Nursing Care Plan for Myocardial Infarction

Nursing Assessment for Acute Myocardial Infarction (AMI)

Nursing Assessment for Acute Myocardial Infarction (AMI)
Myocardial infarction (MI) or acute myocardial infarction (AMI), commonly known as a heart attack, is the interruption of blood supply to a part of the heart, causing heart cells to die. This is most commonly due to occlusion (blockage) of a coronary artery following the rupture of a vulnerable atherosclerotic plaque, which is an unstable collection of lipids (fatty acids) and white blood cells (especially macrophages) in the wall of an artery. The resulting ischemia (restriction in blood supply) and oxygen shortage, if left untreated for a sufficient period of time, can cause damage or death (infarction) of heart muscle tissue (myocardium).
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Primary Assessment needs to be done on the Nursing Care Plan for Acute Myocardial Infarction (AMI), among others:

Airways

  1. Blockage or accumulation of secretions
  2. Wheezing or crackles
Breathing
  1. Shortness of breath with mild activity or rest
  2. Respiration more than 24 x / min, irregular rhythm shallow
  3. Ronchi, crackles
  4. The expansion of the chest is not full
  5. Use of auxiliary respiratory muscles
Circulation
  1. Weak pulse, irregular
  2. Tachycardia
  3. Blood pressure increase / decrease
  4. Edema
  5. Nervous
  6. Acral cold
  7. Pale skin, cyanosis
  8. Decreased urine output

Secondary Assessment needs to be done on the Nursing Care Plan for Acute Myocardial Infarction (AMI) :
  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.
  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, diabetes mellitus, 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, cracles, wheezing), sputum
  10. Social interactions
    • 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


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