MYOCARDIAL INFARCTION

Myocardial infarction (MI) is caused by marked reduction/loss of blood flow through one or more of the coronary
arteries, resulting in cardiac muscle ischemia and necrosis.

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

RELATED CONCERNS
Angina
Dysrhythmias
Heart failure: chronic
Psychosocial aspects of care
Thrombophlebitis: deep vein thrombosis

Patient Assessment Database

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

EGO INTEGRITY
May report: Denial of significance of symptoms/presence of condition
Fear of dying, feelings of impending doom
Anger at inconvenience of illness/”unnecessary” hospitalization
Worry about family, job, finances
May exhibit: Denial, withdrawal, anxiety, lack of eye contact
Irritability, anger, combative behavior
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
May report: Sudden onset of chest pain unrelieved by rest or nitroglycerin (although most pain is deep
and visceral, 20% of MIs are painless)
Location: Typically anterior chest (substernal, precordium); may radiate to arms, jaw, face;
may have atypical location such as epigastrium/abdomen; elbow, jaw, back,
neck, between shoulder blades, severe sore throat; throat fullness (females)
Quality: Crushing, constricting, viselike, squeezing, heavy, steady
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.
Precipitating factor: May/may not be associated with activity
May exhibit: Facial grimacing, changes in body posture, may place clenched fist on midsternum when
describing pain
Crying, groaning, squirming, stretching
Withdrawal, lack of eye contact
Autonomic responses: Changes in heart rate/rhythm, BP, respirations, skin color/moisture,
level of consciousness

RESPIRATION
May report: Dyspnea with/without exertion, nocturnal dyspnea
Cough with/without sputum production
History of smoking, chronic respiratory disease
May exhibit: Increased respiratory rate, shallow/labored breathing
Pallor or cyanosis
Breath sounds clear or crackles/wheezes
Sputum clear, pink-tinged

SOCIAL INTERACTION
May report: Recent stress, e.g., work, family
Difficulty coping with recent/current stressors, e.g., money, work, family problems made
worse by this illness/hospitalization
May exhibit: Difficulty resting quietly, overemotional responses (intense anger, fear)
Withdrawal from family

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

DIAGNOSTIC STUDIES
ECG: ST elevation signifying ischemia; peaked upright or inverted T wave indicating injury; development of Q waves
signifying prolonged ischemia or necrosis.
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.
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.
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.
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.
Electrolytes: Imbalances of sodium and potassium can alter conduction and compromise contractility.
WBC: Leukocytosis (10,000–20,000) usually appears on the second day after MI because of the inflammatory process.
ESR: Rises on second or third day after MI, indicating inflammatory response.
Chemistry profiles: May be abnormal, depending on acute/chronic abnormal organ function/perfusion.
ABGs/pulse oximetry: May indicate hypoxia or acute/chronic lung disease processes.
Lipids (total lipids, HDL, LDL, VLDL, total cholesterol, triglycerides, phospholipids): Elevations may reflect
arteriosclerosis as a cause for coronary narrowing or spasm.
Chest x-ray: May be normal or show an enlarged cardiac shadow suggestive of HF or ventricular aneurysm.
Two-dimensional echocardiogram: May be done to determine dimensions of chambers, septal/ventricular wall
motion, ejection fraction (blood flow), and valve configuration/function.
Nuclear imaging studies: Persantine or Thallium: Evaluates myocardial blood flow and status of myocardial cells,
e.g., location/extent of acute/previous MI.
Cardiac blood imaging/MUGA: Evaluates specific and general ventricular performance, regional wall motion, and
ejection fraction.
Technetium: Accumulates in ischemic cells, outlining necrotic area(s).
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.
Digital subtraction angiography (DSA): Technique used to visualize status of arterial bypass grafts and to detect
peripheral artery disease.
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.
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.
 NURSING DIAGNOSIS: Pain, acute
May be related to
Tissue ischemia (coronary artery occlusion)
Possibly evidenced by
Reports of chest pain with/without radiation
Facial grimacing
Restlessness, changes in level of consciousness
Changes in pulse, BP
DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:
Pain Level (NOC)
Verbalize relief/control of chest pain within appropriate time frame for administered medications.
Display reduced tension, relaxed manner, ease of movement.
Pain Control (NOC)
Demonstrate use of relaxation techniques.

ACTIONS/INTERVENTIONS RATIONALE
Pain Management (NIC)

Independent
Monitor/document characteristics of pain, noting verbal Variation of appearance and behavior of patients in pain
reports, nonverbal cues (e.g., moaning, crying, may present a challenge in assessment. Most patients with
restlessness, diaphoresis, clutching chest, rapid an acute MI appear ill, distracted, and focused on pain.
breathing), and hemodynamic response (BP/heart rate Verbal history and deeper investigation of precipitating
changes). factors should be postponed until pain is relieved.
Respirations may be increased as a result of pain and
associated anxiety; release of stress-induced
catecholamines increases heart rate and BP.

Obtain full description of pain from patient including Pain is a subjective experience and must be described by
location, intensity (0–10), duration, patient. Provides baseline for comparison to aid in
characteristics(dull/crushing), and radiation. Assist patient determining effectiveness of therapy,
to quantify pain by comparing it to other experiences. resolution/progression of problem.

Review history of previous angina, anginal equivalent, or May differentiate current pain from preexisting patterns,
MI pain. Discuss family history if pertinent. as well as identify complications such as extension of
infarction, pulmonary embolus, or pericarditis.

Instruct patient to report pain immediately. Delay in reporting pain hinders pain relief/may require
increased dosage of medication to achieve relief. In
addition, severe pain may induce shock by stimulating the
sympathetic nervous system, thereby creating further
damage and interfering with diagnostics and relief of
pain.

Provide quiet environment, calm activities, and comfort Decreases external stimuli, which may aggravate anxiety
measures (e.g., dry/wrinkle-free linens, backrub). and cardiac strain, limit coping abilities and adjustment to
Approach patient calmly and confidently. current situation.
ACTIONS/INTERVENTIONS RATIONALE
Pain Management (NIC)

Independent
Assist/instruct in relaxation techniques, e.g., deep/slow Helpful in decreasing perception of/ response to pain.
breathing, distraction behaviors, visualization, guided Provides a sense of having some control over the
imagery. situation, increase in positive attitude.

Hypotension/respiratory depression can occur as a result

Check vital signs before and after narcotic medication.
of narcotic administration. These problems may increase
myocardial damage in presence of ventricular
insufficiency.

Collaborative
Administer supplemental oxygen by means of nasal Increases amount of oxygen available for myocardial
cannula or face mask, as indicated. uptake and thereby may relieve discomfort associated
with tissue ischemia.

Administer medications as indicated:

Antianginals, e.g., nitroglycerin (Nitro-Bid, Nitrates are useful for pain control by coronary
Nitrostat, Nitro-Dur), isosorbide denitrate (Isordil), vasodilating effects, which increase coronary blood flow
mononitrate (Imdur) and myocardial perfusion. Peripheral vasodilation effects
reduce the volume of blood returning to the heart
(preload), thereby decreasing myocardial workload and
oxygen demand.

Beta-blockers, e.g., atenolol (Tenormin), Important second-line agents for pain control through
pindolol(Visken), propranolol (Inderal), nadolol effect of blocking sympathetic stimulation, thereby
(Corgard), metoprolol (Lopressor) reducing heart rate, systolic BP, and myocardial oxygen
demand. May be given alone or with nitrates. Note: beta-
blockers may be contraindicated if myocardial
contractility is severely impaired, because negative
inotropic properties can further reduce contractility.

Analgesics, e.g., morphine, meperidine (Demerol) Although intravenous (IV) morphine is the usual drug of
choice, other injectable narcotics may be used in acute-
phase/recurrent chest pain unrelieved by nitroglycerin to
reduce severe pain, provide sedation, and decrease
myocardial workload. IM injections should be avoided, if
possible, because they can alter the CPK diagnostic
indicator and are not well absorbed in underperfused
tissue.
 NURSING DIAGNOSIS: Activity intolerance
May be related to
Imbalance between myocardial oxygen supply and demand
Presence of ischemia/necrotic myocardial tissues
Cardiac depressant effects of certain drugs (beta-blockers, antidysrhythmics)
Possibly evidenced by
Alterations in heart rate and BP with activity
Development of dysrhythmias
Changes in skin color/moisture
Exertional angina
Generalized weakness
DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:
Activity Tolerance (NOC)
Demonstrate measurable/progressive increase in tolerance for activity with heart rate/rhythm and BP
within patient’s normal limits and skin warm, pink, dry.
Report absence of angina with activity.

ACTIONS/INTERVENTIONS RATIONALE
Energy Management (NIC)

Independent
Record/document heart rate and rhythm and BP changes Trends determine patient’s response to activity and may
before, during, and after activity, as indicated. Correlate indicate myocardial oxygen deprivation that may require
with reports of chest pain/shortness of breath. (Refer to decrease in activity level/return to bedrest, changes in
ND: Cardiac Output, risk for decreased.) medication regimen, or use of supplemental oxygen.

Encourage rest (bed/chair) initially. Thereafter, limit Reduces myocardial workload/oxygen consumption,
activity on basis of pain/ adverse cardiac response. reducing risk of complications (e.g., extension of MI).
Provide nonstress diversional activities. Note: American Heart Association/American College of
Cardiology guidelines (1996) suggest that patients with
cardiac conditions should not be kept in bed longer than
24 hr. Patients with uncomplicated MI are encouraged to
engage in mild activity out of bed, including short walks
12 hr after incident.

Instruct patient to avoid increasing abdominal pressure, Activities that require holding the breath and bearing
e.g., straining during defecation. down (Valsalva maneuver) can result in bradycardia
(temporarily reduced cardiac output) and rebound
tachycardia with elevated BP.

Explain pattern of graded increase of activity level, e.g., Progressive activity provides a controlled demand on the
getting up to commode or sitting in chair, progressive heart, increasing strength and preventing overexertion.
ambulation, and resting after meals.

Review signs/symptoms reflecting intolerance of present Palpitations, pulse irregularities, development of chest
activity level or requiring notification of nurse/physician. pain, or dyspnea may indicate need for changes in
exercise regimen or medication.

Collaborative

Refer to cardiac rehabilitation program. Provides continued support/additional supervision and

participation in recovery and wellness process.
 NURSING DIAGNOSIS: Anxiety [specify level]/Fear
May be related to
Threat to or change in health and socioeconomic status
Threat of loss/death
Unconscious conflict about essential values, beliefs, and goals of life
Interpersonal transmission/contagion
Possibly evidenced by
Fearful attitude
Apprehension, increased tension, restlessness, facial tension
Uncertainty, feelings of inadequacy
Somatic complaints/sympathetic stimulation
Focus on self, expressions of concern about current and future events
Fight (e.g., belligerent attitude) or flight behavior
DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:
Anxiety/Fear Control (NOC)
Recognize feelings.
Identify causes, contributing factors.
Verbalize reduction of anxiety/fear.
Demonstrate positive problem-solving skills.
Identify/use resources appropriately.

ACTIONS/INTERVENTIONS RATIONALE
Anxiety Reduction (NIC)

Independent
Identify and acknowledge patient’s perception of Coping with the pain and emotional trauma of an MI is
threat/situation. Encourage expressions of, and do not difficult. Patient may fear death and/or be anxious about
deny feelings of, anger, grief, sadness, fear. immediate environment. Ongoing anxiety (related to
concerns about impact of heart attack on future lifestyle,
matters left unattended/unresolved, and effects of illness
on family) may be present in varying degrees for some
time and may be manifested by symptoms of depression.

Note presence of hostility, withdrawal, and/or denial Research into survival rates between type A and type B
(inappropriate affect or refusal to comply with medical individuals and the impact of denial has been ambiguous;
regimen). however, studies show some correlation between degree/
expression of anger or hostility and an increased risk for MI.

Maintain confident manner (without false reassurance). Patient and SO can be affected by the anxiety/uneasiness
displayed by health team members. Honest explanations
can alleviate anxiety.

Observe for verbal/nonverbal signs of anxiety, and stay Patient may not express concern directly, but
with patient. Intervene if patient displays destructive words/actions may convey sense of agitation, aggression,
behavior. and hostility. Intervention can help patient regain control
of own behavior.
ACTIONS/INTERVENTIONS RATIONALE
Anxiety Reduction (NIC)

Independent
Accept but do not reinforce use of denial. Avoid Denial can be beneficial in decreasing anxiety but can
confrontations. postpone dealing with the reality of the current situation.
Confrontation can promote anger and increase use of denial,
reducing cooperation and possibly impeding recovery.

Orient patient/SO to routine procedures and expected Predictability and information can decrease anxiety for
activities. Promote participation when possible. patient.

Answer all questions factually. Provide consistent Accurate information about the situation reduces fear,
information; repeat as indicated. strengthens nurse-patient relationship, and assists
patient/SO to deal realistically with situation. Attention
span may be short, and repetition of information helps
with retention.

Encourage patient/SO to communicate with one another, Sharing information elicits support/comfort and can
sharing questions and concerns. relieve tension of unexpressed worries.

Provide privacy for patient and SO. Allows needed time for personal expression of feelings;
may enhance mutual support and promote more adaptive
behaviors.

Provide rest periods/uninterrupted sleep time, quiet Conserves energy and enhances coping abilities.
surroundings, with patient controlling type, amount of
external stimuli.

Support normality of grieving process, including time Can provide reassurance that feelings are normal response
necessary for resolution. to situation/perceived changes.

Encourage independence, self-care, and decision making Increased independence from staff promotes self-
within accepted treatment plan. confidence and reduces feelings of abandonment that can
accompany transfer from coronary unit/discharge from
hospital.

Encourage discussion about postdischarge expectations. Helps patient/SO identify realistic goals, thereby reducing
risk of discouragement in face of the reality of limitations
of condition/pace of recuperation.

Collaborative

Administer antianxiety/hypnotics as indicated, e.g., Promotes relaxation/rest and reduces feelings of anxiety.
alprazolam (Xanax), diazepam (Valium), lorazepam
(Ativan), flurazepam (Dalmane).
 NURSING DIAGNOSIS: Cardiac Output, risk for decreased
Risk factors may include
Changes in rate, rhythm, electrical conduction
Reduced preload/increased SVR
Infarcted/dyskinetic muscle, structural defects, e.g., ventricular aneurysm,
septal defects
Possibly evidenced by
[Not applicable; presence of signs and symptoms establishes actual diagnosis.]
DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:
Cardiac Pump Effectiveness (NOC)
Maintain hemodynamic stability, e.g., BP, cardiac output within normal range, adequate urinary output,
decreased frequency/absence of dysrhythmias.
Report decreased episodes of dyspnea, angina.
Demonstrate an increase in activity tolerance.

ACTIONS/INTERVENTIONS RATIONALE
Cardiac Care: Acute (NIC)

Independent
Auscultate BP. Compare both arms and obtain lying, Hypotension may occur related to ventricular
sitting, and standing pressures when able. dysfunction, hypoperfusion of the myocardium, and vagal
stimulation. However, hypertension is also a common
phenomenon, possibly related to pain, anxiety,
catecholamine release, and/or preexisting vascular
problems. Orthostatic (postural) hypotension may be
associated with complications of infarct, e.g., HF.

Evaluate quality and equality of pulses, as indicated. Decreased cardiac output results in diminished
weak/thready pulses. Irregularities suggest dysrhythmias,
which may require further evaluation/monitoring.
Auscultate heart sounds:
Note development of S3, S4; S3 is usually associated with HF, but it may also be noted
with the mitral insufficiency (regurgitation) and left
ventricular overload that can accompany severe
infarction. S4 may be associated with myocardial
ischemia, ventricular stiffening, and pulmonary or
systemic hypertension.

Presence of murmurs/rubs. Indicates disturbances of normal blood flow within the

heart, e.g., incompetent valve, septal defect, or vibration
of papillary muscle/chordae tendineae (complication of
MI). Presence of rub with an infarction is also associated
with inflammation, e.g., pericardial effusion and
pericarditis.

Auscultate breath sounds. Crackles reflecting pulmonary congestion may develop

because of depressed myocardial function.
ACTIONS/INTERVENTIONS RATIONALE
Cardiac Care: Acute (NIC)

Independent
Monitor heart rate and rhythm. Document dysrhythmias Heart rate and rhythm respond to medication, activity,
via telemetry. and developing complications. Dysrhythmias (especially
premature ventricular contractions or progressive heart
blocks) can compromise cardiac function or increase
ischemic damage. Acute or chronic atrial
flutter/fibrillation may be seen with coronary artery or
valvular involvement and may or may not be
pathological.
Note response to activity and promote rest appropriately.
(Refer to ND: Activity intolerance.) Overexertion increases oxygen consumption/demand and
can compromise myocardial function.
Provide small/easily digested meals. Limit caffeine
intake, e.g., coffee, chocolate, cola. Large meals may increase myocardial workload and
cause vagal stimulation, resulting in bradycardia/ectopic
beats. Caffeine is a direct cardiac stimulant that can
increase heart rate. Note: New guidelines suggest no need
to restrict caffeine in regular coffee drinkers.
Have emergency equipment/medications available.
Sudden coronary occlusion, lethal dysrhythmias,
extension of infarct, and unrelenting pain are situations
that may precipitate cardiac arrest, requiring immediate
life-saving therapies/transfer to CCU.
Collaborative

Administer supplemental oxygen, as indicated.

Increases amount of oxygen available for myocardial
uptake, reducing ischemia and resultant cellular
irritation/dysrhythmias.
Measure cardiac output and other functional parameters
as appropriate. Cardiac index, preload/afterload, contractility, and
cardiac work can be measured noninvasively with
thoracic electrical bioimpedance (TEB) technique. Useful
in evaluating response to therapeutic interventions and
identifying need for more aggressive/emergency care.
Maintain IV/Hep-Lock access as indicated.
Patent line is important for administration of emergency
drugs in presence of persistent lethal dysrhythmias or
chest pain.
Review serial ECGs.
Provides information regarding progression/resolution of
infarction, status of ventricular function, electrolyte
balance, and effects of drug therapies.
Review chest x-ray.
May reflect pulmonary edema related to ventricular
dysfunction.
Monitor laboratory data, e.g., cardiac enzymes, ABGs,
electrolytes. Enzymes monitor resolution/extension of infarction.
Presence of hypoxia indicates need for supplemental
oxygen. Electrolyte imbalance, e.g.,
hypokalemia/hyperkalemia, adversely affects cardiac
rhythm/contractility.
ACTIONS/INTERVENTIONS RATIONALE
Cardiac Care: Acute (NIC)

Collaborative
Administer antidysrhythmic drugs as indicated. (Refer to Dysrhythmias are usually treated symptomatically, except
CP: Dysrhythmias.) for PVCs, which are often treated prophylactically. Early
inclusion of ACE inhibitor therapy (especially in presence
of large anterior MI, ventricular aneurysm, or HF)
enhances ventricular output, increases survival, and may
slow progression of HF. Note: Use of routine lidocaine is
no longer recommended.

Assist with insertion/maintain pacemaker, when used. Pacing may be a temporary support measure during acute
phase or may be needed permanently if infarction
severely damages conduction system, impairing systolic
function. Evaluation is based on echocardiography or
radionuclide ventriculography.

NURSING DIAGNOSIS: Tissue Perfusion, ineffective

Risk factors may include
Reduction/interruption of blood flow, e.g., vasoconstriction, hypovolemia/shunting, and thromboembolic
formation
Possibly evidenced by
[Not applicable; presence of signs and symptoms establishes an actual diagnosis.]
DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:
Cardiac Pump Effectiveness (NOC)
Demonstrate adequate perfusion as individually appropriate, e.g., skin warm and dry, peripheral pulses
present/strong, vital signs within patient’s normal range, patient alert/oriented, balanced I&O, absence of
edema, free of pain/discomfort.

ACTIONS/INTERVENTIONS RATIONALE
Hemodynamic Regulation (NIC)

Independent
Investigate sudden changes or continued alterations in Cerebral perfusion is directly related to cardiac output
mentation, e.g., anxiety, confusion, lethargy, stupor. and is also influenced by electrolyte/acid-base variations,
hypoxia, and systemic emboli.

Inspect for pallor, cyanosis, mottling, cool/clammy skin. Systemic vasoconstriction resulting from diminished
Note strength of peripheral pulse. cardiac output may be evidenced by decreased skin
perfusion and diminished pulses. (Refer to ND: Cardiac
Output, risk for decreased, p. 000.)
ACTIONS/INTERVENTIONS RATIONALE
Hemodynamic Regulation (NIC)

Independent
Monitor respirations, note work of breathing. Cardiac pump failure and/or ischemic pain may
precipitate respiratory distress; however,
sudden/continued dyspnea may indicate thromboembolic
pulmonary complications.

Monitor intake, note changes in urine output. Record Decreased intake/persistent nausea may result in reduced
urine specific gravity as indicated. circulating volume, which negatively affects perfusion
and organ function. Specific gravity measurements reflect
hydration status and renal function.

Assess GI function, noting anorexia, decreased/absent Reduced blood flow to mesentery can produce GI
bowel sounds, nausea/vomiting, abdominal distension, dysfunction, e.g., loss of peristalsis. Problems may be
constipation. potentiated/aggravated by use of analgesics, decreased
activity, and dietary changes.
Circulatory Care: Venous Insufficiency (NIC)

Encourage active/passive leg exercises, avoidance of Enhances venous return, reduces venous stasis, and
isometric exercises. decreases risk of thrombophlebitis; however, isometric
exercises can adversely affect cardiac output by
increasing myocardial work and oxygen consumption.

Assess for Homans’ sign (pain in calf on dorsiflexion), Indicators of deep vein thrombosis (DVT), although DVT
erythema, edema. can be present without a positive Homans’ sign.

Instruct patient in application/periodic removal of Limits venous stasis, improves venous return, and reduces
antiembolic hose, when used. risk of thrombophlebitis in patient who is limited in
activity.

Hemodynamic Regulation (NIC)

Collaborative
Monitor laboratory data, e.g., ABGs, BUN, creatinine, Indicators of organ perfusion/function. Abnormalities in
electrolytes, coagulation studies (PT, aPTT, clotting coagulation may occur as a result of therapeutic measures
times). (e.g., heparin/Coumadin use and some cardiac drugs).

Administer medications as indicated: Reduces mortality in MI patients, and is taken daily.

Antiplatelet agents, e.g., aspirin, abciximab Aspirin also reduces coronary reocclusion after
(ReoPro), clopidogrel (Plavix); percutaneous transluminal coronary angioplasty (PTCA).
ReoPro is an IV drug used as an adjunct to PTCA for
prevention of acute ischemic complications.

Anticoagulants, e.g., heparin/enoxaparin (Lovenox); Low-dose heparin is given during PTCA and may be
given prophylactically in high-risk patients (e.g., atrial
fibrillation, obesity, ventricular aneurysm, or history of
thrombophlebitis) to reduce risk of thrombophlebitis or
mural thrombus formation.

Oral anticoagulants, e.g., anisindione (Miradon), Used for prophylaxis and treatment of thromboembolic
warfarin (Coumadin); complications associated with MI.

Cimetidine (Tagamet), ranitidine (Zantac), antacids; Reduces or neutralizes gastric acid, preventing discomfort
and gastric irritation, especially in presence of reduced
 mucosal circulation.

ACTIONS/INTERVENTIONS RATIONALE
Hemodynamic Regulation (NIC)

Collaborative
Assist with reperfusion therapy:
Administer thrombolytic agents, e.g., alteplase Thrombolytic therapy is the treatment of choice (when
(Activase, rt-PA), reteplase (Retavase), streptokinase initiated within 6 hr) to dissolve the clot (if that is the
(Streptase), anistreplase (Eminase), urokinase, cause of the MI) and restore perfusion of the
(Abbokinase); myocardium.

Prepare for PTCA (balloon angioplasty),

with/without intracoronary stents; This procedure is used to open partially blocked coronary
arteries before they become totally blocked. The
mechanism includes a combination of vessel stretching
and plaque compression. Intracoronary stents may be
placed at the time of PTCA to provide structural support
within the coronary artery and improve the odds of long-
term patency.
Transfer to critical care.
More intensive monitoring and aggressive interventions
are necessary to promote optimum outcome.

NURSING DIAGNOSIS: Fluid Volume, risk for excess

Risk factors may include
Decreased organ perfusion (renal)
Increased sodium/water retention
Increased hydrostatic pressure or decreased plasma proteins (sequestering of fluid in interstitial
space/tissues)
Possibly evidenced by
[Not applicable; presence of signs and symptoms establishes an actual diagnosis.]
DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:
Fluid Balance (NOC)
Maintain fluid balance as evidenced by BP within patient’s normal limits.
Be free of peripheral/venous distension and dependent edema, with lungs clear and weight stable.

ACTIONS/INTERVENTIONS RATIONALE
Fluid Management (NIC)

Independent

Auscultate breath sounds for presence of crackles. May indicate pulmonary edema secondary to cardiac
decompensation.

Note JVD, development of dependent edema. Suggests developing congestive failure/fluid volume excess.
ACTIONS/INTERVENTIONS RATIONALE
Fluid Management (NIC)

Independent
Measure I&O, noting decrease in output, concentrated Decreased cardiac output results in impaired kidney
appearance. Calculate fluid balance. perfusion, sodium/water retention, and reduced urine
output.

Weigh daily. Sudden changes in weight reflect alterations in fluid

balance.

Maintain total fluid intake at 2000 mL/24 hr within Meets normal adult body fluid requirements, but may
cardiovascular tolerance. require alteration/restriction in presence of cardiac
decompensation.

Collaborative

Provide low-sodium diet/beverages. Sodium enhances fluid retention and should therefore be
restricted during active MI phase and/or if heart failure is
present.

Administer diuretics, e.g., furosemide (Lasix), May be necessary to correct fluid overload. Drug choice
spironolactone with hydrochlorothiazide (Aldactazide), is usually dependent on acute/chronic nature of
hydralazine (Apresoline). symptoms.

Monitor potassium as indicated.

Hypokalemia can limit effectiveness of therapy and can
occur with use of potassium-depleting diuretics.

NURSING DIAGNOSIS: Knowledge, deficient [Learning Need] regarding cause/treatment of

condition, self-care, and discharge needs
May be related to
Lack of information/misunderstanding of medical condition/therapy needs
Unfamiliarity with information resources
Lack of recall
Possibly evidenced by
Questions; statement of misconception
Failure to improve on previous regimen
Development of preventable complications
DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:
Knowledge: Disease Process (NOC)
Verbalize understanding of condition, potential complications, individual risk factors, and function of
pacemaker (if used).
Relate signs of pacemaker failure.
Knowledge: Treatment Regimen (NOC)
Verbalize understanding of therapeutic regimen.
List desired action and possible adverse side effects of medications.
Correctly perform necessary procedures and explain reasons for actions.
ACTIONS/INTERVENTIONS RATIONALE
Teaching: Individual (NIC)

Independent
Assess patient/SO level of knowledge and ability/desire Necessary for creation of individual instruction plan.
to learn. Reinforces expectation that this will be a “learning
experience.” Verbalization identifies misunderstandings
and allows for clarification.

Be alert to signs of avoidance, e.g., changing subject Natural defense mechanisms, such as anger or denial of
away from information being presented or extremes of significance of situation, can block learning, affecting
behavior (withdrawal/euphoria). patient’s response and ability to assimilate information.
Changing to a less formal/structured style may be more
effective until patient/SO is ready to accept/deal with
current situation.

Present information in varied learning formats, e.g., Using multiple learning methods enhances retention of
programmed books, audiovisual tapes, question-and- material.
answer sessions, group activities.

Cardiac Care: Rehabilitation (NIC)

Independent
Reinforce explanations of risk factors, dietary/activity Provides opportunity for patient to retain information and
restrictions, medications, and symptoms requiring to assume control/participate in rehabilitation program.
immediate medical attention. Note: Routine use of supplements/herbal remedies (e.g.,
ginkgo biloba, garlic, vitamin E) can result in alterations
in blood clotting, especially when anticoagulant/ASA
therapy is prescribed.

Encourage identification/reduction of individual risk These behaviors/chemicals have direct adverse effects on
factors, e.g., smoking/alcohol consumption, obesity. cardiovascular function and may impede recovery,
increase risk for complications.

Warn against isometric activity, Valsalva maneuver, and These activities greatly increase cardiac workload and
activities requiring arms positioned above head. myocardial oxygen consumption and may adversely
affect
myocardial contractility/output.
Review programmed increases in levels of activity.
Educate patient regarding gradual resumption of Gradual increase in activity increases strength and
activities, e.g., walking, work, recreational and sexual prevents overexertion, may enhance collateral circulation,
activity. Provide guidelines for gradually increasing and allows return to normal lifestyle. Note: Sexual
activity and instruction regarding target heart rate and activity can be safely resumed once patient can
pulse taking, as appropriate. accomplish activity equivalent to climbing two flights of
stairs without adverse cardiac effects.
Identify alternative activities for “bad weather” days,
such as measured walking in house or shopping mall. Provides for continuing daily activity program.

Review signs/symptoms requiring reduction in activity

and notification of healthcare provider. Differentiate Pulse elevations beyond established limits, development
between increased heart rate that normally occursduring of chest pain, or dyspnea may require changes in exercise
various activities and worsening signs of cardiac stress and medication regimen.
(e.g., chest pain, dyspnea, palpitations, increased heart
rate lasting more than 15 min after cessation of activity,
excessive fatigue the following day).
ACTIONS/INTERVENTIONS RATIONALE
Cardiac Care: Rehabilitation (NIC)

Independent
Stress importance of follow-up care, and identify Reinforces that this is an ongoing/continuing health
community resources/support groups, e.g., cardiac problem for which support/assistance is available after
rehabilitation programs, “coronary clubs,” smoking discharge. Note: After discharge, patients encounter
cessation clinics. limitations in physical functioning and often incur
difficulty with emotional, social, and role functioning
requiring ongoing support.

Emphasize importance of contacting physician if chest Timely evaluation/intervention may prevent

pain, change in anginal pattern, or other symptoms recur. complications.

Stress importance of reporting development of fever in Post-MI complication of pericardial inflammation

association with diffuse/atypical chest pain (pleural, (Dressler’s syndrome) requires further medical
pericardial) and joint pain. evaluation/intervention.

Encourage patient/SO to share concerns/feelings. Discuss Depressed patients have a greater risk of dying 6–18 mo
signs of pathological depression versus transient feelings following a heart attack. Timely intervention may be
frequently associated with major life events. Recommend beneficial. Note: Selective serotonin reuptake inhibitors
seeking professional help if depressed feelings persist. (SSRIs), e.g., paroxetine (Paxil), have been found to be as
effective as tricyclic antidepressants but with significantly
fewer adverse cardiac complications.

POTENTIAL CONSIDERATIONS following discharge from care setting (dependent on patient’s age,
physical condition/presence of complications, personal resources, and life responsibilities)

Activity intolerance —imbalance between myocardial oxygen supply/demand.

Grieving, anticipatory—perceived loss of general well-being, required changes in lifestyle, confronting mortality.
Decisional Conflict (treatment)—multiple/divergent sources of information, perceived threat to value system, support
system deficit.
Family Processes, interrupted—situational transition and crisis.
Home Management, impaired—altered ability to perform tasks, inadequate support systems, reluctance to request
assistance.