Nursing Care Plan (NCP) for Myocardial Infarction (MI)
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Lesson Objective for Nursing Care Plan (NCP) for Myocardial Infarction (MI)
- Understand the Pathophysiology of Myocardial Infarction:
- Identify the underlying mechanisms leading to myocardial infarction, including atherosclerosis, plaque rupture, and coronary artery occlusion.
- Recognize the consequences of ischemia and necrosis on cardiac function.
- Assessment and Diagnosis:
- Learn the clinical manifestations of myocardial infarction, including chest pain, shortness of breath, diaphoresis, and nausea.
- Understand the diagnostic criteria and laboratory tests used to confirm and assess the extent of myocardial infarction.
- Pharmacological Interventions:
- Explore the pharmacological treatments commonly used in managing myocardial infarction, such as antiplatelet agents, beta-blockers, and thrombolytics.
- Understand the rationale behind medication choices and potential side effects.
- Cardiac Monitoring and Complication Prevention:
- Comprehend the importance of continuous cardiac monitoring in the acute phase.
- Learn strategies to prevent complications, such as arrhythmias, heart failure, and cardiogenic shock.
- Patient Education and Rehabilitation:
- Develop effective patient education strategies regarding medication adherence, lifestyle modifications, and symptom recognition.
- Emphasize the importance of cardiac rehabilitation and long-term management to prevent future events.
Pathophysiology of Myocardial Infarction
- Atherosclerosis Development:
- Atherosclerosis, the buildup of fatty plaques within coronary arteries, initiates the pathophysiological process.
- Plaques consist of cholesterol, inflammatory cells, and other substances, leading to arterial narrowing and reduced blood flow.
- Plaque Rupture or Erosion:
- Plaques may rupture or erode, exposing the underlying tissue to the bloodstream.
- This triggers platelet activation and aggregation, forming a blood clot (thrombus) at the site of rupture.
- Coronary Artery Occlusion:
- The formed thrombus can partially or completely occlude the coronary artery.
- Occlusion results in reduced oxygen and nutrient supply to the heart muscle (myocardium).
- Ischemia and Myocardial Infarction:
- The compromised blood supply causes myocardial ischemia (inadequate oxygenation) in the affected area.
- If blood flow is not restored promptly, irreversible damage occurs, leading to myocardial infarction (death of heart muscle cells).
- Inflammatory Response and Scar Formation:
- Following myocardial infarction, an inflammatory response is initiated, involving immune cells.
- Scar tissue forms in the damaged area as part of the healing process, but this tissue lacks the contractile properties of normal myocardium, impacting cardiac function.
Etiology (Causes) of Myocardial Infarction
- Atherosclerosis:
- Primary cause of myocardial infarction.
- Gradual buildup of fatty deposits (plaques) within coronary arteries.
- Plaques may rupture or erode, leading to thrombus formation and subsequent occlusion of blood vessels.
- Coronary Artery Disease (CAD):
- CAD is a major contributing factor.
- Conditions such as hypertension, hyperlipidemia, and diabetes mellitus increase the risk of atherosclerosis and coronary artery narrowing.
- Thrombosis:
- Formation of blood clots (thrombi) within coronary arteries.
- Thrombosis can result from plaque rupture, endothelial injury, or conditions that promote abnormal blood clotting.
- Coronary Vasospasm:
- Sudden, intense contraction of coronary arteries.
- Can occur spontaneously or be triggered by drug use, stress, or other factors.
- Vasospasm leads to temporary or prolonged reduction of blood flow to the myocardium, causing ischemia and potential infarction.
- Risk Factors:
- Smoking: Increases atherosclerosis and promotes clot formation.
- Hypertension: Raises the workload on the heart and contributes to arterial damage.
- Diabetes: Accelerates atherosclerosis and impairs blood vessel function.
- Hyperlipidemia: Elevated levels of cholesterol contribute to plaque formation.
- Family History: Genetic predisposition may increase susceptibility to CAD and myocardial infarction.
Desired Outcomes of Nursing Care Plan for Myocardial Infarction
- Restoration of Coronary Blood Flow:
- Prompt and effective interventions, such as percutaneous coronary intervention (PCI) or thrombolytic therapy, aim to restore blood flow to the affected coronary arteries.
- Timely reperfusion helps minimize myocardial damage and preserves cardiac function.
- Pain Relief and Symptom Resolution:
- Adequate pain management to relieve chest pain and discomfort associated with myocardial infarction.
- Resolution of other symptoms, such as shortness of breath, nausea, and diaphoresis.
- Preservation of Cardiac Function:
- Minimization of myocardial damage to preserve overall cardiac function.
- Prevention of complications such as heart failure, arrhythmias, and cardiogenic shock.
- Prevention of Recurrent Events:
- Implementation of secondary prevention measures to reduce the risk of future cardiovascular events.
- Medication adherence, lifestyle modifications, and ongoing medical management contribute to long-term prevention.
- Psychosocial and Emotional Well-Being:
- Addressing the emotional impact of myocardial infarction, including anxiety and fear.
- Providing support, education, and resources to enhance coping mechanisms and overall psychosocial well-being.
Myocardial Infarction (MI) Nursing Care Plan
Subjective Data:
- Chest Pain
- Chest Pressure/Squeezing
- PQRST pain assessment
- P- provoke, precipitate, palliate
- Q- quality
- R- radiate
- S- severity, symptoms
- T- time
- Patient may report a feeling of impending doom
- Shortness of Breath
Objective Data:
- ST elevation on the ECG- Called an STEMI
- Decreased oxygenation
- Signs of left ventricular failure such as crackles in the lungs or S3 heart sound
- Tachycardia (Bradycardia can be seen if patient is having an inferior MI)
- Elevated Cardiac Enzymes
Nursing Assessment for Myocardial Infarction
- Chest Pain Assessment:
- Thorough assessment of chest pain characteristics, including location, intensity, quality, radiation, and duration.
- Use of a pain scale to quantify pain levels and monitor changes over time.
- Vital Signs Monitoring:
- Continuous monitoring of vital signs, including heart rate, blood pressure, respiratory rate, and oxygen saturation.
- Regular assessments to detect signs of hemodynamic instability.
- Cardiac Monitoring:
- Continuous electrocardiogram (ECG) monitoring to identify and monitor changes in cardiac rhythm and ST-segment deviations.
- Prompt recognition of arrhythmias or ischemic changes.
- Symptom Assessment:
- Evaluation of associated symptoms such as shortness of breath, nausea, vomiting, diaphoresis, and lightheadedness.
- Documentation of the onset and progression of symptoms.
- Past Medical History:
- Review of the patient’s medical history, with a focus on cardiovascular risk factors, previous cardiac events, and comorbid conditions (e.g., hypertension, diabetes).
- Medication History:
- Documentation of current medications, including anticoagulants, antiplatelet agents, beta-blockers, and other relevant cardiovascular medications.
- Identification of any known drug allergies.
- Physical Examination:
- Thorough cardiovascular examination, including assessment of heart sounds, peripheral pulses, and signs of heart failure (e.g., jugular venous distention, peripheral edema).
- Inspection and palpation of the chest for signs of trauma, deformities, or surgical scars.
- Psychosocial Assessment:
- Evaluation of the patient’s emotional well-being and psychological response to the event.
- Identification of stressors, anxiety, and coping mechanisms.
- Assessment of the patient’s support system and understanding of the diagnosis.
Nursing Implementation of Managing Myocardial Infarction
- Emergency Interventions:
- Activate Rapid Response: Initiate emergency response protocols promptly to ensure a rapid and coordinated team response.
- Administer Medications: Provide prescribed medications urgently, including aspirin, nitroglycerin, and, if indicated, thrombolytics or antiplatelet agents.
- Ongoing Cardiac Monitoring:
- Continuous ECG Monitoring: Maintain continuous electrocardiogram (ECG) monitoring to detect any changes in cardiac rhythm or ST-segment deviations.
- Hemodynamic Monitoring: Monitor vital signs and hemodynamic parameters regularly to identify signs of hemodynamic instability.
- Pain Management:
- Administer Analgesics: Provide appropriate analgesics, such as morphine, to alleviate chest pain and discomfort.
- Evaluate Pain Relief: Assess the effectiveness of pain management interventions and adjust as needed.
- Collaborative Interventions:
- Coordinate Reperfusion Therapy: Collaborate with the healthcare team to facilitate reperfusion therapy, such as percutaneous coronary intervention (PCI) or thrombolytic therapy.
- Manage Complications: Address and manage complications promptly, including arrhythmias, heart failure, or cardiogenic shock.
- Patient Education and Support:
- Educate on Medication Regimen: Provide clear explanations of prescribed medications, their purposes, and potential side effects.
- Discuss Lifestyle Modifications: Offer guidance on lifestyle changes, including diet, exercise, smoking cessation, and stress management.
- Facilitate Emotional Support: Address the emotional impact of myocardial infarction, providing emotional support and resources for coping.
Nursing Interventions and Rationales
- MONA:
- Morphine
- Oxygen
- Nitroglycerin
- Aspirin (ASA)
*note – this is only a mnemonic and not the correct order of administration – see rationale for details*
Initial treatment for acute coronary syndrome.
- Morphine: given ONLY if aspirin and nitroglycerin do not relieve chest pain. Initial dose is 2-4 mg IV.
- Oxygen: helps for you to remember to check oxygenation for chest pain – if under 94% or if patient is short of breath give 2L NC initially. Administer oxygen only when clinically relevant.
- Nitroglycerin: This is the initial medication given, along with aspirin. This medication dilates the blood vessels to help allow any blood flow that might be impeded. Give 0.4 mg sublingual tab, wait 5 minutes, if the chest pain is not relieved administer another dose. This can happen 3 times total. Monitor a patient’s blood pressure, hold for a systolic BP of less than 90 mmHg.
- Aspirin: given to thin the blood and decrease mortality risk. A total of 4 baby aspirin (81 mg each) can be given for a total of 324 mg, or a single 325 mg dose.
- 12-Lead ECGIf initial 12-lead ECG indicates inferior MI, do a right-sided 12-lead ECG.
- 3 or 5 Lead monitoring
- Cardiac Catheterization with Percutaneous Coronary Intervention (PCI)
- BP Monitoring
- The measurement is determined by the doctor, who is determining this based on evidence based research married with patient factors.
- It can be measured by the systolic BP or the Mean Arterial Pressure (MAP).
- This can also be monitored by an arterial line.
- Heparin
This is an anticoagulant that prevents clots.
- Monitor aPTT or Anti-Xa Q6H to adjust and maintain therapeutic levels.
For STEMI
- Bolus: 60 units/kg (max 4,000 units)
- Continuous infusion: 12 units/kg/hr
- -Adjust according to your organization’s nomogram (Q6H- based on results of aPPT or Anti-Xa)
For N-STEMI
- Bolus: 60-70 units/kg (max 5,000 units)
- Continuous Infusion: 12-15 units/kg/hr
- -Adjust according to your organization’s nomogram (Q6H- based on results of aPPT or Anti-Xa)
- Insert Large Bore IV and draw initial Cardiac Enzymes
IV access is important for administration of medications, possible interventions if angina worsens, and any scans that may be needed to rule out thrombosis. Cardiac enzymes further serve to rule out Myocardial Infarction and can give an indication to the extent of myocardial damage.
- Troponin I
- CK
- CK-MB
- Myoglobin
- Monitor Cardiac Enzymes:
- Troponin I
- Creatine Kinase-MB (CKMB)
The values of these enzymes are based on your institutional laboratory technique. If they are elevated it indicates that the cardiac muscle is stressed out or injured.
- Troponin I is an enzyme that helps the interaction of myosin and actin in the cardiac muscle. When necrosis of the myocyte happens, the contents of the cell eventually will be released into the bloodstream.
- Troponin can become elevated 2-4 hours after in ischemic cardiac event and can stay elevated for up to 14 days.
- Creatine Kinase MB: This enzyme is found in the cardiac muscle cells and catalyses the conversion of ATP into ADP giving your cells energy to contract. When the cardiac muscle cells are damaged the enzyme is eventually released into the bloodstream.
- CKMB levels should be checked at admission, and then every 8 hours afterwards.
Evaluation for Nursing Care Plan (NCP) for Myocardial Infarction (MI)
- Cardiovascular Stability:
- Evaluate the patient’s cardiovascular status for stability in vital signs and absence of dysrhythmias.
- Pain Relief:
- Assess the effectiveness of pain management interventions.
- Ensure the patient’s comfort and relief from chest pain.
- Medication Efficacy:
- Monitor the patient’s response to medications, adjusting doses as needed.
- Evaluate for any adverse effects.
- Complication Prevention:
- Assess for the prevention or early identification of complications such as heart failure or cardiogenic shock.
- Patient Understanding:
- Evaluate the patient’s understanding of the condition, treatment plan, and the importance of ongoing care and lifestyle modifications.
References
- http://www.heart.org/HEARTORG/Conditions/HeartAttack/SymptomsDiagnosisofHeartAttack/Cardiac-Catheterization_UCM_451486_Article.jsp#.WQVGalMrIzY
- http://www.heart.org/HEARTORG/Conditions/HeartAttack/TreatmentofaHeartAttack/Cardiac-Procedures-and-Surgeries_UCM_303939_Article.jsp#.WQVILlMrIzY
- http://reference.medscape.com/drug/calciparine-monoparin-heparin-342169
- https://acls.com/free-resources/knowledge-base/acute-coronary-syndrome/mona-morphine-oxygen-nitroglycerin-and-aspirin
- http://www.mayomedicallaboratories.com/test-catalog/Clinical+and+Interpretive/82428
- http://www.mayomedicallaboratories.com/test-catalog/Overview/82429
- http://www.medscape.com/viewarticle/805698
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4900358/
- http://www.heart.org/HEARTORG/Conditions/HeartAttack/AboutHeartAttacks/About-Heart-Attacks_UCM_002038_Article.jsp#.WQvquVMrIzY
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3042154/
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2941782/
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Transcript
Hey guys, in this lesson, we are going to take a look at the care plan for myocardial infarction or MI. So in this lesson, we will talk about the pathophysiology and etiology of an MI. We’ll also take a look at subjective and objective data your patient may present with as well as nursing interventions and rationales for this issue.
So myocardial Infarction is cardiac muscle tissue death from lack of blood flow, which is super important because blood carries nutrients and oxygen to the cells. If this doesn’t occur, cell necrosis occurs. So, this causes them an MI, including narrowing or occlusion of cardiac vessels, DVT that has broken off or is an embolus and it lands in the heart. So, the desired outcome would be reperfusion to cardiac muscle and return of cardiac muscle functionality.
Let’s take a look at some of the subjective and objective data that your patient with an MI may present with. Now, remember subjective data are going to be things that are based on your patient’s opinions or feelings. So for an MI, this may include chest pain or chest pressure and squeezing, and feeling of impending doom, or shortness of breath.
So guys for objective data, be sure to do a pain assessment. For example, the PQRST assessment for pain objective data can include ST elevation on the EKG and this is called a STEMI, decreased oxygenation, signs of left ventricular failure like crackles in the lungs or S3 heart sounds, tachycardia, elevated cardiac enzymes, or with an inferior MI, bradycardia can be seen.
Let’s take a look at the nursing interventions included with the MI care plan. Mona, which stands for medicine, for pain, oxygen, nitroglycerin, and aspirin, is the initial treatment for acute coronary syndrome. Remember, Mona is not the correct order of administration, just an easy way to remember the components of this treatment. So, I just want to mention that “M” used to be for morphine, if both aspirin and nitroglycerin did not relieve the chest pain, but morphine isn’t really used anymore as it increases mortality. So, for the “M” in Mona, think medicine, because some type of medicine will be given for pain. Now, oxygen reminds you to check oxygenation for chest pain. If the patient is short of breath, or has a SAT of less than 94%, you’re going to apply two liters of nasal cannula, but remember, only administer oxygen if clinically necessary.
Nitroglycerin is the initial medication that is given along with aspirin. Nitroglycerin works as a dilator to help a low blood flow that might be disrupted. So, you’re going to give 0.4 milligram sublingual, wait five minutes, and if chest pain isn’t relieved, administer another dose, but no more than three doses. Make sure the patient’s blood pressure is being monitored and hold the dose if the systolic blood pressure is less than 90 millimeters of mercury. Aspirin is given because it decreases mortality by thinning the patient’s blood. A single dose of 325 milligrams can be given, or for baby aspirin, which are 81 milligrams each, can be given a total of 324 milligrams. Also a 12 lead EKG should be completed immediately on anyone who is complaining of chest pain to determine if there is an ST elevated MI occurring.
If it is, this patient needs to go to the cath lab stat. Now, if the 12 lead is normal sinus or a rhythm that is not of concern, place the patient on a three or five lead cardiac monitor to frequently assess, because we are most definitely worried about a worsening condition or cardiac arrest. Also, a right-sided 12 lead EKG shows the right side of the heart to assess for right ventricular ischemia. Remember, inferior MI’s need to be treated differently.
I already mentioned that if the patient has a STEMI, they must be taken to the cath lab quickly to locate the clot and have a stent placed to regain blood flow to the heart. I also want to mention that it is definitely possible for the patient to go to the cath lab without having a STEMI and a clot may still be located, although most non STEMI’s are treated without catheterization. Patients who are coming in must definitely have their BP monitored closely. The values or limits are going to be determined by the provider. It’s measured by the MAP, or mean arterial pressure, or systolic BP within the arterial line. And, why is this important? Well, the higher the blood pressure, the more pressure on a blood clot, and it isn’t terribly uncommon for a patient to have more than one clot, which could definitely break free with a high blood pressure.
Heparin is an important intervention as this drug is an anticoagulant, and breaks up clots, as well as prevents them. With heparin administration, something like a PTT needs to be monitored every six hours to adjust the dose to keep the levels therapeutic. For a STEMI, there are different values such as 60 unit per kilo bolus is given with a max of 4,000 units and then a continuous fusion of 12 units per kilo/ per hour. For a non-STEMI a 60 to 70 unit per kilos bolus is given with a max of 5,000 units and then a continuous infusion of 12 to 15 units per kilo/ per hour. Remember to always follow your facility’s protocol.
IV access is critical to administer medications and also to draw initial cardiac enzymes, which are important to rule out an MI and can also indicate how much damage has occurred. Not only do we draw cardiac enzymes, but they also need to be monitored. Troponin 1 is an enzyme that helps with the interaction of myosin and actin in the cardiac muscle. So, Troponin can become elevated two to four hours after an ischemic event and can stay elevated for up to 14 days. When we talk about CK-MB, this is an enzyme that is found in cardiac muscle, so when cardiac muscle cells are damaged, this enzyme is released into the bloodstream. CK-MB should be measured at admission and then every eight hours after.
Here’s a look at the completed care plan for an MI. Let’s do a quick review. An MI occurs from cardiac muscle tissue death from lack of blood flow. Causes include narrowing of cardiac vessels, DVT, or an embolus. Subjective data includes chest pain, pressure, squeezing, impending doom, and shortness of breath. Objective data includes ST Elevation, decreased O2, crackles, being tachycardic, and elevated cardiac enzymes. Nursing interventions include a 12 lead EKG, Mona or medicine for pain, oxygen, nitroglycerin, aspirin, starting a large bore IV, and drawing initial cardiac enzymes. BP monitoring and the continuation of monitoring of cardiac enzymes is important in managing the patient. Also, preparing for the cath lab If a STEMI is present. Following your facility’s nomogram for heparin administration and adjustment is critical.
Alright guys, that is it on this care plan. We love you guys. Now, go out and be your best self today and as always, happy nursing!
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