Wednesday, November 2, 2011

Nursing Care Plan - Assessment, Diagnosis and Interventions for Acute Myocardial Infarction

Acute Myocardial Infarction (AMI)

Acute Myocardial Infarction (AMI) is a sudden loss of blood supply to an area of the heart, causing permanent heart damage or death. There are different types of AMI, classified by the location of the actual event in the heart (e.g., inferior wall vs. anterior wall) or the type of changes seen on an electrocardiogram (ST elevation or non-ST elevation).

Every year, several million people in North America are diagnosed with an AMI, and approximately one-third of these patients die during the acute phase. Health Canada has identified cardiovascular disease or heart diseases as the number one killer in Canada. It is also the most costly disease in Canada, putting the greatest burden on our national healthcare system.

Clinical Manifestations of Myocardial Infarction

Clinical Manifestations of Myocardial Infarction

Pain
  1. Chest pain that occurs suddenly and constantly not subside, usually above the sternal region and upper abdomen, this is the main symptom.
  2. The severity of pain can increase settled until unbearable pain.
  3. Pain is very ill, such as punctured-pin that can spread to the shoulder and continued down to the arm (usually the left arm).
  4. The pain started spontaneously (not occur after activity or emotional disturbance), persist for several hours or days, and do not disappear with the help of rest or nitroglycerin (NTG).
  5. Pain may spread to the jaw and neck.
  6. Pain is often accompanied by shortness of breath, pale, cold, severe diaphoresis, dizziness or head was floating, and nausea and vomiting.
  7. Patients with diabetes mellitus will not experience severe pain because of neuropathy that accompany diabetes can interfere neuroreseptor (collect the experience of pain).

Laboratory examination Examination of cardiac enzymes :
  1. CPK-MB/CPK
    Isoenzymes found in heart muscle increased by between 4-6 hours, peaks in 12-24 hours, returned to normal within 36-48 hours.
  2. LDH / HBDH
    Increases in the 12-24 hour time-consuming dams to return to normal
  3. AST
    Increases (less real / special) occurred within 6-12 hours, culminating in 24 hours, returning to normal within 3 or 4 days


ECG ECG changes that occur in the early phase of T wave height and symmetrical. After this there is ST segment elevation. Changes that occur later are the presence of a wave of Q / QS which indicate the presence of necrosis.


Pain scores according to White:

  1. = Do not experience pain
  2. = Pain on one side without disturbing activities
  3. = More pain at one place and resulted in disruption of activities, such as difficulty getting out of bed, hard to bend the head and others.


Primary Assessment for Acute Myocardial Infarction Nursing Care Plan (AMI) :

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 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

Nursing Diagnosis for Acute Myocardial Infarction (AMI)

  1. Acute Pain
  2. Decreased Cardiac Output
  3. Activity Intolerance
  4. Imbalanced Nutrition: Less than Body Requirements
  5. Ineffective Tissue Perfusion
  6. Anxiety
  7. Ineffective Coping
  8. Ineffective Sexuality Patterns

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