NURSING CARE PLAN The Client with Acute Myocardial Infarction

Kelompok 4 Dian Riza Sepriani Falryan M.Yogi Mayusen Winda Septi Lestari

Nursing Diagnosis : Acute Pain related to myocardial ischemia resulting from coronary artery occlusion with loss or restriction of blood flow to an area of the myocardium and necrosis of the myocardium Goal : relief of chest pain / discomfort Outcomes : The client will experience improved comfort in the chest, as evidenced by a decrease in the rating of the chest pain, the ability to rest and sleep comfortably, less need for analgesia or nitroglicerin, and reduced anxiety.

Intervention 1. Assess the characteristics of chest pain, including location, duration, quality, intensity, presence of radiation precipitating and alleviating factors and associated manifestations. Have the client rate pain on a scale of 0 to 10, and document findings in nurses notes. 2. Assess respirations, blood pressure, and heart rate with each episode of chest pain

Rationale 1. Pain is an indication of myocardial ischemia. Assisting the client in quantifying pain may differentiate pre-existing and current pain patterns as well as identify complications. Usually a scale 0f 0 to 10 is used, with being the worst pain and 0 being none. 2. respirations may be increased as a result of pain and associated anxiety

3. obtain a 12-lead 3. serial ECGs and stat electrokardiogram ( ECG ) ACGs record changes that on admission, then each time can give evidence of further chest pain recurs for cardiac damage and evidence of further infarction location of myocardial 4. monitor the response to drug ischemia. therapy. notify the physician 4. pain control is a priority if pain does not abate within because it indicates 15 to 20 minute ischemia 5. provide care in a calm, 5. external stimuli may worsen efficient manner that anxiety and cardiac strain reassures the client and and limit coping abilities minimizes anxiety . stay with the client until discomfort is relieved

6. limit visitors as the client requests 7. administer morphine as ordered 8. administer nitrates as ordered

6. limiting visitors prevents overstimulation and promotes rest 7. morphine is an opiate analgesic and alters the client's perception of pain and reduces preload time vasoconstriction 8. nitrates relax the smooth muscles of coronary blood vessels, decreasing ischemia and hence decreasing pain

evaluation : the client should be pain- free within 15 to 20 minutes after administration of drug therapy . the client will verbalize relief of pain and will not exhibit associated manifestations of pain

nursing diagnosis : decreased cardiac output related to negative inotropic changes in the heart secondary to myocardial ischemia, injury , or infarction, as evidenced by change in the level of consciousness, weakness, dizziness, loss of peripheral pulses , abnormal heart sounds, hemodynamic compromise, and cardiopulmonary arrest Goal : Maintenance / attainment of adequate tissue perfusion outcomes : the client will have improved cardiac output, as evidenced by normal cardiac rate, rhythm and hemodynamic parameters, dysrhythmias controlled or absent , and absence of angina

assess for and document the following as evidence of myocardial dysfunction with decreased cardiac output : interventions : 1. mental status- be alert to restlessness and decreased responsiveness 2. lung sounds - monitor for crackles and rhonchi 3. blood pressure - monitor for hypertension or hypotension 4. heart sounds- note the presence of gallop, murmur and increased or decreased heart rate

1. cerebral perfusion is directly related to cardiac output and aortic perfusion pressure and is influenced by hypoxia and electrolyte and acid- base variations 2. crackles may develop, reflecting pulmonary congestion related to alterations in myocardial function 3. hypotension related to hypoferfusion,vagal stimulation , dysrhythmias , or ventricular dysfunction may occur, it may be related to pain anxiety , catecholamine release , or preexisting vascular problems 4. bradycardia may be present because of vagal stimulation or conduction disturbances related to the area of myocardial injury. tachycardia may be a compensatory mechanism related to decresed cardiac output. A gallop may be related to fluid volume overload or heart failure, and a murmur may be present if a ruptured chordae tendineae occurred

5.urine output - be alert to output less than 0.5 ml/kg/hr 6. peripheral perfusion- monitor for pallor, mottling, cyanosis, coolness, diaphoresis , and peripheral pulses. 7. monitor arterial blood gas (ABG ) levels 8. if a pulmonary artery catheter is used , record hemodynamic parameters every 2 to 4 hours and as required ( pm ). Be alert to pulmonary capillary wedge pressure ( PCWP ) greater than 18 mm Hg, cardiac output less than 4 L/min, and cardiac index less than 2,5L /min, 9 . maintain hemodynamic stability by monitoring the effects of betablockers and inotropic agents 10. monitor and assess angina for type severity and duration

5. urine output less than 0.5 ml/kg.hr may reflect reduced renal perfusion and glomerular filtration as aresult of reduced cardiac output 6. decresed peripheral pulses may indicate a decrease in cardiac output 7. acidosis may cause dysrhythmias and depressed cardiac function and some cardiac medications increase oxygen demand and may cause hypoxia 8. A PCWP greater than 18 mmHg may indicate fluid volume overload or heart failure , A cardiac output less than 4 L/ min and a cardiac index less than 2,5 L/min indicate heart failure or decrased in cardiac output . use hemodynamic monitoring to assess drug therapy and for prevention or early detection of complications of AMI ( i.e. extention , heart failure , cardiogenic shock ) 9. assess the effect of drug therapy on myocardial contractility and function 10. angina indicates myocardial ischemia , which may decrease cardiac output

evaluation : within 2 to 3 days of admission, the client will have normal hemodynamic pressures, normal vital signs, clear breath sounds, no shortness of breath , normal ABG values , and normal sinus rhythm with rate between 60 and 100 beats/ min

nursing diagnosis : excess fluid volume related to reduced glomerular filtration rate ( GFR ) , decreased cardiac output , increased antidiuretic hormone ( ADH ) production , and sodium and water retention , as evidenced by orthopnea, S3 heart sound , oliguria , edema, jugular neck vein distention, increased weight , increased blood pressure , respiratory distress, and abnormal breath sounds outcomes : the client's fluid volume balance will be adequate , as evidenced by balanced intake and output (I&O ) , clear or clearing breath sounds, vital sign within normal limits , stable weight and minimal edema

intervention : 1. monitor I&O ( especially note color , specific gravity and amount ) every 2 to 4 hours , and as needed and 24 hour totals 2. maintain chair or bed rest in the semi-fowler position 3. involve the client and family in fluid schedules, especially if there are restrictions, and provide frequent oral care 4 weigh the client daily 5. assess for jugular neck vein distention , edema, peripheral pulses, ang presence of anasarca 6. auscultate breath sounds sounds. note adventitious sounds, and monitor for dyspnea or tachypnea

Rationale: 1. intake greater than output may indicate fluid volume excess if client receives diuretic therapy , an increase in output is expected 2. this position promotes diuresis by recumbency- induced increased GFR and reduced ADH production 3. involving the client in the therapy regimen may enhance a sense of control and fosters cooperation with restrictions. fluid restrictions dry the oral mucous membranes 4. daily weights can show the increase or decrease in congestion and edema in response to therapy , A gain of 5 pounds represents about 2 L of fluid. 5. excessive fluid retention may be demonstrated by venous engorgement and edema formation. peripheral edema often begins in the feet and ascends upward as heart failure worsens 6. these manifestations of pulmonary congestion reflect increased vascular volume and pulmonary hypertension or worsening of heart failure

7. monitor for sudden extreme 7. these are manifestations of extreme pulmonary capillary hypertension ( shortness of breath and pulmonary edema ) feelings of panic 8. advancing heart failure leads to venous congestion, which result in 8. palpate for hepatomegaly . liver engorgement and altered liver note complaints of right function ( i.e. impaired drug upper quadrant pain or metabolism, prolonged drug half life ) tenderness 9. fluid shifts and use of diuretics can alter electrolytes , especially 9. evaluate the effectiveness potassium and chloride , which of diuretics and potassium affects cardiac rhytm and contractility supplements these are manifestations of 10. note increased lethargy , 10. hypokalemia and hyponatremia that hypotension, and muscle may occur because of fluid shifts and diuretic therapy cramping 11. restrictions of foods high in sodium 11. assess the need for dietary may be necessary . the client may consultation as needed need to eat foods enriched with
potassium when taking loop diuretics

evaluation : depending on the degree of heart failure, fluid volume excess may be slow to resolve. initially, there may be a resolution of manifestations after diuresis . fluid balance adjustments may then be made daily.

collaborative problem : risk for bleeding related to coagulopathies associated with thrombolytic therapy or arterial puncture after angioplasty outcomes : the nurse will monitor for bleeding and reduce bleeding risk. if bleeding does occur , it will be recognized and treated at once

intervention : 1. obtain coagulation studies as ordered 2. monitor invasive line sites for active bleeding 3. inspect all body fluids for presence of blood 4. hold pressure on any discontinued lines 15 minutes, if arterial , hold for 30 minutes 5. if the client has had an angioplasty , monitor puncture sight frequently for hemorrhage 6. observe neurologic status

Rationale : 1. coagulation studies can help determine the tendency to bleed 2. thrombolytic therapy disrupts the normal coagulation process, and bleeding may occur at any invasive site 3. internal bleeding may be manifested in urine , sputum, and gastrointestinal drainage 4. pressure is used to achieve hemostatis at catheter sites 5. active bleeding may occur after angioplasty 6. a change in neurologic status may indicate intracranial bleeding

7. avoid intramuscular ( IM ) injection 8. assess for back or flank pain 9. keep an IV line patent 10. maintain an active tye and crossmatch on the client

7. IM injection may cause bleeding 8. flank or back pain may suggest retroperitoneal bleeding 9. in case of active bleeding , a patent line must be maintained to transfuse blood product 10. if the client requires blood or blood products, an active type and crossmatch help eliminate any delay in treatment

evaluation : the nurse will monitor for and prevent bleeding