A myocardial infarction, or heart attack, happens when a blocked coronary artery cuts off blood to part of the heart muscle and the muscle starts to die. Time is muscle, so fast treatment matters. Your priorities are relieving pain, restoring blood flow, and watching for dysrhythmias and heart failure.
A · AssessmentD · DiagnosisP · PlanningI · InterventionE · Evaluation
Each care plan below follows the nursing process (ADPIE).
CARE PLAN 1 · NURSING DIAGNOSIS
PLANNING · EXPECTED OUTCOMES
ASSESSMENT
Acute Pain
Related to
- Death of heart muscle from blocked blood flow
As evidenced by
- Crushing chest pain that may spread to the arm, jaw, or back
- Pain not relieved by rest
- Diaphoresis, nausea, and anxiety
Short-term goals
- Client reports pain decreasing within 30 minutes of treatment
Long-term goals
- Client is free of chest pain after blood flow is restored
- Pain using PQRST
- 12-lead ECG for ST changes
- Troponin as ordered
- Vital signs and SpO2
| INTERVENTION | RATIONALE |
|---|---|
| Give aspirin as ordered | Aspirin blocks platelets and limits clot growth. |
| Give nitroglycerin as ordered, checking BP first | It improves blood flow but can lower BP. |
| Give morphine as ordered for pain not relieved by nitroglycerin | It eases pain and lowers the heart's workload. |
| Prepare the client for PCI or thrombolytics as ordered | Opening the artery quickly saves heart muscle. |
EVALUATION
- Client reports pain relief
- ST changes improve on the ECG
- Client is prepared for procedures on time
CARE PLAN 2 · NURSING DIAGNOSIS
PLANNING · EXPECTED OUTCOMES
ASSESSMENT
Decreased Cardiac Output
Related to
- Damaged heart muscle
- Dysrhythmias
As evidenced by
- Tachycardia or bradycardia
- Low BP
- Crackles and shortness of breath
- Low urine output
Short-term goals
- Client maintains a stable rhythm and BP within the ordered range
Long-term goals
- Client follows cardiac medications and rehab to protect heart function
- Continuous cardiac monitoring
- Lung sounds and signs of heart failure
- Urine output
- Peripheral pulses and skin perfusion
| INTERVENTION | RATIONALE |
|---|---|
| Monitor and report dysrhythmias right away | Dysrhythmias are a common cause of death after an MI. |
| Give beta blockers, ACE inhibitors, and statins as ordered | These protect the heart and reduce the chance of another MI. |
| Maintain rest and increase activity slowly as ordered | Rest lowers oxygen demand while the heart heals. |
| Teach signs of heart failure to report | Weakened muscle may lead to heart failure later. |
EVALUATION
- Rhythm and BP stay stable
- Lungs stay clear
- Client names heart medications and their purpose
Practice this in Rhythm Summit
Spot ST elevation and dangerous rhythms after a heart attack.
Play Rhythm SummitQuick answers
Which lab confirms damage to the heart muscle?
Troponin. It rises within hours of an MI and stays elevated for days.
What is the most common complication in the first hours after an MI?
Dysrhythmias, so the client needs continuous cardiac monitoring.
For learning only. Individualize every care plan to your client, and follow your program, current guidelines, provider orders, and facility policy.