent measure if the MI severely
damages the conduction system.
|
Discharge or Maintenance Evaluation
·
Patient will have no chest pain or shortness of
breath.
·
Vital signs and hemodynamic parameters will be
within normal limits for age and disease condition.
·
Minimal activity will be tolerated without
fatigue or dyspnea.
·
Urinary output will be adequate. Cardiac output
will be adequate to ensure adequate perfusion of all body systems.
Risk for fluid volume excess
Related
to: increased
sodium and water retention, decreased organ perfusion.
Defining
characteristics: edema, weight gain, intake greater than output, increased blood
pressure, increased heart rate, shortness of breath, dyspnea, orthopnea, crackles
(rales), oliguria, jugular vein distention, pleural effusion, specific gravity
changes, altered electrolyte levels
Outcome Criteria
Blood pressure
will be maintained within normal limits and edema will be absent or minimal in
all body parts.
INTERVENTION
|
RATIONALES
|
Auscultate lungs for presence of crackles (rales).
|
May indicate pulmonary edema from cardiac decompensation.
|
Observe for jugular vein distention and dependent edema.
|
May indicate impending congestive failure and fluid excess.
|
Determine fluid balance by measuring intake and output, and
observing for decreases in output and concentrated urine.
|
Renal perfusion is impaired with decreased cardiac output, which
leads to sodium and water retention and oliguria.
|
Weigh daily and notify MD of greater than 2 Ib/day
increase.
|
Abrupt changes in weight usually indicate excess fluid.
|
Provide patient with fluid intake of 2 L/day, unless fluid
restricrion is warranted.
|
Fluids provide hydration of tissues. Fluids may need to be restricted
due to cardiac decompensation.
|
Administer diuretics as ordered (furosemide, hydralazine, spirolactone,
hydrochlorothiazide).
|
Drugs may be necessary to cor- rect fluid overload depending on
emergent nature of problem.
|
Monitor electrolyte for imbalances.
|
Hypokalemia can occur with the administration of diuretics.
|
Instruction, Information, Demonstration
INTERVENTIONS
|
RATIONALES
|
Instruct patient regarding dietary restrictions of sodium.
|
Fluid retention is increased with intake of sodium.
|
Instruct patient to observe for weight changes
and report these to MD
|
Weight gain may be first overt sign of fluid excess and should
be monitored to prevent complications.
|
Instruct patient in medications prescribed after discharge, with
dose, effect, side effects, contraindications.
|
Promotes knowledge and compliance with treatment regimen.
|
Discharge or
Maintenance Evaluation
·
Patient will have no edema or fluid excess.
·
Fluid balance will be maintained and blood
pressure will be within normal limits of baseline.
·
Lung fields will be clear, without adventitious
breath sounds, and weight will be stable.
·
Patient will be able to verbalize understanding
of dietary restrictions and medications.
Anxiety
Related to: change in health status, fear of death, threat
to body image, threat to role functioning, pain
Defining characteristics: restlessness, insomnia, anorexia, increased respirations,
increased heart rate, increased blood pressure, difficulty concentrating, dry
mouth, poor eye contact, decreased energy, irritability, crying, feelings of
helplessness
Outcome
Criteria
Patient will be able to use coping mechanisms
effectively, will appear less anxious, and be able to verbalize feelings.
INTERVENTIONS
|
RATIONALES
|
Identify patient’s perception of illness or situation. En-
courage expressions of anger, grief, sadness, fear, and loss.
|
Patient may be afraid of dying and be anxious about his
immediate problem as related to his lifestyle and the problems that have been
left unattended.
|
Explain all procedures to patient in concise
and reassuring manner. Repeat informations needed based on patient’s ability to
comprehend.
|
Knowledge reduces fear of the unknown. Establishes feelings of
trust and concern. Informa-tion may need to be repeated or reintbrced
due to competing stimuli.
|
Encourage the patient to discuss his fears and
feelings. Provide an atmosphere of acceptance without judgment. Accept his
use of denial, but do not reinforce false beliefs. Avoid confrontations and
upsets.
|
Assists the patient in verbalizing concerns and provides the
opportunity to deal with matters of import to the patient. Accepting the
patient’s feelings may decrease his anxiety which can facilitate a
therapeutic environment for instruction. Denial can be useful to decrease
anxiety but can postpone dealing with the reality of the problem.
Confrontations can lead to anger and exacerbate the use of denial and
decrease cooperation.
|
Provide opportunities for the family to visit and assist with
care if possible. Orient to routines.
|
Familiar people can decrease anxiety of the patient, as well as provide a more con- ducive atmosphere for learn- ing and
recovery. Predicta- bility can decrease anxiety. Supportive family members
can comfort the patient and relieve worries.
|
Provide private time for patient and family member(s) to
verbalize feelings.
|
Allows time for expression of concerns and
feelings, and relieves tension by establishing a more normal routine.
|
Provide opportunities for patient to control his environment and
activities as much as feasible based on condition.
|
Allows the patient to have some control over his situation and
facilitates compliance with care of which patient is not in control.
|
Provide opportunity for patient to rest withour interruption as much as possible.
|
Facilitates coping mechanism by conserving energy, and by
providing required rest.
|
Administer antianxiety drugs as ordered (diazepam, flurazepam,
lorazepam).
|
Promotes rest and reduces anxiety.
|
Information, Instruction, Demonstration
INTERVENTIONS
|
RATIONALES
|
Instruct patient and family as to all procedures, tests,
medications, and care in a factual consistent manner. Reinforce as needed.
|
Accurate information reduces anxiety, facilitates the
relationship between patient and nurse, and allows the patienr and family to
deal with the problem in a realistic manner. Repetition, when needed, helps
in the retention of information when the attention span is diminished.
|
Instruct patient in relaxation techniques. Provide for
diversionary activities.
|
Reduces anxiety and stress.
|
Instruct about post-discharge care, activities, limitations,
symptoms to report, problems that might be encountered, and goals.
|
Reduces anxiety and promores increased independence and self confidence;
decreases fear of abandonment that can occur with discharge from hospital;
assists patient and family to identify realistic goals and decreases the
chances of discouragement with limitations during recuperation.
|
Discharge or
Maintenance Evaluation
·
Patient is able to recognize feelings and
identify mechanisms to cope and identify causes.
·
Patient has significant reduction in fear and
anxiety and appears less tense, with normal vital signs.
·
Patiendfamily can appropriately utilize
problem-solving skills.
·
Patient can verbalize concerns easily and has
increased energy.
·
Patient can make appropriate decisions based on
factual information regarding his condition and is able to discuss future
plans.
Knowledge
deficit
Related to: lack of understanding,
lack of understanding of medical condition, lack of recall
Defining characteristics:
verbalized questions regarding problems, inadequate followup on instructions
given, misconceptions, lack of improvement of previous regimen, development of
preventable complications
Outcome Criteria
Patient will be able to
verbalize and demonstrate understanding of information given regarding
condition, medications, and treatment regimen.
Information, Instruction, Demonstration
INTERVENTIONS
|
RATIONALES
|
Determine
patient’s baseline of knowledge regarding disease process, normal physiology,
and function of the heart.
|
Provides
information regarding patient$ understanding of condition as well as
a baseline from which to base teaching.
|
Monitor
patient’s readiness to learn and determine best methods to use for teaching.
Attempt to incorporate family members in learning process. Reinstructure inforce
information as needed.
|
Promotes
optimal learning en- vironment when patient shows willingness to learn.
Family members may assist with helping the patient to make in- formed choices
regarding his treatment. Anxiety or latge volumes of instruction may impede
comprehension and limit learning.
|
Provide
time for individual interaction with patient.
|
Promotes
relationship between patient and nurse, and establishes trust.
|
Instruct
patient on procedures that may be performed.
|
Provides
knowledge and pro- motes the ability to make informed choices.
|
Instruct patient on medications, dose, effects, side
effects, contraindications, and signs/ symptoms to report to MD.
|
Provides
information to the patient to manage medication regimen and ensure
compliance.
|
Instruct
in dietary needs and restrictions, such as limiting
caffeine and sodium or in- creasing potassium, etc.
|
Patient
may need to increase dietary potassium if placed on diuretics; caffeine
should be limited due to the direct stimulant effect on the heart; sodium
should be limited due to the potential for fluid retention.
|
Provide
printed materials when possible for patientlfamily to review.
|
Provides
references for patient and family to refer to once discharged, and can enhance
the understanding of verbally given instructions.
|
Demonstrate
and instruct on technique for checking pulse rate and regularity Instruct in
situations where immediate action must be taken.
|
Self
monitoring promotes self independence and can provide timely intervention for
abnormalities or complications. Heart rates that exceed set parameters
may require furrher medial alteration in medications or regimen.
|
Have
patient demonstrate all skills that will be necessary for post-discharge.
|
Provides
information that patient has gained a full understanding of instruction and
is able to demonstrate correct information.
|
Instruct/demonstrate
exercises to be performed, avoiding over taxing activities, signs/ symptoms
that may require the cessation of any activity, and to report symptoms that
may require medical attention.
|
Exercise programs are helpful in improving
cardiac function.
|
Discharge or Maintenance Evaluation
·
Patient will be able to verbalize understanding of
condition, treatment regimen, and signs/symptoms to report.
·
Patient will be able to correctly perform all tasks prior to
discharge.
·
Patient will be able to verbalize understanding of cardiac
disease, risk factors, dietary restrictions, and lifestyle adaptations.
COMPLICATIONS
RESULTING FROM MI THAT MAY LEAD TO DEATH IF NOT TREATED:
·
Congestive
heart failure
·
Dysrhythmias
Conduction problems
·
Cardiogenic
shock
·
Systemic
embolus
·
Pulmonary
embolus
·
Papillary
muscle rupture D
·
ressler’s
syndrome
·
Ventricular
rupture
·
Ventricular
septal defects
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