Myocardial Infarction (MI)

page 1 Admission to
Algorithms of care Emergency Room

NURSING ASSESSMENT
MEDICAL HISTORY

ASSESSMENT 1: HISTORY 1:
Ask for Chief Complaint: Confirm for previous history
The primary reason for seeking emergency health of disease that may result to
service is CHEST PAIN, with similar presentations or further aggravate MI:
(Coronary Atherosclerosis,

ASSESSMENT 2:
Observe for LEVINE’S SIGN or hand/s clutching HISTORY 2:
the chest (Universal Sign of Angina Pectoris & MI) to Obtain information about
support assessment of chest pain. risk factors present in the
patient:
NONMODIFIABLE: Age 40 &
ASSESSMENT 3: above, Female (smaller
Assess pain for LCD (Location, Character & coronary arteries), Family
Duration) to further classify pain as MI or Angina History of CADs)
Pectoris only. (Qualities of pain that suggest MI MODIFIABLE: hyperlipidemia,
obesity, hyperglycemia,
sedentary lifestyle,
LOCATION CHARACTER DURATION
 Across the  Severe,  >15
chest crushing, DIAGNOSTICS
mins:
 May squeezing, suspect for
radiate to prolonged MI
one or  unrelieved by DIAGNOSTICS 1:
both REST  >30
Obtain ECG within 10
mins: high
minutes upon admission to
identify, location, evolution
& resolution of MI. Classic
ASSESSMENT 4: ECG changes are: T-WAVE
Assess for other parameters indicating INVERSION, ST-SEGMENT
severity of pain including FACIAL GRIMACE and ELEVATION, and appearance
PAIN SCALE.

DIAGNOSTICS 2:
ASSESSMENT 5: Obtain blood samples for
Assess for LEVEL of ANXIETY which may tests of CARDIAC
further stimulate sympathetic response. Patient BIOMARKERS:
may manifest “FEELING of DOOM” and CK-MB (Creatine Kinase –
Myocardium Band)
Myoglobin
ASSESSMENT 6: Troponin I or T
Assess for S/Sx of STIMULATED NERVOUS These enzymes, which are
RESPONSE to disease or stress. (Tachycardia; released secondary to
Tachypnea; Cool, pale, moist skin) myocardial damage, helps in

ASSESSMENT 7:
Assess for S/Sx of PULMONARY CONGESTION DIAGNOSTICS 3:
that result from pooling of fluid in the lungs Obtain other diagnostics
secondary to weakening of left ventricle. Patient such as Echocardiogram to
may manifest dyspnea, feeling of suffocation, clarify diagnosis of MI and
crackles, or gurgling or bubbling respiration. detect hypokinetic and
 NSG DIAGNOSIS OTHER NSG NSG DIAGNOSIS NSG DIAGNOSIS MEDICAL
PRIORITY 3 DIAGNOSIS PRIORITY 2 PRIORITY 1 THERAPY
Myocardial infarction (MI)
page 2
Algorithms of care

NURSING DIAGNOSIS DRUG THERAPY

Confirmation of MI NURSING NURSING DRUG 1: ANALGESICS

through NURSING ASSESSMENT 1- ASSESSMENT 5 Relief of pain is a priority
ASSESSMENT, 4 through analgesics.
MEDICAL HISTORY MORPHINE SULPHATE is the
drug of choice for it reduces
pain, anxiety, preoload and
afterload of the heart
decreasing heart workload

PRIORITY 1: PRIORITY 2: PRIORITY 3: DRUG 2: THROMBOLYTICS

INEFFECTIVE ACUTE PAIN ANXIETY r/t STREPTOKINASE,
MYOCARDIAL r/t irritation of knowledge of UROKINASE, TISSUE
TISSUE PERFUSION myocardial the severity of PLASMINOGEN ACTIVATOR
r/t obstruction of nerve endings present illness to dissolve clots by
coronary blood flow by lactic acid and condition activating fibrinolytic
from coronary secondary to process resulting to
thrombus & myocardial improved coronary blood

Planning 1 Planning 2 Planning 3 DRUG 3: BETA-BLOCKERS

AND ACE INHIBITORS

PLANNING
DIET THERAPY
Planning 1 Planning 2 Planning 3
Within 8 hours Within 6 hours Within 3 hours
LOW CALORIE, LOW
of nursing of nursing of nursing
CHOLESTEROL, LOW—
intervention, the intervention, intervention, the
SODIUM DIET to minimize
patient shall the patient shall patient shall
severity of
attain an manifest manifest
improved increased level decreased level of
myocardial tissue of comfort as anxiety as
perfusion as evidenced by evidenced by the SURGICAL MANAGEMENT
evidenced by the the following: following:
following Decreased  Verbalizati PERCUTANEOUS
Pulse rate: 60- pain scale on of improved TRANSLUMINAL CORONARY
100bpm (-) Facial anxiety levels ANGIOPLASTY (PCTA): an
Decreased level grimace and better invasive interventional
procedure wherein a balloon-
tipped catheter is used to open
blocked coronary vessels and

Nursing Interventions
Myocardial infarction (MI)
page 3
Algorithms of care

NURSING INTERVENTIONS

INTERVENTION 1
Place patient on a comfortable, SEMI-FOWER’S
POSITION and maintain on COMPLETE BED REST to
allow greater lung expansion for improved gas
exchange and to decrease oxygen demand by heart

INTERVENTION 2
Administer OXYGEN THERAPY per NASAL CANNULA
as ordered to provide greater oxygen supply to the
myocardium. (Addresses PLANNING 1, 2 & 3)

INTERVENTION 3
Start an IV line as prescribed to provide route for
drug therapy.

INTERVENTION 4
Administer MORPHINE SULPHATE as ordered to
relieve severe pain. Decreased level of pain helps
lessen anxiety thus, minimizing further stimulation of
sympathetic nervous response. (Addresses PLANNING

INTERVENTION 5
Administer NITROGLYCERIN, THROMBOLYTICS, and
ASPIRIN as ordered (Addresses PLANNING 1, 2 & 3).
Assess for bleeding, and changes in neurologic status

INTERVENTION 6
Hook into CARDIAC MONITOR as prescribed to allow
monitoring of the evolution and resolution of MI
(Addresses PLANNING 1)

INTERVENTION 7
Provide a calm and quiet environment to the
patient. Develop a trusting and caring relationship.
Provide information to the patient and family in an
honest and supportive manner. Encourage diversional
activities. (Addresses PLANNING 2 & 3)

INTERVENTION 8
Monitor for complication such as shock,
dysrhythmias, pulmonary congestion and congestive
heart failure.