Download Care of the Patient With an Uncomplicated Myocardial

Chapter 14: Nursing Management: Patients With Coronary Vascular
Disorders
*The following is a sample care plan meant for adaptation. Always revise to meet your facility’s
protocols and the latest research and nursing diagnoses.
PLAN OF NURSING CARE
Care of the Patient With an Uncomplicated Myocardial Infarction (MI)
NURSING DIAGNOSIS:
Ineffective cardiac tissue perfusion related to reduced
coronary blood flow.
GOAL:
Relief of chest pain/discomfort
Nursing Interventions
Rationale
Expected Outcomes
1. Initially assess,
1. These data assist in
• Reports beginning
document, and report
determining the cause
relief of chest
to the provider the
and effect of the chest
discomfort and
following:
discomfort and provide
symptoms
a baseline with which
a. The patient’s
• Appears comfortable
post-therapy
and is free of pain and
symptoms can be
other signs or
compared.
symptoms:
a. There are many
Respiratory rate,
description of chest
conditions
cardiac rate, and
discomfort, including
associated with
blood pressure
location, intensity,
chest discomfort.
return to
radiation, duration,
There are
prediscomfort level
and factors that
characteristic
Skin warm and dry
affect it. Other
clinical findings of
symptoms such as
ischemic pain and
output as evidenced
nausea,
symptoms.
by: stable/improving
• Adequate cardiac
diaphoresis, or
ECG
complaints of
Heart rate and rhythm
unusual fatigue.
b. The effect of chest
b. MI decreases
Blood pressure
discomfort on
myocardial
Mentation
cardiovascular
contractility and
Urine output
perfusion—to the
ventricular
Serum BUN and
heart (eg, change in
compliance and
blood pressure,
may produce
heart sounds), to
arrhythmias.
temperature, and
the brain (eg,
Cardiac output is
moisture
changes in LOC), to
reduced, resulting
the kidneys (eg,
in reduced blood
decrease in urine
pressure and
output), and to the
decreased organ
skin (eg, color,
perfusion. The heart
temperature).
rate may increase
as a compensatory
mechanism to
creatinine
Skin color,
maintain cardiac
output.
2. Obtain a 12-lead ECG
2. An ECG during
recording during the
symptoms may be
symptomatic event, as
useful in the diagnosis
prescribed, to
of an extension of MI.
determine extension of
infarction.
3. Administer oxygen as
prescribed.
3. Oxygen therapy
increases the oxygen
supply to the
myocardium if actual
oxygen saturation is
less than normal.
4.
Administer
4. Medication therapy
medication therapy as
(nitroglycerin,
prescribed and evaluate
morphine, beta
the patient’s response
blocker, aspirin) is the
continuously.
first line of defense in
preserving myocardial
tissue. The side
effects of these
medications can be
hazardous and the
patient’s status must
be assessed.
5. Ensure physical rest:
5. Physical rest reduces
use of the bedside
myocardial oxygen
commode with
consumption. Fear
assistance; backrest
and anxiety precipitate
elevated to promote
the stress response;
comfort; diet as
this results in
tolerated; arms
increased levels of
supported during
endogenous catechol-
upper extremity
amines, which
activity; use of stool
increase myocardial
softener to prevent
oxygen consumption.
straining at stool.
Also, with increased
Provide a restful
epinephrine, the pain
environment, and allay
threshold is
fears and anxiety by
decreased, and pain
being supportive,
increases myocardial
calm, and competent.
oxygen consumption.
Individualize visitation,
based on patient
response.
NURSING DIAGNOSIS:
GOAL:
Potential impaired gas exchange related to fluid overload
Absence of respiratory difficulties
Nursing Interventions
Rationale
Expected Outcomes
1. Initially, every 4 hours,
1. These data are useful
• No shortness of
and with chest
in diagnosing left
breath, dyspnea on
discomfort or
ventricular failure.
exertion, orthopnea, or
symptoms, assess,
Diastolic filling sounds
paroxysmal nocturnal
document, and report
(S3 and S4 gallop)
dyspnea
to the provider
result from decreased
abnormal heart
left ventricular
than 20 breaths/min
sounds (particularly S3
compliance associated
with physical activity
and S4 gallops and the
with MI. Papillary
and 16 breaths/min
holosystolic murmur of
muscle dysfunction
with rest
left ventricular
(from infarction of the
• Skin color normal
papillary muscle
papillary muscle) can
• PaO2 and PaCO2
dysfunction),
result in mitral
abnormal breath
regurgitation and a
sounds (particularly
reduction in stroke
100 beats/min
crackles), and patient
volume, leading to left
and greater than 60
intolerance to specific
ventricular failure. The
beats/min, with blood
activities.
presence of crackles
pressure within
(usually at the lung
patient’s normal limits
• Respiratory rate less
within normal range
• Heart rate less than
bases) may indicate
• Chest x-ray normal
pulmonary congestion
• Relief of chest
from increased left
heart pressures. The
a. To adhere to the
• Appears comfortable:
association of
Appears rested
symptoms and activity
Respiratory rate,
can be used as a
cardiac rate, and
guide for activity
blood pressure
prescription and a
return to
basis for patient
prediscomfort level
teaching.
2. Teach patient:
discomfort
2.
a. Low-sodium diet
diet prescribed (for
may reduce
example, explain
extracellular
low-sodium, low-
volume, thus
calorie diet)
reducing preload
and afterload, and
thus myocardial
oxygen
consumption. In the
obese patient,
weight reduction
Skin warm and dry
b. To adhere to
may decrease
activity prescription
cardiac work and
improve tidal
volume.
b. The activity
prescription is
determined
individually to
maintain the heart
rate and blood
pressure within safe
limits.
NURSING DIAGNOSIS:
Risk for ineffective peripheral tissue perfusion related to
decreased cardiac output
GOAL:
Maintenance/attainment of adequate tissue perfusion
Nursing Interventions
Rationale
Expected Outcomes
1. Initially, every 4 hours,
1. These data are useful
• Blood pressure within
and with chest
in determining a low
the patient’s normal
discomfort, assess,
cardiac output state.
range
document, and report
An ECG with pain
to the provider the
may be useful in the
rhythm without
following:
diagnosis of an
arrhythmia is
• Ideally, normal sinus
a. Hypotension
extension of
maintained, or
b. Tachycardia and
myocardial ischemia,
patient’s baseline
other arrhythmia
injury, and infarction,
rhythm is maintained
c. Activity intolerance
and of variant angina.
between 60 and 100
d. Mentation changes
beats/min without
(use family input)
further arrhythmia.
• No complaints of
e. Reduced urine
output
fatigue with prescribed
(less.5mL/kg/hr)
activity
• Remains fully alert
f. Cool, moist, cyanotic
extremities
and oriented and
without cognitive or
behavioral change
• Appears comfortable
• Urine output greater
than 30 mL/hr
• Extremities warm and
dry with normal color
NURSING DIAGNOSIS:
GOAL:
Death anxiety
Reduction of anxiety
Nursing Interventions
Rationale
Expected Outcomes
1. Assess, document,
1. These data provide
• Reports less anxiety
• Patient and family
and report to the
information about the
provider the patient’s
psychological well-
discuss their anxieties
and family’s level of
being and a baseline
and fears about death
anxiety and coping
so that post-therapy
mechanisms.
symptoms can be
compared. Causes of
• Patient and family
appear less anxious
• Appears restful,
anxiety are variable
respiratory rate less
and individual, and
than 16/min, heart
may include acute
rate less than 100/min
illness, hospitalization,
without ectopic beats,
pain, disruption of
blood pressure within
activities of daily living
patient’s normal limits,
at home and at work,
skin warm and dry
changes in role and
• Participates actively in
self-image due to
a progressive
illness, and financial
rehabilitation program
concerns. Because
anxious family
members can transmit
anxiety to the patient,
the nurse must also
identify strategies to
reduce the family’s
• Practices stress
reduction techniques
fear and anxiety.
2. Assess the need for
2. If a patient finds
spiritual counseling
support in a religion,
and refer as
spiritual counseling
appropriate.
may assist in reducing
anxiety and fear.
3. Assess the need for
social service referral.
3. Social services can
assist with posthospital care and
financial concerns.
4. Allow patient (and
4. Unresolved anxiety
family) to express
(the stress response)
anxiety and fear:
increases myocardial
a. By showing genuine
oxygen consumption.
interest and concern
b. By facilitating
communication
(listening, reflecting,
guiding)
c. By answering
questions
5. Use of flexible visiting
hours allows the
5. The presence of
supportive family
presence of a
members may reduce
supportive family to
both patient’s and
assist in reducing the
family’s anxiety.
patient’s level of
anxiety.
6. Encourage active
6. Prescribed cardiac
participation in a
rehabilitation may help
cardiac rehabilitation
reduce anxiety,
program.
enhance feelings of
well-being, and
facilitate compliance
with risk factor
recommendations.
7. Teach stress reduction
techniques.
7. Stress reduction may
help to reduce
myocardial oxygen
consumption and may
enhance feelings of
well-being.
NURSING DIAGNOSIS:
GOAL:
Deficient knowledge about post-MI self-care
Adheres to the home health care program, chooses lifestyle consistent
with heart-healthy recommendations.
Promoting Health After Myocardial Infarction and Other Acute Coronary
Syndromes
To extend and improve the quality of life, a patient who has had an MI must
learn to adjust his or her lifestyle to promote heart-healthy living. With this in
mind, the nurse and patient develop a program to help the patient achieve
desired outcomes.
Changing Lifestyle During Convalescence and Healing
Adaptation to an MI is an ongoing process and usually requires some
modification of lifestyle. Some specific modifications include:
• Avoiding any activity that produces chest pain, extreme dyspnea, or undue
fatigue
• Avoiding extremes of heat and cold and walking against the wind
• Losing weight, if indicated
• Stopping smoking and use of tobacco; avoiding second-hand smoke
• Using personal strengths to support lifestyle changes
• Developing heart-healthy eating patterns and avoiding large meals and
hurrying while eating
• Modifying meals to align with the Therapeutic Lifestyle Changes (TLC) or the
Dietary Approaches to Stopping Hypertension (DASH) diet
• Adhering to medical regimen, especially in taking medications
• Following recommendations that ensure blood pressure and blood glucose
are in control
• Pursuing activities that relieve and reduce stress
Adopting an Activity Program
Additionally, the patient needs to undertake an orderly program of increasing
activity and exercise for long-term rehabilitation as follows:
• Engaging in a regimen of physical conditioning with a gradual increase in
activity duration and then a gradual increase in activity intensity
• Walking daily, increasing distance and time as prescribed
• Monitoring pulse rate during physical activity until the maximum level of
activity is attained
• Avoiding activities that tense the muscles: isometric exercise, weight-lifting,
any activity that requires sudden bursts of energy
• Avoiding physical exercise immediately after a meal
• Alternating activity with rest periods (some fatigue is normal and expected
during convalescence)
• Participating in a daily program of exercise that develops into a program of
regular exercise for a lifetime
Managing Symptoms
The patient must learn to recognize and take appropriate action for possible
recurrences of symptoms as follows:
• Call 911 if chest pressure or pain (or anginal equivalent) is not relieved in 15
minutes by nitroglycerin
• Contacting the provider if any of the following occur: shortness of breath,
fainting, slow or rapid heartbeat, swelling of feet and ankles