MYOCARDIAL INFARCTION

-the formation of localized necrotic areas within the myocardium. MI usually follows sudden
coronary occlusion and the abrupt cessation of blood and oxygen flow to the muscle.
-In an MI, an area of the myocardium is permanently destroyed, typically because plaque rupture
and subsequent thrombus formation result in complete occlusion of the artery.
-Most commonly known as heart attack
-Prolonged ischemia lasting more than 35 to 45 minutes produces irreversible cellular damage
and necrosis of the myocardium (Ischemia is the inadequate flow of blood to a part of the body)
CAUSES:
- Coronary Atherosclerotic Heart Disease
- Coronary Thrombosis/ Embolism
- Decreased Blood Flow with Shock and/or Hemorrhage
- Direct Trauma
- Vasospasm of a coronary artery
- Decreased oxygen supply
- Increased demand for oxygen
RISK FACTORS:
Non-Modifiable:
- Age
- Family History
- Gender (Men are more likely to suffer heart attacks than women if they are less than 75
years old. Above age 75, women are as likely as men to have heart attacks)
- Ethnic Group (Certain ethnic groups - for example, British Asians - have a higher risk of
developing cardiovascular diseases)
Modifiable:
- Hyperlipidemia (the presence in the blood of an abnormally high concentration of
cholesterol and/or triglycerides in the form of lipoprotein)
- High Blood Pressure (Hypertension)
- Smoking
- Diabetes
- Overweight
- Sedentary Lifestyle

Myocardial Infarction

PATHOPHYSIOLOGY:
Causes

Myocardial

Stimulatio
n of
Sympathet

Decrease
Myocardial O2

Stimulation
of

Increase
Peripheral
Increase
Myocardial

Decrease
Arterial
Pressure

Increase
Cellular

Decrease
Cardiac

Altered Cell
Membrane

Decrease
Myocardial

Increase
Afterload
Increase
Heart

Decrease
Diastolic

Decrease
Myocardial
Tissue

Increase
Myocardial O2

CLINICAL MANIFESTATIONS:

Pain
-Crushing, severe, prolonged, unrelieved by rest or nitroglycerin
-Fullness and/or squeezing sensation on the chest
-Pain often radiates to one arm (most commonly left) or both arms, the neck and the back
-Characterized by Levines Sign (clenched fist held over the chest to describe ischemic
chest pain)

Anxiety and feeling of apprehension

-Restlessness

Shock
Oliguria
Fever

Myocardial Infarction

Indigestion
-Gas pain around the heart
-Nausea and vomiting
Heartburn

Sweating
Shortness of breath
Acute pulmonary edema
ECG changes
Elevated Ck-Mb, elevated LDH, elevated AST
Cool, pale and moist skin
RR faster than normal

ASSESSMENT & DIAGNOSTIC FINDINGS:

Electrocardiogram
12-lead ECG provides information that assists in ruling out or diagnosing an acute MI. It
should be obtained w/in 10 min from the time a pt. reports pain or arrives in ER. ECG
changes that occur with an MI are seen in the leads that view the involved surface of the
heart.
Echocardiogram
Used to evaluate ventricular function. Echocardiogram can detect hypokinetic and
akinetic wall motion and can detect ejection fraction.
Laboratory Tests
Creatinine Kinase
Myoglobin
Troponin

MEDICAL MANAGEMENT:
Pharmacologic

Analgesic
For relief of pain
Morphine sulfate, Lidocaine or Nitroglycerine administered intravenously

ACE Inhibitors
prevent the conversion of angiotensin I to angiotensin II, a potent vasoconstrictor,
resulting in lower aldosterone secretion
Catopril, Enalapril, Lisinopril, Quinapril

Myocardial Infarction

Thrombolytics
Disintegrate blood clot by activating the fibrinolytic process
Administration is most crucial between 3 to 6 hrs after the initial infarction has occurred

Anticoagulant and antiplatelet medications are administered after thrombolytic therapy to

maintain arterial patency

Other medications: Beta-Adrenergic Agents: Diazepam

PRIMARY ASSESSMENT FOR MYOCARDIAL INFARCTION:

Airways:
1. Blockage or accumulation of secretions
2. Wheezing or crackles
Breathing:
1.
2.
3.
4.
5.

Shortness of breath with mild activity or rest

Respiration more than 24 x / min, irregular rhythm shallow
Ronchi, crackles
The expansion of the chest is not full
Use of auxiliary respiratory muscles

Circulation:
1.
2.
3.
4.
5.
6.
7.

Weak pulse, irregular

Tachycardia
Blood pressure increase / decrease
Edema
Nervous
Pale skin, cyanosis
Decreased urine output

Myocardial Infarction

SECONDARY ASSESSMENT FOR MYOCARDIAL INFARCTION:

1. Activities
Symptoms:
Weakness
Fatigue
Can not sleep
Settled lifestyle
No regular exercise schedule
Signs:
Tachycardia
Dyspnea at rest or activity
2. Circulation
Symptoms:
History of Acute Myocardial Infarction (AMI)
Coronary artery disease
Blood pressure problems
Diabetes mellitus.
Signs:
Blood pressure: normal / up / down. Postural changes recorded from the bed to sit or
stand
Pulse: normal, full or not strong or weak / strong quality with slow capillary filling,
irregular (dysrhythmias)
Heart sound: an extra heart sound: S3 or S4 may indicate heart failure or decreased
contractility / complaints ventricle
Murmur: If there are shows valve failure or dysfunction of heart muscle
Friction: suspected pericarditis
Heart rhythm can be regular or irregular
Edema: juguler venous distention, edema dependent, peripheral, general edema,
cracles may exist with heart failure or ventricular
Color: Pale or cyanotic, flat nail, on mucous membranes or lips
3. Ego integrity
Symptoms: an important symptom or deny the existence of conditions of fear of dying,
feeling the end is near, angry at the disease or treatment, worry about finances, work,
family
Signs: turned, denial, anxiety, lack of eye contact, anxiety, anger, aggression, coma pain
4. Elimination
Signs: normal, decreased bowel sounds.
Myocardial Infarction

5. Food or fluid
Symptoms: nausea, anorexia, belching, heartburn, or burning
Signs: decreased skin turgor, dry skin, sweating, vomiting, weight changes
6. Hygiene
Symptoms or signs: difficulty perform maintenance tasks
7. Neuro Sensory
Symptoms: dizziness, throbbing during sleep or while awake (sitting or resting)
Signs: mental changes, weakness
8. Pain or discomfort
Symptoms:
Sudden onset of chest pain (may or may not relate to activities), not relieved by rest
or nitroglycerin (although most deep and visceral pain)
Location: Typical on the anterior chest, Substernal, precordial, can spread to the
hands, jaw, face. No specific location such as epigastric, elbow, jaw, abdomen, back,
neck.
Quality: "Crushing", narrow, heavy, settle down, depressed, as can be seen.
Intensity: Usually 10 (on a scale of 1-10), may experience the worst pain ever
experienced.
Note: there may be no pain in postoperative patients, diabetesmellitus, hypertension,
elderly
9. Respiratory:
Symptoms:
Dyspnea with or without job
Nocturnal dyspnea
Cough with or without sputum production
History of smoking, chronic respiratory disease.
Signs:
Increased respiratory rate
Shortness of breath / strong
Pallor, cyanosis
Breath sounds (clean, crackles, wheezing), sputum
10. Social interactions
Myocardial Infarction

Symptoms:
Stress
Difficulty coping with the stressors that exist eg illness, treatment in hospital
Signs:
Difficulty rest sleep
Response too emotional (angry constantly, fear)
Withdraw

NURSING DIAGNOSIS:
1.
2.
3.
4.
5.
6.
7.
8.

Acute Pain
Decreased Cardiac Output
Activity Intolerance
Imbalanced Nutrition: Less than Body Requirements
Ineffective Tissue Perfusion
Anxiety
Ineffective Coping
Ineffective Sexuality Patterns

TREATMENT:

Goals
Prevention of further tissue injury and limitation of infarct size
Maximize myocardial tissue perfusion and reduce myocardial tissue demands
Supplemental oxygen by nasal cannula. This increases myocardial oxygen supply and
relieves pain
Cardiac monitoring to detect occurrence of dysrhythmias
Percutaneous transluminal coronary angioplasty may be done to reopen an occluded
artery
Diet: Low cholesterol, low salt
Activity: Bed rest is usually prescribed for 24 to 48 hours to decrease oxygen demand.
Progressive ambulation is implemented as soon as possible, unless complications
occurred

NURSING MANAGEMENT:
1. Promoting oxygenation and tissue perfusion
Instruct the pt. to avoid overfatigue; stop the activity immediately in the presence of chest
pain, dyspnea, lightheadedness or faintness
Oxygen therapy by cannula for the first 24 to 48 hrs or longer if pain, hypotension,
dyspnea, or dysrhythmias persist. Monitor VS changes, indicative of complications
Myocardial Infarction


2.

3.

4.

5.

6.

7.

8.

Position the client in a semi-fowlers to allow greater diaphragm expansion, thereby lung
lung expansion and better CO2-O2 exchange.
Promoting adequate cardiac output
Monitor the ff. parameters:
Dysrhythmias on ECG tracings
VS
Effects of daily activities on cardiac status
Rate and rhythm of puls
Administer pharmacotherapy as prescribed
Promote rest and minimize unnecessary disturbances
Promoting comfort
Relieve pain. Administer morphine sulfate as ordered. This is to decrease sympathetic
stimulation, which increases myocardial oxygen demand. In addition, this will prevent
shock which may result from severe pain
Providing rest
The client is usually placed on bed rest with commode privileges for 24 to 48 hrs
Administer diazepam as ordered
Explain that the purpose of CCU is for continuous monitoring and safety during early
recovery period
Provide psychosocial support to the client and his family. Calmness and competency are
extremely reassuring
Promoting activity
Gradual increase in activity is encouraged after the first 24 to 48 hrs. May be allowed to
sit on a chair for increasing periods of time and begins ambulation on the 4th to 5th day
Monitor signs of dysrhythmias, chest pain, and changes in VS during activity
Promoting nutrition and elimination
Provide small, frequent feedings
Provide low calorie, low cholesterol, low sodium diet
Avoid stimulants
Avoid taking very hot or very cold beverages and gas forming foods. Vasovagal
stimulation may occur, thereby bradycardia and cardiac arrest
Use of bedpan and straining at stool should be avoided. Valsalva maneuver causes
changes in blood pressure and heart rate, which may trigger ischemia, dysrhythmias,
pulmonary embolism or cardiac arrest
Use bedside commode
Administer stool softener as ordered
Promoting relief of anxiety and feeling of well-being
Provide an opportunity for the client and family to explore their concerns and to identify
alternative methods of coping as necessary
Facilitating learning
Teaching is started once the client is free of pain and excessive anxiety
Promote a positive attitude and active participation of the client and the family

Myocardial Infarction

COMPLICATIONS OF MYOCARDIAL INFARCTION:

1.
2.
3.
4.
5.
6.

Dysrhythmias
Cardiogenic shock
Thromboembolism
Pericarditis
Rupture of the myocardium
Ventricular aneurysm
7. Congestive heart failure

Myocardial Infarction