{ "name": "Myocardial Infarction", "slug": "myocardial-infarction", "url": "https://nursingplex.com/care-plans/myocardial-infarction", "category": "Cardiac", "summary": "Heart attack care: rapid reperfusion, pain relief, arrhythmia watch and cardiac rehab teaching.", "nursing_diagnoses": [ "Acute pain", "Decreased cardiac output", "Anxiety", "Activity intolerance" ], "overview": [ "Myocardial infarction is irreversible death of heart muscle from prolonged interruption of coronary blood flow, nearly always because an atherosclerotic plaque ruptures and a thrombus forms on top of it. Ischemic tissue can recover; infarcted tissue cannot. That single fact drives all of the urgency in the first hours, because the size of the eventual scar depends almost entirely on how quickly flow is restored.", "The classic presentation is crushing, pressure-like substernal chest pain lasting longer than 15–20 minutes, radiating to the left arm, jaw, neck or back, unrelieved by rest or nitroglycerin, with diaphoresis, nausea, dyspnea and a feeling of impending doom. Women, older adults and people with diabetes often present atypically instead — fatigue, indigestion, shortness of breath or simple weakness — and those atypical presentations are the ones that get missed.", "Diagnosis rests on ECG and cardiac biomarkers. ST elevation with new Q waves indicates full-thickness injury needing immediate reperfusion; ST depression and T-wave inversion suggest non-ST-elevation infarction or unstable angina. Troponin I and T are the most specific markers, rising within about 3 hours and staying elevated for up to two weeks. Dysrhythmia is the leading cause of death in the first hours, so continuous monitoring is not optional." ], "key_facts": [ { "label": "Reperfusion targets", "text": "Percutaneous coronary intervention within 90 minutes of first medical contact; fibrinolytics within 30 minutes of arrival when PCI is not available." }, { "label": "Initial memory aid", "text": "MONA — morphine, oxygen if hypoxic, nitroglycerin, aspirin chewed — plus antiplatelet therapy, a beta blocker and a statin as ordered." }, { "label": "Most specific biomarker", "text": "Troponin. CK-MB is less specific and myoglobin is early but nonspecific." }, { "label": "Nitroglycerin caution", "text": "Contraindicated with a systolic pressure under about 90, right ventricular infarction, or phosphodiesterase inhibitor use in the past 24–48 hours." }, { "label": "Leading early complication", "text": "Ventricular dysrhythmia; later complications include heart failure, cardiogenic shock, pericarditis and ventricular wall rupture." } ], "nursing_priorities": [ "Relieve ischemic pain and restore coronary blood flow fast.", "Detect and treat life-threatening dysrhythmias immediately.", "Reduce myocardial oxygen demand while maintaining perfusion.", "Monitor for pump failure and cardiogenic shock.", "Relieve anxiety, which itself increases myocardial oxygen demand.", "Begin risk-factor modification and cardiac rehabilitation before discharge." ], "assessment": { "subjective": [ "Chest pain described as crushing, squeezing, heavy or vise-like, with radiation and no relief from rest", "Nausea, indigestion-like discomfort or epigastric burning", "Shortness of breath, weakness, lightheadedness", "A stated sense of doom, fear of dying, or extreme restlessness", "In atypical presentations, only unusual fatigue or shoulder and jaw ache" ], "objective": [ "Diaphoresis, pallor, cool clammy skin, anxious facial expression, clutching the chest", "Tachycardia or bradycardia, dysrhythmias, hypotension or hypertension", "ST-segment elevation or depression, T-wave inversion, new Q waves, new bundle branch block", "Elevated troponin, CK-MB; possible leukocytosis and elevated glucose in the acute phase", "S3 or S4 gallop, new murmur, crackles, jugular venous distention if pump failure develops", "Decreased urine output, restlessness or confusion with falling output" ], "related_factors": [ "Coronary artery occlusion by plaque rupture and thrombus with myocardial tissue ischemia", "Reduced contractility of the infarcted segment and altered electrical conduction", "Imbalance between myocardial oxygen supply and demand", "Fear of death, unfamiliar critical care environment and loss of control", "Modifiable risk factors: smoking, hypertension, dyslipidemia, diabetes, obesity, inactivity, stress" ] }, "goals": [ "The client will report chest pain relieved to zero or an agreed tolerable level within the first hours of treatment and will demonstrate a relaxed body posture.", "The client will maintain a stable cardiac rhythm and hemodynamic status with no sustained dysrhythmia.", "The client will maintain adequate cardiac output as evidenced by clear mentation, warm dry skin, urine output above 30 mL/hr and stable vital signs.", "The client will report reduced anxiety and use effective coping techniques.", "The client will describe their medications, activity progression and the risk factors they will modify before discharge." ], "interventions": [ { "title": "1. Relieving ischemic chest pain", "points": [ "Assess pain location, quality, radiation, severity and duration at onset and after each intervention; changes in the pain pattern indicate extension of the infarct or a new complication.", "Obtain a 12-lead ECG during the pain episode — the tracing during pain is the most diagnostic one.", "Give oxygen only if saturation falls below the ordered threshold; routine oxygen in a normally saturated patient offers no benefit.", "Administer nitroglycerin as ordered and reassess pain and blood pressure after each dose; nitrates dilate coronary vessels and reduce preload but can drop pressure sharply.", "Give IV morphine when pain persists — it relieves pain, reduces anxiety and lowers preload and myocardial oxygen demand.", "Give chewable aspirin at once unless contraindicated; chewing speeds antiplatelet effect.", "Maintain bed rest with the head elevated during the acute pain phase to reduce workload, and provide a quiet environment." ] }, { "title": "2. Monitoring rhythm and preventing dysrhythmia", "points": [ "Keep the patient on continuous cardiac monitoring with alarm limits set and audible; ventricular fibrillation is the most common cause of death in the first hour.", "Assess for premature ventricular contractions, ventricular tachycardia, new heart block and bradycardia, and report per protocol.", "Keep emergency equipment, a defibrillator and antiarrhythmics immediately available.", "Maintain potassium and magnesium within normal ranges; both hypokalemia and hypomagnesemia lower the threshold for ventricular arrhythmia.", "Avoid vagal stimulation — no straining at stool, no rectal temperatures — and provide stool softeners." ] }, { "title": "3. Supporting cardiac output and reperfusion therapy", "points": [ "Prepare the patient for emergency PCI: consent, NPO status, labs, IV access, allergy and renal history for contrast.", "If fibrinolytics are given, screen for contraindications, monitor for bleeding at every site, watch for reperfusion dysrhythmias, and observe for pain resolution and ST-segment normalization as signs of success.", "After catheterization, keep the affected extremity straight per protocol, check the insertion site for bleeding or hematoma, and assess distal pulses, color, temperature and sensation frequently.", "Monitor hemodynamics, urine output, lung sounds and mentation for developing pump failure or cardiogenic shock.", "Give beta blockers, ACE inhibitors, high-intensity statins and dual antiplatelet therapy as ordered, and explain the purpose of each so the patient continues them at home." ] }, { "title": "4. Reducing anxiety and fear", "points": [ "Stay with the patient during acute pain; a calm, competent presence lowers catecholamine release and therefore oxygen demand.", "Explain equipment, alarms and each procedure in simple terms before doing them, and answer questions honestly.", "Let the patient express fear of dying rather than redirecting it, and involve the family early.", "Teach slow breathing and relaxation techniques and provide uninterrupted rest periods." ] }, { "title": "5. Activity progression and cardiac rehabilitation", "points": [ "Advance from bed rest to dangling, chair, then ambulation as ordered, monitoring the vital sign and symptom response to each step.", "Stop activity for chest pain, dyspnea, dizziness, a heart rate rise over about 20 beats per minute above resting, or a fall in systolic pressure, and report it.", "Teach that fatigue after activity is expected early but should improve week to week.", "Refer to a formal cardiac rehabilitation program, which reduces mortality and repeat events." ] } ], "patient_teaching": [ "Call emergency services immediately for chest pain lasting more than 5 minutes and unrelieved by rest or nitroglycerin — do not drive yourself.", "Use nitroglycerin correctly: sit down, one dose under the tongue, repeat every 5 minutes up to three doses, and call for help if pain persists after the first dose.", "Store nitroglycerin in its original dark container away from heat and replace it as directed.", "Take antiplatelet, beta blocker, statin and ACE inhibitor therapy exactly as prescribed, and never stop antiplatelets after a stent without talking to the cardiologist.", "Stop smoking completely, including secondhand exposure, and get help doing it — this is the single highest-yield change.", "Follow a heart-healthy diet lower in saturated fat, trans fat and sodium, and control diabetes, cholesterol and blood pressure.", "Resume activity, work and sexual activity on the schedule your provider gives; report chest pain with any of them.", "Avoid heavy lifting, straining and extremes of temperature during recovery.", "Attend cardiac rehabilitation and every follow-up appointment." ] }