VI. Nursing Diagnosis
• Decreased myocardial perfusion related to reduced coronary artery blood flow due to coronary thrombus and atherosclerotic plaque.
• Potential impaired gas exchange related to fluid overload due to left ventricular dysfunction
• Risk for ineffective peripheral tissue perfusion related to decreased cardiac output due to left ventricular function
• Anxiety related to fear of death
• Deficient knowledge about post-MI self-care
VII. Nursing Management
• Establish a patent IV line
• Provide pain relief; morphine sulfate IV (given IV because after an infarction there is poor peripheral perfusion and because serum enzymes would be affected by IM injections) as ordered.
• Administer oxygen as ordered to relieve dyspnea and prevent arrhythmias
• Provide bed rest with semi-Fowler’s position to decrease cardiac workload
• Monitor ECG and hemodynamic procedures
• Administer arrhythmias as ordered
• Perform complete lung/cardiovascular assessment
• Monitor urinary output and report output of less than 30 ml/hr; indicates decreased cardiac output
• Maintain full liquid diet with gradual increase to soft; low sodium
• Maintain quiet environment
• Administer stool softeners as ordered to facilitate bowel evacuation and prevent straining
• Relieve anxiety associated with coronary care unit (CCU) environment
• Administer coagulants, as ordered
• Administer thrombolytics (tissue-type plasminogen activator or t-pa and streptokinase) and monitor for side effects; bleeding
• Provide client teaching and discharge planning concerning
o Effects of MI, healing process and treatment regimen
o Medication regimen including name, purpose, schedule, dosage, side effects
o Risk factors, with necessary lifestyle modifications
o Dietary restrictions: low sodium, low cholesterol, avoidance of caffeine
o Importance of participation in a progressive activity program
o Resumption of sexual activity according to physician’s orders (usually 4-6 weeks)
o Need to report the following symptoms increased persistent chest pain, dyspnea, weakness, fatigue, persistent palpitations, light-headedness
o Enrollment of client in a cardiac rehabilitation program