Myocardial infarction (MI) or acute myocardial infarction (AMI), commonly known as a heart attack, is the interruption of blood supply to a part of the heart, causing heart cells to die. This is most commonly due to occlusion (blockage) of a coronary artery following the rupture of a vulnerable atherosclerotic plaque, which is an unstable collection of lipids (fatty acids) and white blood cells (especially macrophages) in the wall of an artery. The resulting ischemia (restriction in blood supply) and oxygen shortage, if left untreated for a sufficient period of time, can cause damage or death (infarction) of heart muscle tissue (myocardium).
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Nursing Diagnosis for Myocardial Infarction
Acute Pain related to tissue ischemic, secondary to clogged arteries.
Marked by :
- Chest pain with or without spread
- Facial grimacing
- Nervous
- Delirium
- Changes in pulse, blood pressure.
Pain reduced / no pain
Expected Outcome :
- Chest pain is reduced, eg from scale 3 to 2, or from 2 to 1
- Facial expression relaxed / calm, not tense
- Not anxious
- Pulse 60-100 x / min
- Blood pressure 120/80 mmHg
- Observation of the characteristics, location, time, and the course of chest pain.
- Instruct the client to stop activity and rest during an attack.
- Help the client to do relaxation techniques, eg deep breathing, distraction behavior, visualization, or imagination guidance.
- Maintain oxygenation with bicanul example (2-4 lt / min)
- Monitor vital signs (pulse and blood pressure) every two hours.
- Collaboration with the health team in providing analgesic.
Nursing Diagnosis for Myocardial Infarction
Risk for Decreased Cardiac Output related to changes in power factors, reduction miocard characteristics.
Goal :
Cardiac Output: improved / stable.
Expected Outcome
- No edema
- No dysrhythmias
- Normal urine output
- Vital Signs within normal limits
Nursing Intervention for Myocardial Infarction
- Maintain bed rest during the acute phase
- Assess and report any signs of decreased cardiac output, blood pressure
- Monitor urine output
- Assess and monitor vital signs every hour
- Assess and monitor ECG every day
- Give oxygen as needed
- Auscultation of respiratory and heart every hour as indicated
- Keep parenteral fluids and medications appropriate advice.
- Provide appropriate food diet.
- Avoid Valsalva maneuver, straining (use laxan).
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