Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will
Cardiac Pump Effectiveness
Demonstrate adequate perfusion as individually appropriate, such as skin warm and dry, peripheral pulses present and strong, vital signs within client’s normal range, client alert or oriented, balanced intake and output (I&O), absence of edema, free of pain or discomfort, stable, improving ECG, vitals, and mentation.
Nursing intervention with rationale:
1. Investigate sudden changes or continued alterations in mentation, such as anxiety, confusion, lethargy, and stupor.
Rationale: Cerebral perfusion is directly related to cardiac output and is influenced by electrolyte and acid-base variations, hypoxia, and systemic emboli.
2. Inspect for pallor, cyanosis, mottling, and cool or clammy skin. Note strength of peripheral pulses.
Rationale: Systemic vasoconstriction resulting from diminished cardiac output may be evidenced by decreased skin perfusion and diminished pulses.
3. Monitor respirations, noting work of breathing.
Rationale: Cardiac pump failure and ischemic pain may precipitate respiratory distress; however, sudden or continued dyspnea may indicate thromboembolic pulmonary complications.
4. Monitor intake, noting changes in urine output. Record urine specific gravity, as indicated.
Rationale: Decreased intake or persistent nausea may result in reduced circulating volume, which negatively affects perfusion and organ function. Specific gravity measurements reflect
hydration status and renal function.
5. Assess gastrointestinal function, noting anorexia, decreased or absent bowel sounds, nausea and vomiting, abdominal distention, and constipation.
Rationale: Reduced blood flow to mesentery can produce gastrointestinal dysfunction, such as loss of peristalsis. Problems may be potentiated or aggravated by use of analgesics, decreased
activity, and dietary changes.
6. Encourage active or assist with passive leg exercises, with avoidance of isometric exercises.
Rationale: Enhances venous return, reduces venous stasis, and decreases risk of thrombophlebitis; however, isometric exercises can adversely affect cardiac output by increasing myocardial work and oxygen consumption.
7. Assess for pain in lower extremity and Homans’ sign, erythema, and edema.
Rationale: Indicators of deep vein thrombosis (DVT), although calf pain is not always present.
8. Instruct client in application and periodic removal of antiembolic hose when used.
Rationale: Limits venous stasis, improves venous return, and reduces risk of thrombophlebitis in client who is limited in activity.
9. Apply elastic compression stockings or intermittent pneumatic compression devices, as indicated.
Rationale: May be desired to prevent DVT, especially in client who is unable to be out of bed or cannot ambulate freely.
10. Obtain a 12-lead ECG recording.
Rationale: Determines extension of infarction.
11. Monitor laboratory data, such as ABGs, blood urea nitrogen (BUN), creatinine, electrolytes, and coagulation studies (prothrombin time [PT], activated prothrombin time [aPTT],
clotting times).
Rationale: Indicators of organ perfusion and function. Abnormalities in coagulation may occur as a result of therapeutic measures, such as heparin or Coumadin use and some cardiac drugs.
12. Provide supplemental oxygen as prescribed.
Rationale: Increases oxygen supply to the myocardium.
13. Administer medications, as indicated, for example: Antiplatelet agents, such as aspirin, abciximab (ReoPro),clopidogrel (Plavix), and eptifibatide (Integrilin).
Rationale: Reduces mortality in MI clients and is taken daily. Aspirin also reduces coronary reocclusion after percutaneous transluminal coronary angioplasty (PTCA). IV antiplatelet drugs such as ReoPro and Integrilin are used as adjuncts to PTCA to decrease complication of platelet clumping within stent when placed.
14. Anticoagulants, such as heparin/enoxaparin (Lovenox)
Rationale: Low-dose heparin is given during PTCA and may be given prophylactically in high-risk clients, such as those with atrial fibrillation, obesity, ventricular aneurysm, or history of thrombophlebitis, to reduce risk of thrombophlebitis or mural thrombus formation.
15. Cimetidine (Tagamet), ranitidine (Zantac), and antacids
Rationale: May occasionally be used to reduce or neutralize gastric acid, preventing discomfort and gastric irritation, especially in presence of reduced mucosal circulation.
16. Assist with reperfusion therapy: Administer thrombolytic agents: alteplase (Activase, rt-PA), reteplase (Retavase), streptokinase (Streptase), anistreplase (Eminase), and urokinase (Abbokinase).
Rationale: Thrombolytic therapy is the treatment of choice if angioplasty is not immediately available within 90 minutes. The goal is to restore perfusion to the myocardium.
17. Prepare for procedures such as balloon PTCA, with or without intracoronary stents.
Rationale: Angioplasty is used to open blocked coronary arteries and immediately restore myocardial perfusion. The mechanism includes a combination of vessel stretching and plaque compression and removal of thrombotic material. Intracoronary stents may be placed at the time of PTCA to provide structural support within the coronary artery. Drug-eluting (drug coated) stents may be used to decrease risk of restenosis and improve long-term patency.
18. Transfer to CCU or step-down unit.
Rationale: Depending on client’s condition—degree of heart damage or other chronic health conditions—telemetry or more intensive monitoring and aggressive interventions may be necessary to promote optimum outcome.
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