Tuesday, December 22, 2009

Myocardial Infarction (MI)
Myocardial Infarction (MI)
Nursing care plans for Myocardial infarction (MI). Myocardial infarction (MI) or acute Myocardial infarction is an acute coronary syndrome, results from reduced blood flow through one or more coronary arteries, which causes myocardial ischemia and necrosis. Myocardial infarction (MI) results when myocardial tissue becomes necrotic because of absent or diminished blood supply. When myocardial tissue is deprived of oxygenated blood supply for a period of time, an area of myocardial necrosis develops, this necrosis is surrounded by injured and ischemic tissue. 
The infarction site depends on the vessels involved. For instance: 

  • Occlusion of the circumflex coronary artery causes a lateral Myocardial infarction (MI). 
  • Occlusion of the left anterior coronary artery causes an anterior Myocardial infarction (MI). 
  • Occlusion of the right coronary artery or one of its branches causes True posterior and inferior Myocardial infarction (MI) 
  • Right ventricular infarctions can also result from right coronary artery occlusion, can accompany inferior MI, and may cause right-sided heart failure. 
  • If a thrombus partially occludes a coronary vessel, distal microthrombi may cause necrosis in some myocytes, leading to a non-ST-segment elevation MI (NSTEMI). 
  • If a thrombus fully occludes the vessel for a prolonged time, an ST-segment elevation MI (STEMI) usually develops. 

Men are more susceptible to Myocardial infarction (MI) than premenopausal women, although incidence is rising among women who smoke and take a hormonal contraceptive. The incidence in postmenopausal women resembles that in men. 

Causes for Myocardial Infarction (MI) 
A Myocardial infarction (MI) results from occlusion of one of the coronary arteries. The occlusion can stem from atherosclerosis, thrombosis, platelet aggregation, or coronary artery stenosis or spasm. Predisposing risk factors include: 

  • Aging 
  • Diabetes Mellitus 
  • Elevated serum triglyceride, low-density lipoprotein, and cholesterol levels, and decreased serum high-density lipoprotein levels 
  • Excessive intake of saturated fats, carbohydrates, or salt 
  • Hypertension 
  • Obesity 
  • Positive family history of coronary artery disease 
  • Sedentary lifestyle 
  • Smoking 
  • Stress or a type a personality (aggressive, competitive attitude, addiction to work, chronic impatience). 
  • In addition, use of such drugs as amphetamines or cocaine can cause a Myocardial infarction (MI). 

Complications for Myocardial Infarction (MI) 
Cardiac complications of Acute Myocardial infarction (MI) 
Cardiogenic shock. 
Heart failure. 
Pulmonary edema 

Other complications for Myocardial Infarction (MI) include 

  • Rupture of the atrial or Ventricular septum, Ventricular wall, or valves; 
  • Ventricular aneurysms 
  • Cerebral or pulmonary emboli.
  •  Dressler’s syndrome can occur days to weeks after an Myocardial infarction (MI) and cause residual pain, malaise, and fever. 
  • Typically, elderly patients are more prone to complications and death. Psychological problems can also occur, either from the patient’s fear of another Myocardial infarction (MI) or from an organic brain disorder caused by tissue hypoxia. Occasionally, a patient may have a personality change. 

Nursing Assessment nursing care plans for Myocardial infarction (MI)
Symptomatology is very important in diagnosing Myocardial infarction (MI). Ask about chest, jaw, arm, and epigastric pain. Remember that not all people have the “typical” chest pain; evaluate the whole clinical picture because some people may experience no pain at all. Ask about shortness of breath, racing heart rate, diaphoresis, clammy skin, dizziness, nausea, and vomiting. Note that sudden death and full cardiac arrest may be the first indication of Myocardial infarction (MI). 
Patients with coronary artery disease may report increasing anginal frequency, severity, or duration (especially when not precipitated by exertion, a heavy meal, or cold and wind). The patient may also report a feeling of impending doom, fatigue, nausea, vomiting, and shortness of breath. Sudden death, however, may be the first and only indication of an Myocardial infarction (MI). 

Physical Examination

  • Inspection may reveal an extremely anxious and restless patient with dyspnea and diaphoresis. 
  • If right-sided heart failure is present, you may note jugular vein distention. 
  • Anterior Myocardial infarction (MI), patients exhibit sympathetic nervous system hyperactivity, such as tachycardia and hypertension. 
  • Patients with an inferior Myocardial infarction (MI) exhibit parasympathetic nervous system hyperactivity, such as bradycardia and hypotension. 
  • In patients who develop ventricular dysfunction, auscultation may disclose an S4, an S3, paradoxical splitting of S2, and decreased heart sounds. 
  • A systolic murmur of mitral insufficiency may be heard with papillary muscle dysfunction secondary to infarction. 
  • A pericardial friction rub may also be heard, especially in patients who have a transmural Myocardial infarction (MI) or have developed pericarditis. 
  • Fever is unusual at the onset of MI, but a low-grade fever may develop during the next few days. 

Diagnostic tests for Myocardial infarction (MI)
Persistent chest pain, ST-segment changes on ECG, and elevated levels of total creatine kinase (CK) and the CK-MB isoenzyme over a 72-hour period usually confirm Myocardial infarction (MI). Cardiac troponins are useful in differentiating MI from skeletal muscle injury, or when CK-MB measurements are low and a small MI has actually occurred. 
Diagnostic Highlights

  • Electrocardiogram 
  • Creatine kinase isoenzyme (MB-CK) 
  • Cardiac troponin I (cTnI) 
  • cardiac troponin T (cTnT) 

Elevated homocysteine and C-reactive protein levels have been found incidentally in patients with Myocardial infarction (MI) and may indicate a newer risk factor. The practical value of these tests remains unknown. Folic acid supplementation is used as treatment for elevated homocysteine levels

Nursing diagnosis Nursing Care Plans For Myocardial Infarction (MI).
Primary Nursing Diagnosis: Altered tissue perfusion (myocardial) related to narrowing of the coronary arteryies associated with atherosclerosis, spasm, or thrombosis
Common nursing diagnosis found on Myocardial infarction (MI).

  • Activity intolerance 
  • Acute pain 
  • Anxiety 
  • Decreased cardiac output 
  • Excess fluid volume 
  • Fatigue 
  • Imbalanced nutrition: Less than body requirements 
  • Ineffective coping 
  • Ineffective denial 
  • Ineffective sexuality patterns 
  • Ineffective tissue perfusion: Cardiopulmonary 

Nursing outcomes for Myocardial Infarction (MI), Patients will

  • Perform activities of daily living without excessive fatigue or exhaustion.
  • Express feelings of comfort and decreased pain. 
  • Verbalize strategies to reduce anxiety and stress. 
  • Maintain adequate cardiac output. 
  • Develop no complications of fluid volume excess. 
  • Verbalize the importance of balancing activities, as tolerated, with adequate rest periods. 
  • Achieve ideal weight. 
  • Develop adequate coping skills. 
  • The patient will recognize his acute condition and accept the lifestyle changes he needs to make. 
  • Express feelings about changes in sexual patterns. 
  • Maintain hemodynamic stability and develop no arrhythmias. 

Nursing interventions Nursing Care Plans for Myocardial Infarction (MI) 

  • Nursing Care for patients who have suffered a Myocardial Infarction (MI), Most most of them receive treatment in the coronary care unit (CCU), where they’re under constant observation for complications. 
  • On admission to the CCU, monitor and record the patient’s ECG readings, blood pressure, temperature, and heart and breath sounds. 
  • Assess pain and give an analgesic as ordered. 
  • Record the severity of pain, location, type, and duration of pain. 
  • Check the patient’s blood pressure before and after giving nitroglycerin, especially the first dose. 
  • Frequently monitor ECG rhythm strips to detect rate changes and arrhythmias. if any new arrhythmias are documented, if chest pain occurs, or at least every shift change or according to facility protocol. 
  • Obtain ECG readings and blood pressure and pulmonary artery catheter measurements, if applicable, to determine changes. During episodes of chest pain 
  • Watch for crackles, cough, tachypnea, and edema, which may indicate impending left-sided heart failure. 
  • Monitor daily weight, intake and output, respiratory rate, serum enzyme levels, ECG readings, and blood pressure. 
  • Organize patient care and activities to maximize periods of uninterrupted rest. 
  • Provide a clear liquid diet dietary until nausea subsides. A low-cholesterol, low-sodium diet, without caffeine-containing beverages, may be ordered. 
  • Provide a stool softener to prevent straining during defecation, which causes vagal stimulation and may slow heart rate. 
  • Allow the patient to use a bedside commode, and provide as much privacy as possible. 
  • Assist with ROM exercises. 
  • If the patient is immobilized by a severe Myocardial Infarction (MI), turn him often. 
  • Give Antiembolism stockings to prevent venostasis and thrombophlebitis. 
  • Provide emotional support, and help reduce stress and anxiety . 
  • If the patient has undergone PTCA, sheath care is necessary. Keep the sheath line open with a heparin drip. Observe the patient for generalized and site bleeding. Keep the leg with the sheath insertion site immobile. Maintain strict bed rest. Check peripheral pulses in the affected leg frequently. Provide an analgesic for back pain if needed. 
  • After thrombolytic therapy, administer continuous heparin as ordered. Monitor the partial thromboplastin time every 6 hours, and monitor the patient for evidence of bleeding. 

Patient Teaching and Home Healthcare Guide for Patients with Myocardial Infarction (MI) 
Explain procedures and answer questions for both the patient and family. Explain the CCU environment and routine. Remember that you may need to repeat explanations after the emergency situation has resolved. 

  • To promote compliance with the prescribed medication regimen and other treatment measures, thoroughly explain dosages and therapy. Inform the patient of the drug’s adverse reactions, and advise him to watch for and report signs and symptoms of toxicity (for example, anorexia, nausea, vomiting, mental depression, vertigo, blurred vision, and yellow vision, if the patient is receiving a cardiac glycoside). 
  • Explain the need to treat recurrent chest pain or Myocardial Infarction (MI) discomfort with sublingual nitroglycerin every 5 minutes for three doses. If the pain persists for 20 minutes, teach the patient to seek medical attention. If the patient has severe pain or becomes short of breath with chest pain, teach the patient to take nitroglycerin and seek medical attention right away 
  • Review dietary restrictions with the patient. If he must follow a low-sodium, low-fat, or low-cholesterol diet, provide a list of foods to avoid. Ask the dietitian to speak to the patient and family. 
  • Explore mechanisms to implement diet control, an exercise program, and smoking cessation if appropriate. 
  • Encourage the patient to participate in a cardiac rehabilitation exercise program. The physician and the exercise physiologist should determine the level of exercise and then discuss it with the patient and secure his agreement to a stepped-care program. 
  • Counsel the patient to resume sexual activity progressively. He may need to take nitroglycerin before sexual intercourse to prevent chest pain from the increased activity. 
  • Advise the patient about appropriate responses to new or recurrent symptoms. 
  • Advise the patient to report typical or atypical chest pain. Post Myocardial Infarction (MI) syndrome may develop, producing chest pain that must be differentiated from a recurrent MI, pulmonary infarction, and heart failure. 
  • Stress the need to stop smoking. If necessary, refer the patient to a support group. 
  • Be sure the patient understands all the medications, including the dosage, route, action, and adverse effects. 
  • Instruct the patient to keep the nitroglycerin bottle sealed and away from heat. 
  • The medication may lose patients potency.

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