Nursing Intervention for Myocardial Infarction
Myocardial infarction is a condition of cessation of blood flow from the coronary artery in the affected area which causes lack of oxygen (ischemia) and heart cells become dead (myocardial necrosis).
The most common cause is the rupture of atherosclerotic lesions in coronary arteries that lead to the formation of a thrombus that clog arteries and lead to interruption of the blood supply to the region of the heart supplied.
Clinical manifestations of myocardial infarction is typical chest pain described as heavy, pressing, tightness, and is settled.
In individuals who lack the vitamins and other essential nutrients, especially vitamin C in millions of vascular wall cells for many years will damage / weaken the function of blood vessels. This condition causes the formation of cracks that will be enlarged on the walls of the arteries, especially the coronary arteries.
Automatic mechanisms of the body to repair the damage done through the production of fat molecules (including cholesterol), sugar, clotting factors and other factors in the liver in greater numbers than usual, and then channeled through the bloodstream to the coronary artery wall.
Because coronary artery had suffered severe damage, then the required intensive treatment, or in other words an increase higher than these factors. A large number of these factors over time will be buried beneath the endothelium in many arteries of the body. When the pile is to penetrate the endothelium, this area will be invaded by fibrous tissue and often calcified, which led to the formation of atherosclerotic plaques that protrude into the lumen of the blood vessel.
These plaques prone to rupture due to the tension of the strain caused by blood flow. Plaque rupture causing exposure to subendothelial collagen and activation of the clotting cascade, which in turn triggers platelet aggregation resulting in ischemic state. The degree of coronary occlusion and myocardial damage is also influenced by endothelial damage due to plaque formation. Severe ischemia and long will cause a necrotic region that stretches across the myocardial wall thickness.
Nursing Diagnosis for Myocardial Infarction
Acute Pain related to tissue ischemic, secondary to clogged arteries.
Marked by :
Pain reduced / no pain
Expected Outcome :
Nursing Diagnosis for Myocardial Infarction
Risk for Decreased Cardiac Output related to changes in power factors, reduction miocard characteristics.
Goal :
Cardiac Output: improved / stable.
Expected Outcome
Nursing Intervention for Myocardial Infarction
Myocardial infarction is a condition of cessation of blood flow from the coronary artery in the affected area which causes lack of oxygen (ischemia) and heart cells become dead (myocardial necrosis).
The most common cause is the rupture of atherosclerotic lesions in coronary arteries that lead to the formation of a thrombus that clog arteries and lead to interruption of the blood supply to the region of the heart supplied.
Clinical manifestations of myocardial infarction is typical chest pain described as heavy, pressing, tightness, and is settled.
In individuals who lack the vitamins and other essential nutrients, especially vitamin C in millions of vascular wall cells for many years will damage / weaken the function of blood vessels. This condition causes the formation of cracks that will be enlarged on the walls of the arteries, especially the coronary arteries.
Automatic mechanisms of the body to repair the damage done through the production of fat molecules (including cholesterol), sugar, clotting factors and other factors in the liver in greater numbers than usual, and then channeled through the bloodstream to the coronary artery wall.
Because coronary artery had suffered severe damage, then the required intensive treatment, or in other words an increase higher than these factors. A large number of these factors over time will be buried beneath the endothelium in many arteries of the body. When the pile is to penetrate the endothelium, this area will be invaded by fibrous tissue and often calcified, which led to the formation of atherosclerotic plaques that protrude into the lumen of the blood vessel.
These plaques prone to rupture due to the tension of the strain caused by blood flow. Plaque rupture causing exposure to subendothelial collagen and activation of the clotting cascade, which in turn triggers platelet aggregation resulting in ischemic state. The degree of coronary occlusion and myocardial damage is also influenced by endothelial damage due to plaque formation. Severe ischemia and long will cause a necrotic region that stretches across the myocardial wall thickness.
Nursing Diagnosis for Myocardial Infarction
Acute Pain related to tissue ischemic, secondary to clogged arteries.
Marked by :
- Chest pain with or without spread
- Facial grimacing
- Nervous
- Delirium
- Changes in pulse, blood pressure.
Pain reduced / no pain
Expected Outcome :
- Chest pain is reduced, eg from scale 3 to 2, or from 2 to 1
- Facial expression relaxed / calm, not tense
- Not anxious
- Pulse 60-100 x / min
- Blood pressure 120/80 mmHg
- Observation of the characteristics, location, time, and the course of chest pain.
- Instruct the client to stop activity and rest during an attack.
- Help the client to do relaxation techniques, eg deep breathing, distraction behavior, visualization, or imagination guidance.
- Maintain oxygenation with bicanul example (2-4 lt / min)
- Monitor vital signs (pulse and blood pressure) every two hours.
- Collaboration with the health team in providing analgesic.
Nursing Diagnosis for Myocardial Infarction
Risk for Decreased Cardiac Output related to changes in power factors, reduction miocard characteristics.
Goal :
Cardiac Output: improved / stable.
Expected Outcome
- No edema
- No dysrhythmias
- Normal urine output
- Vital Signs within normal limits
Nursing Intervention for Myocardial Infarction
- Maintain bed rest during the acute phase
- Assess and report any signs of decreased cardiac output, blood pressure
- Monitor urine output
- Assess and monitor vital signs every hour
- Assess and monitor ECG every day
- Give oxygen as needed
- Auscultation of respiratory and heart every hour as indicated
- Keep parenteral fluids and medications appropriate advice.
- Provide appropriate food diet.
- Avoid Valsalva maneuver, straining (use laxan).