Emergency Nursing Care Plan for Myocardial infarction

Myocardial infarction (MI) is a critical emergency that requires timely management to save heart muscle and limit the damage that may evolve over several hours. Blood flow is abruptly decreased or stopped through the coronary arteries and results in ischemia and necrosis to the myocardium if not treated. Many people die prior to receiving medical care due to the denial that anything may be wrong and postponement of seeking medical care. Cardiac dysrhythmias, mainly ventricular fibrillation, is usually the cause of death in these individuals. An MI is diagnosed based on the type of chest pain, electrocardiographic changes, and increase of cardiac enzymes, such as CK, SGOT, and LDH. Precordial pain is similar to but usually more intense and prolonged than anginal pain, and in the instance of MI, the chest pain is usually constant and not relieved with nitroglycerin or rest.
Atherosclerosis of the arteries is usually the most common finding in patients. Atherosclerosis and arteriosclerosis are used interchangeably when discussing the fatty plaques that adhere to the inner layer of the arteries. The continuous build-up of these plaques, as well as the potential for hemorrhage at the intimal layer, may result in alterations of the blood flow through the coronary arteries and abnormalities in platelet aggregation may contribute to changes in coronary perfusion. Infarction may occur without coronary artery disease or occlusion, and if the patient has developed an adequate collateral circulation, coronary occlusion may occur without infarction.
MI is usually a disease involving the left ventricle but the damage may extend to other areas, such as the atria or right ventricle. A right ventricular myocardial infarction usually has high right ventricular filling pressures and often has severe tricuspid regurgitation. Transmural infarcts involve the entire thickness of the myocardium and are characterized by Q waves on the electrocardiogram. Nontransmural infarcts are characterized by S-T segment and T wave changes. Subendocardial infarcts usually involve the inner portion of the myocardium where wall tension is highest and the blood flow is most vulnerable to circulatory problems. Occlusion of the right coronary artery will result in an inferior infarction that may also include posterior portions of the heart. Occlusion of the left main artery, known as “the widow maker,” usually results in death due to the extensive damage. Occlusion of the left anterior descending artery results in an anterior infarction and may include some inferior parts of the heart, and occlusion of the circumflex artery results in a lateral infarction.
Precipitating factors that preclude MI include heredity, age, gender, the presence of hypertension, the presence of diabetes mellitus, cigarette smoking, hyperlipidemia, obesity, sedentary lifestyles, and stress.
The main goals in treating myocardial infarction are to increase blood flow to the coronary arteries and thus decrease infarction size, increase oxygen supply and decrease oxygen demand to prevent myocardial death or injury, and control or correct dysrhythmias.

Oxygen: to increase available oxygen supply
Analgesics: morphine is the drug of choice, given in incremental doses IV every 5 minutes as needed; IM injections are avoided because they can raise the enzyme levels and do not act as quickly
Thrombolytic agents: Streptokinase, Urokinase, or Tissue Plasminogen Activator (tPa) given either intracoronary or intravenously to activate the body’s own fibrinolytic system to dissolve the clot and resume coronary blood perfusion
Cardiac glycosides: digitalis to increase force and strength of ventricular contractions and to decrease the conduction and rate of contractions in order to increase cardiac output; usually not used in the acute phase
Diuretics: furosemide (Lasix) to promote excess fluid removal, to decrease edema and pulmonary venous pressure by preventing sodium and water reabsorption
Vasodilators: hydralazine (Apresoline), nifedipine (Procardia, Adalat), nitroglycerin (Nitropaste, Nitrodur, Nitrostat, Tridil, Nitroglycerine), prazosin (Minipress), captopril (Capoten) used to relax venous and/or arterial smooth muscle to decrease preload, decrease afterload, and decrease oxygen demand
Beta-adrenergic blockers: used to decrease blood pressure, decrease elevated plasma renins, and with non-selective blockers, may do so without related reflex tachycardias; used to treat ventricular dysrhythmias and for the prophylaxis of angina
Aspirin: used to decrease platelet aggregation and helps with vasodilation of peripheral vessels
Thrombolytics: used in the treatment of acute MI; acts by activating mechanisms for conversion of plasminogen to plasmin which is able to dissolve the clot; commonly used are streptokinase, urokinase, alteplase, or anistreplase
Heparin: used with thrombolytic protocols, and in the treatment of MI; prevents conversion of fibrinogen to fibrin and prothrombin to thrombin by its action on antithrombin III
leukocyte count, sed rate, and blood glucose may be elevated; creatinine phosphokinase (CK, CPK) will normally increase within 4-6 hours, peak between 12-24 hours, and last 2-3 days but should not be used as sole indicator due to possibility of elevation with other problems such as surgery or trauma; lactate dehydrogenase (LDH) will normally increase within 8-12 hours, peak between 2-4 days, and last 10-14 days but should not be used as sole indicator due to possi- bility of elevation with other problems such as liver failure; serum glutamic oxaloacetic transami- nase (SGOT) is occasionally used as an infarct indicator; isoenzymes of CPK are very specific with CPK-MB most specific for MI, and levels will not rise with transient chest pain or in surgi- cal procedures; a definitive level for CPK-MB is greater than or equal to 4% of the total CDK; LDH isoenzymes, specifically LDHl is more spe- cific for MI; if the total LDH is elevated and LDHl is most predominant, MI is confirmed; both CPK-MB and LDHl will return to normal 72-96 hours after elevation
Chest x-ray:
shows any enlargement of the heart and pulmonary vein, the presence of pulmonary edema or pleural effusion
shows indicative changes associated with sites of acute infarcts using Q waves, S-T segment elevation, and T wave inversion. Also reveals changes in atrial and ventricular enlargement, rhythm and conduction abnormalities, ischemia, electrolyte abnormalities, drug toxicity, and presence of dysrhythmias
used to study structural abnormalities and blood flow through the heart; M-mode echocardiography measures structures with a single ultrasonic beam that provides a narrow view of the heart; two-dimensional (2D) echocardiography shows a two dimensional and wider look at the heart that is more useful in diagnosing right ventricular infarcts; documents increased right ventricular size, performance and segmental wall motion abnormalities, and blood flow through the heart
Nuclear cardiologic testing:
MUGA (multiple gated acquisition study) provides information that approximates ejection fractions and the analysis of the ventricular wall motion; 99mTc (Technetium-99 pyrophosphate scan) shows infarcted areas as increased levels of radioactivity, or “hot spots’’ that appear 12-36 hours after infarct and remain for 4- 7 days; PET (positron emission tomography) allows measurement of myocardial blood flow, fatty acid and glucose metabolism, and blood volume; thallium scans can determine size and location of damage as a “cold spot”

Magnetic resonance imaging (MRI):
provides a three dimensional view that can detect changes in tissues before structural damage is done and is safe for pregnant women and children Cardiac catheterization: used to assess pathophysiology of the patient‘s cardiovascular disorder, to provide left ventricular function information, to allow for measurement of heart pressures and cardiac output, to evaluate stenotic lesions, and to measure blood gas content

Intra-aortic balloon pump (IABP):
decreases the workload on the heart, decreases myocardial oxygen demand, increases coronary perfusion, decreases afterload, decreases preload, and helps to limit infarct size if quickly initiated, improves cardiac output and tissue perfusion; used in cardiogenic shock, for support post cardiac surgery, intractable chest pain, and in cardiac catheterizations or other cardiovascular procedures of high-risk patients

Ventricular assist device (VAD):
used on either or both ventricles to provide total support to the heart and circulation in order to allow recovery to the heart; usually indicated in patients who are awaiting cardiac transplantation or in those patients with cardiogenic shock and ventricular failure; may be used in conjunction with IABP

either temporary or permanent, used in anticipation of lethal dysrhythmias and/or conduction problems Surgery: coronary artery bypass grafting to reroute the coronary blood flow around the diseased vessel to enable coronary perfusion

Alteration in comfort
Related to: chest pain due to decreased blood flow to myocardium, myocardial ischemia or infarct, post procedure discomfort, chest wall pain post-surgery, pericarditis

Defining characteristics: chest pain with or without radiation, facial grimacing, clutching of hands or chest, restlessness, diaphoresis, changes in pulse and blood pressure, dyspnea, dizziness
Outcome Criteria
·        Chest pain will be relieved or controlled to patient’s satisfaction.
Evaluate chest pain as to type, location, severity, relief, change with activity or rest, other symptoms concurrenrly noted, such as pallor, diaphoresis, radiation of pain, nausea, vomiting, shortness of breath, and vital sign changes.

Variations may occur with patients regarding specific complaints and behavior. Most MI patients look acutely ill and can only focus on their pain. Respirations may be increased as a result of anxiety and pain. Heart rate may increase due to increased catecholamines, stress, and pain, which can also increase blood pressure.
Obtain the description of intensity using 0-10 scale, with 0 being no pain and 10 being the worst pain experienced.
Pain is a subjective experience and personal to that patient. Intensity scales are useful to gauge improvement or deterioration as perceived by the patient.
Obtain history (when possible) of previous cardiac pain and familial history of cardiac problems.

This provides information that may help to differentiate current pain from previous problems, as well as identify new problems and complications.
Administer oxygen by nasal cannula or mask as indicated.

Supplemental oxygen can increase the available oxygen and can relieve pain associated with myocardial ischemia.
Administer analgesic as ordered, such as morphine sulfate, meperidine (Demerol), or Dilaudid IV.

Morphine is the drug of choice to control MI pain, but other analgesics may be used to reduce pain and reduce the workload on the heart. IM injections should be avoided because they can alter cardiac enzymes and are not absorbed well in tissue that is non or underperfused.
Administer beta-blockers as ordered (such as atenolol, pindolol, and propranolol).

These drug block sympathetic stimulation, reduce heart rate and systolic blood pressure, and thus lowers the myocardial oxygen demand. Beta blockers should not be given in severely impaired contractility states due to the negative inotropic properties.
Administer calcium channel blockers as ordered (such as verapamil, diltiazem, or nifedipine).

These drugs can increase coronary blood flow and collateral circulation, reduce preload and myocardial oxygen demands, which can decrease pain due to ischemia.
Maintain bedrest during pain, with the position of comfort; nurse to stay with the patient during pain.
Reduces oxygen consumption, and demand; alleviates fear and provides caring atmosphere.
Maintain relaxing environment to promote calmness.
Reduces competing stimuli and reduces anxiety.

Information, Instruction, Demonstration
Instruct to notify nurse immediately of any chest pain.

Delay in notification can delay pain relief and may require increased amounts of medication in order to finally achieve relief. Pain can cause further damage to an already injured myocardium and may signal extension of MI, spasm, or other complication.
Instruct in relaxation techniques, deep breathing, guided imagery, visualization, etc.
Helps to decrease pain and anxiety and provides the distraction from pain.
Instruct in nitroglycerin SL administration after hospitalization; 1 q5 minutes up to 3 times, and if the pain is unrelieved, the patient should seek emergency medical care.
Knowledge facilitates cooperation and compliance with the medical regimen. Pain unrelieved with NTG may be indicative of MI.

Instruct in activity alterations and limitations.
Decreases myocardial oxygen demand and workload on the heart.
Instruct in medication effects, side effects, contraindications, and symptoms to report.
Promores knowledge and compliance with therapeutic regimen. Alleviates fear of unknown.

Discharge or Maintenance Evaluation
·        Patient will report pain being absent or controlled with medication administration.
·        Medication will be administered prior to pain becoming severe.
·        Patient will be able to recall effects, side effects, and contraindications of medications accurately.
·        Activity will be modified in such a way as to prevent the onset of chest pain.

Altered tissue perfusion: cardiopulmonary, cerebral, peripheral
Related to: tissue ischemia, reduction or interruption of blood flow, vasoconstriction, hypovolemia, shunting, depressed ventricular function, dysrhythmias, conduction defects
Defining characteristics: abnormal hemodynamic readings, dysrhythmias, decreased peripheral pulses, cyanosis, decreased blood pressure, shortness of breath, dyspnea, cold and clammy skin, decreased mental alertness, changes in mental status, oliguria, anuria, sluggish capillary refill, abnormal electrolyte and digoxin levels, hypoxia, ABG changes, chest pain, ventilation perfusion imbalances, changes in peripheral resistance, impaired oxygenation of myocardium, EKG changes (S-T segment, T wave, U wave), LV enlargement, palpitations
Outcome Criteria
·        Blood flow and perfusion to vital organs will be preserved and circulatory function will be maximized.
·        Patient will be free of dysrhythmias.
·        Hemodynamic parameters will be within normal limits.

Monitor vital signs. Obtain hemodynamic values, noting deviations from baseline values. for problems.
Provides information about the hemodynamics of the patient and facilitates early intervention for problems.
Monitor EKG for disturbances in conduction and for dysrhythmias and treat as indicated.

Decreased cardiac perfusion may instigate conduction abnormalities. Ventricular fibrillation is the most common dysrhythmia following MI. Reperfusion dysrhythmias may occur after the administration of thrombolytic therapy.
Administer oxygen by nasal cannula as ordered, with rate dependent on disease process and condition.
Provides oxygen necessary for tissues and organ perfusion.

Auscultate lungs for crackles (rales), rhonchi, or wheezes.
May indicate fluid overload that will further decrease tissue perfusion.
Auscultate heart sounds for S3 or S4 gallop, new murmurs, the presence of jugular vein distention, or hepatojugular reflex.
May indicate impending or present heart failure.
Monitor oxygen status with ABGs, Sv02 monitoring, or with pulse oximetry.

Provides information about the oxygenation status of the patient. Continuous monitoring of saturation levels provides an instant analysis of how activity affects oxygenation and perfusion for the patient.
Monitor for changes in respi- ratory status, increased work of breathing, dyspnea, etc.

Decreased cardiac perfusion may result in pump failure and precipitate respiratory distress and failure.
 Determine the presence and character of peripheral pulses, capillary refill time, skin color and temperature.
May indicate decreased perfusion resulting from impaired coronary blood flow.
Discourage any non-essential activity.

Ambulation, exercise, transfers, and Valsalva-type maneuvers can increase blood pressure and decrease tissue perfusion.
Assist patient with planned, graduated levels of activity.

Allows for balance between rest and activity to decrease myocardial workload and oxygen demand. Gradual increases help to increase patient tolerance to activity without pain.
Titrate vasoactive drugs as ordered.

Maintain blood pressure and heart rate at parameters set by MD for optimal perfusion with the minimal workload on the heart.
Administer thrombolytic drugs as ordered.

Drugs Iyse the clot that may be occluding the coronary artery and promote restoration of oxygen and blood flow to increase perfusion.
Auscultate for bowel sounds and monitor for complaints of nausea, vomiting, anorexia, abdominal distention, abdominal pain, or constipation.
Decreased perfusion to mesentery may result in loss or change in peristalsis, resulting in GI use of analgesics, and change in surroundings may contribute to changes in GI status.
Monitor urine output for adequate amounts, the character of urine, the presence of sediment, and specific gravity.

Decreased perfusion to renal arteries may result in oliguria. Dehydration secondary to nausea and vomiting may affect renal perfusion.
Monitor labwork such as renal or liver profiles.
May indicate organ dysfunction and decreased perfusion.

Information, Instruction, Demonstration

Instruct on medications, dosage, effects, side effects, and contraindications.
Promotes compliance with regimen and knowledge base.
Instruct to refrain from smoking.

Smoking causes vasoconstriction with can decrease perfusion.
Instruct in dietary requirements, menu planning, sodium restrictions, foods to avoid.
Reduction of high-cholesterol and sodium foods will help to control atherosclerosis, hyperlipidemia, fluid retention, and the effects on coronary blood flow.

Discharge or Maintenance Evaluation
·        Lung fields will be clear and free of adventitious breath sounds.
·        Extremities will be warm and pink, with easily palpable pulses.
·        Vital signs and hemodynamic parameters will be within normal limits for the patient.
·        Oxygenation will be optimal as evidenced by pulse oximetry greater than 90%, SvO2 greater than 75%, or normal ABGs.
·        Patient will be free of chest pain and shortness of breath. The patient will be able to verbalize information accurately regarding medications, diet and activity limitations.

Decreased cardiac output
Related to: damaged myocardium, decreased contractility, dysrhythmias, conduction defects, alteration in preload, alteration in afterload, vasoconstriction, myocardial ischemia, ventricular hypertrophy
Defining characteristics: elevated blood pressure, elevated mean arterial pressure greater than 120 mmHg, elevated systemic vascular resistance greater than 1400 dyne-seconds/cm5, cardiac output less than 4 L/min or cardiac index less than 2.7 L/min/m2, tachycardia, cold, pale extremities, absent or decreased peripheral pulses, EKG changes, hypotension, S3 or S4 gallops, decreased urinary output, diaphoresis, orthopnea, dyspnea, crackles (rales), jugular vein distention, edema, chest pain
Outcome Criteria
·        Vital signs and hemodynamic parameters will be
·        within normal limits for the patient, with no dysrhythmias, noted.

Auscultate apical pulses and monitor heart rate and rhythm. Monitor BP in both arms.

Decreased contractility will be compensated by tachycardia, especially concurrently with heart failure. Blood volume will be lowered if blood pressure is increased resulting in increased afterload. Pulse decreases may be noted in association with toxic levels of digoxin. Hypotension may occur as a result of ventricular dysfunction and poor perfusion of the myocardium.
Monitor EKG for dysrhythmias. and treat as indicated.

Conduction abnormalities may occur due to ischemic myocardium affecting the pumping efficiency of the heart.
Determine the level of cardiac function and existing cardiac and other conditions.
Additional disease states and complications may place an additional workload on an already compromised heart.
Measure CO and perform other hemodynamic calculations.
Provides direct measurement of cardiac output function, and calculated measurement of preload and afterload.
Monitor for development of new Sg or S4 gallops.

S3 gallops are usually associated with congestive heart failure but can be found with mitral regurgitation and left ventricular overload after MI. S4 gallops can be associated with myocardial ischemia, ventricular rigidity, pulmonary hypertension, or systemic hypertension, which can decrease cardiac output.
Auscultate for presence of murmurs and/or rubs.

Indicates disturbances of normal blood flow within the heart related to incompetent valves, sepia1 defects, or papillary muscle/chordae tendonae rupture post MI. Presence of a rub with an MI may be associated with pericarditis and/ or pericardial effusions.
Observe lower extremities for edema, distended neck veins, cold hands and feet, mottling, oliguria. Notify MD if urine output is < 30 cc/hr.
Reduced venous return to the heart can resulr in low cardiac output; oliguria results from decreased venous return due to fluid retention.
Position in semi-Fowler's position.

Promotes easier breathing by allowing for chest expansion and prevents pooling of blood in the pulmonary vasculature.
Administer cardiac glycosides, nitrates, vasodilators, diuretics, and Antihypertensives as ordered.

Used in the treatment of vasoconstriction and 10 reduce heart rate and contractility, reduces blood pressure by relaxation of venous and arterial smooth muscle which then in turn increases cardiac output and decreases the workload on the heart.
Titrate vasoactive drugs as ordered per MD parameters.
Maintains blood pressure and heart rate at levels to optimize cardiac output function.
Weigh every day.
Weight gain may indicate fluid retention and possible impending congestive failure.
Arrange activities so as to not overwhelm patient.

Avoids fatiguing patient and decreasing cardiac output further. Balancing rest with activity minimizes energy expenditure and myocardial oxygen demands by maintaining adequate cardiac output.
Avoid Valsalva type maneuvers with straining, coughing or moving.

Increasing intraabdominal pressure results in an abrupt decrease in cardiac output by preventing blood from being pumped into the thoracic cavity and thus, less blood being pumped into the heart which then decreases the heart rate. When the pressure is released, there is a sudden overload of blood which then increases preload and the workload on the heart.
Provide small, easy to digest, meals and restrict caffeine.

Large meals increase the work- load on the heart by diverting blood flow to that area. Caffeine directly stimulates the heart and increases heart rate.
Have emergency equipment and medications availabIe at all times.

Coronary occlusion, lethal dysrhythmias, infarction extensions or intractable pain may precipitate cardiac arrest that requires life support and resuscitation.

Information, Instruction, Demonstration

Instruct on medications, dose, effects, side effects, contraindications, and avoidance of over-the-counter drugs without MD approval.
Promotes knowledge and compliance with regimen.
Prevents any adverse drug interactions.

Instruct in activity limitations. Demonstrate exercises to be done.

Promotes compliance. Reduces potential for decrease in cardiac output by lessening the workload placed on the heart.
Instruct to report chest pain immediately.
May indicate complications of decreased cardiac output.
Instruct patient/family regarding placement of pulmonary artery catheter, and post procedure care.

Alleviates fear and promotes knowledge. Pulmonary artery catheter necessary for direct measurement of cardiac output and for obtaining values for other hemodynamic measurements.
Assist with insertion and maintenance of pacemaker when needed.
Cardiac pacing may be necessary during the acute phase of MI or may be necessary as a permanent measure if the MI severely damages the conduction system.

Discharge or Maintenance Evaluation
·        Patient will have no chest pain or shortness of breath.
·        Vital signs and hemodynamic parameters will be within normal limits for age and disease condition.
·        Minimal activity will be tolerated without fatigue or dyspnea.
·        Urinary output will be adequate. Cardiac output will be adequate to ensure adequate perfusion of all body systems.

Risk for fluid volume excess
Related to: increased sodium and water retention, decreased organ perfusion.
Defining characteristics: edema, weight gain, intake greater than output, increased blood pressure, increased heart rate, shortness of breath, dyspnea, orthopnea, crackles (rales), oliguria, jugular vein distention, pleural effusion, specific gravity changes, altered electrolyte levels
Outcome Criteria
Blood pressure will be maintained within normal limits and edema will be absent or minimal in all body parts.

Auscultate lungs for presence of crackles (rales).
May indicate pulmonary edema from cardiac decompensation.
Observe for jugular vein distention and dependent edema.
May indicate impending congestive failure and fluid excess.
Determine fluid balance by measuring intake and output, and observing for decreases in output and concentrated urine.
Renal perfusion is impaired with decreased cardiac output, which leads to sodium and water retention and oliguria.
Weigh daily and notify MD of greater than 2 Lb/day increase.
Abrupt changes in weight usually indicate excess fluid.
Provide patient with fluid intake of 2 L/day, unless fluid restricrion is warranted.
Fluids provide hydration of tissues. Fluids may need to be restricted due to cardiac decompensation.
Administer diuretics as ordered (furosemide, hydralazine, spirolactone, hydrochlorothiazide).
Drugs may be necessary to correct fluid overload depending on emergent nature of problem.
Monitor electrolyte for imbalances.
Hypokalemia can occur with the administration of diuretics.

Instruction, Information, Demonstration
Instruct patient regarding dietary restrictions of sodium.
Fluid retention is increased with intake of sodium.
Instruct patient to observe for weight changes and report these to MD
Weight gain may be first overt sign of fluid excess and should be monitored to prevent complications.
Instruct patient in medications prescribed after discharge, with dose, effect, side effects, contraindications.
Promotes knowledge and compliance with treatment regimen.

Discharge or Maintenance Evaluation
·        Patient will have no edema or fluid excess.
·        Fluid balance will be maintained and blood pressure will be within normal limits of baseline.
·        Lung fields will be clear, without adventitious breath sounds, and weight will be stable.
·        Patient will be able to verbalize understanding of dietary restrictions and medications.

Related to: change in health status, fear of death, threat to body image, threat to role functioning, pain
Defining characteristics: restlessness, insomnia, anorexia, increased respirations, increased heart rate, increased blood pressure, difficulty concentrating, dry mouth, poor eye contact, decreased energy, irritability, crying, feelings of helplessness
Outcome Criteria
Patient will be able to use coping mechanisms effectively, will appear less anxious, and be able to verbalize feelings.

Identify patient’s perception of illness or situation. En- courage expressions of anger, grief, sadness, fear, and loss.

Patient may be afraid of dying and be anxious about his immediate problem as related to his lifestyle and the problems that have been left unattended.
Explain all procedures to patient in concise and reassuring manner. Repeat informations needed based on patient’s ability to comprehend.
Knowledge reduces fear of the unknown. Establishes feelings of trust and concern. Informa-tion may need to be repeated or reintbrced due to competing stimuli.
Encourage the patient to discuss his fears and feelings. Provide an atmosphere of acceptance without judgment. Accept his use of denial, but do not reinforce false beliefs. Avoid confrontations and upsets.

Assists the patient in verbalizing concerns and provides the opportunity to deal with matters of import to the patient.
Accepting the patient’s feelings may decrease his anxiety which can facilitate a therapeutic environment for instruction.
Denial can be useful to decrease anxiety but can postpone dealing with the reality of the problem. Confrontations can lead to anger and exacerbate the use of denial and decrease cooperation.
Provide opportunities for the family to visit and assist with care if possible. Orient to routines.

Familiar people can decrease anxiety of the patient, as well as provide a more conducive atmosphere for learning and recovery. Predictability can decrease anxiety. Supportive family members can comfort the patient and relieve worries.
Provide private time for patient and family member(s) to verbalize feelings.

Allows time for expression of concerns and feelings, and relieves tension by establishing a more normal routine.
Provide opportunities for patient to control his environment and activities as much as feasible based on condition.
Allows the patient to have some control over his situation and facilitates compliance with care of which patient is not in control.
Provide opportunity for patient to rest withour interruption as much as possible.
Facilitates coping mechanism by conserving energy, and by providing required rest.
Administer antianxiety drugs as ordered (diazepam, flurazepam, lorazepam).
Promotes rest and reduces anxiety.

Information, Instruction, Demonstration

Instruct patient and family as to all procedures, tests, medications, and care in a factual consistent manner. Reinforce as needed.

Accurate information reduces anxiety, facilitates the relationship between patient and nurse, and allows the patienr and family to deal with the problem in a realistic manner. Repetition, when needed, helps in the retention of information when the attention span is diminished.
Instruct patient in relaxation techniques. Provide for diversionary activities.
Reduces anxiety and stress.
Instruct about post-discharge care, activities, limitations, symptoms to report, problems that might be encountered, and goals.
Reduces anxiety and promores increased independence and self confidence; decreases fear of abandonment that can occur with discharge from hospital; assists patient and family to identify realistic goals and decreases the chances of discouragement with limitations during recuperation.

Discharge or Maintenance Evaluation
·        Patient is able to recognize feelings and identify mechanisms to cope and identify causes.
·        Patient has significant reduction in fear and anxiety and appears less tense, with normal vital signs.
·        Patiendfamily can appropriately utilize problem-solving skills.
·        Patient can verbalize concerns easily and has increased energy.
·        Patient can make appropriate decisions based on factual information regarding his condition and is able to discuss future plans.

Knowledge deficit
Related to: lack of understanding, lack of understanding of medical condition, lack of recall
Defining characteristics: verbalized questions regarding problems, inadequate followup on instructions given, misconceptions, lack of improvement of previous regimen, development of preventable complications
Outcome Criteria
Patient will be able to verbalize and demonstrate understanding of information given regarding condition, medications, and treatment regimen.
Information, Instruction, Demonstration
Determine patient’s baseline of knowledge regarding disease process, normal physiology, and function of the heart.
Provides information regarding patients understanding of condition as well as a baseline from which to base teaching.
Monitor patient’s readiness to learn and determine best methods to use for teaching. Attempt to incorporate family members in learning process. Reinstructure inforce information as needed.

Promotes optimal learning en- vironment when patient shows willingness to learn. Family members may assist with helping the patient to make in- formed choices regarding his treatment. Anxiety or latge volumes of instruction may impede comprehension and limit learning.
Provide time for individual interaction with patient.
Promotes relationship between patient and nurse, and establishes trust.
Instruct patient on procedures that may be performed.
Provides knowledge and pro- motes the ability to make informed choices.
Instruct patient on medications, dose, effects, side effects, contraindications, and signs/ symptoms to report to MD.
Provides information to the patient to manage medication regimen and ensure compliance.
Instruct in dietary needs and restrictions, such as limiting caffeine and sodium or in- creasing potassium, etc.

Patient may need to increase dietary potassium if placed on diuretics; caffeine should be limited due to the direct stimulant effect on the heart; sodium should be limited due to the potential for fluid retention.
Provide printed materials when possible for patientlfamily to review.

Provides references for patient and family to refer to once discharged, and can enhance the understanding of verbally given instructions.
Demonstrate and instruct on technique for checking pulse rate and regularity Instruct in situations where immediate action must be taken.   

Self monitoring promotes self independence and can provide timely intervention for abnormalities or complications. Heart rates that exceed set parameters may require furrher medial alteration in medications or regimen.
Have patient demonstrate all skills that will be necessary for post-discharge.

Provides information that patient has gained a full understanding of instruction and is able to demonstrate correct information.
Instruct/demonstrate exercises to be performed, avoiding over taxing activities, signs/ symptoms that may require the cessation of any activity, and to report symptoms that may require medical attention.
 Exercise programs are helpful in improving cardiac function.

Discharge or Maintenance Evaluation
·        Patient will be able to verbalize understanding of condition, treatment regimen, and signs/symptoms to report.
·        Patient will be able to correctly perform all tasks prior to discharge.
·        Patient will be able to verbalize understanding of cardiac disease, risk factors, dietary restrictions, and lifestyle adaptations.

·        Congestive heart failure
·        Dysrhythmias Conduction problems
·        Cardiogenic shock
·        Systemic embolus
·        Pulmonary embolus
·        Papillary muscle rupture D
·        ressler’s syndrome
·        Ventricular rupture
·        Ventricular septal defects

STEMI pathway