MYOCARDIAL INFFARCTION Nursing Interventions for Heart Failure Nursing Diagnosis: Decrease Cardiac Output related to Myocardial Infarction

Goals / Criteria results: NOC: After nursing intervention on the client: Clients can have a heart pump effectively, Status of the circulation, tissue perfusion and vital signs were normal status.

Expected outcomes: Shows adequate cardiac output indicated by blood pressure, pulse, normal rhythm, strong peripheral pulses, without dyspnea activity and pain. Free from side effects of medications used Cardiac Care: acute Evaluation of chest pain Auscultation of heart sounds Evaluation of the crackles Monitor the status of neurology Monitor intake / output, urine output Create an environment that is conducive to rest

Circulatory Care: Evaluation arteries and peripheral edema Monitor skin and extremities Monitor vital signs Move the client's position every 2 hours if needed Teach ROM during bed rest Monitor compliance with liquids

Rational: The emergence of signs of heart failure, showed a decrease in cardiac output The presence of pain suggests inadequate blood supply to the heart Still a gallop rhythm, crackles, tachycardia indicate heart failure Role in CNS disorders may be associated with decreased cardiac output Spending urine less than 30 ml / hour showed a decrease in cardiac output

Ineffective Breathing Pattern, Ineffective Airway Clearance, Impaired Gas Exchange related to respiratory muscle weakness or paralysis, decreased cough reflex, immobilization. Ineffective Breathing Pattern Definition : The exchange of air inspiration and / or expiration inadequate. Ineffective Airway Clearance Definition: Inability to clear secretions or obstructions from the respiratory tract to maintain airway patency.

Impaired Gas Exchange Definition : Circumstances where an individual has decreased course of gas (O2 and CO2) that an actual or risk of lung alveoli and the vascular system. Expected outcomes: Optimal breathing. Normal breath sounds. Patent airway. Blood gas analysis values within normal limits. Intervention: 1. Monitor the number of respiratory rhythm and depth every 1-4 hours. R /: Paralysis of breathing can occur 48 hours. 2. Auscultation of breath sounds every every 4 hours. R /: breath sounds indicate inadequate ventilation. 3. Maintain effective airway, suction and clean the mouth. R /: a patent airway. 4. Help the patient to cough effectively. R /: Increase effective airway. 5. Perform chest physiotherapy. R /: Preventing pneumonia and atelectasis. 6. Collaboration in the provision of oxygenation. R /: Fulfilling the need of oxygen. 7. Monitor blood gas analysis. R /: Knowing the changes in oxygen in the blood. 8. Assess the level of consciousness and skin tone. R /: Changes in blood gas analysis will affect the level of consciousness and skin tone. 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. 2. 3. 4. 5.

Shortness of breath with mild activity or rest Respiration more than 24 x / min, irregular rhythm shallow Ronchi, crackles The expansion of the chest is not full Use of auxiliary respiratory muscles

Circulation

1. 2. 3. 4. 5. 6. 7. 8.

Weak pulse, irregular Tachycardia Blood pressure increase / decrease Edema Nervous Acral cold Pale skin, cyanosis Decreased urine output

Secondary Assessment Acute Myocardial Infarction (AMI) :

1. Activities o Symptoms: Weakness Fatigue Cannot sleep Settled lifestyle No regular exercise schedule o Signs: Tachycardia Dyspnea at rest or activity 2. Circulation o Symptoms: History of Acute Myocardial Infarction (AMI) Coronary artery disease Blood pressure problems Diabetes mellitus. o 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

3. Ego integrity o 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 o Signs: turned, denial, anxiety, lack of eye contact, anxiety, anger, aggression, coma pain 4. Elimination o Signs: normal, decreased bowel sounds. 5. Food or fluid o Symptoms: nausea, anorexia, belching, heartburn, or burning o Signs: decreased skin turgor, dry skin, sweating, vomiting, weight changes 6. Hygiene o Symptoms or signs: difficulty perform maintenance tasks 7. Neuro Sensory o Symptoms: dizziness, throbbing during sleep or while awake (sitting or resting) o Signs: mental changes, weakness 8. Pain or discomfort o 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: o Symptoms: Dyspnea with or without job Nocturnal dyspnea Cough with or without sputum production History of smoking, chronic respiratory disease. o Signs: Increased respiratory rate Shortness of breath / strong Pallor, cyanosis Breath sounds (clean, crackles, wheezing), sputum 10. Social interactions o Symptoms: Stress Difficulty coping with the stressors that exist eg illness, treatment in hospital o Signs: Difficulty rest - sleep Response too emotional (angry constantly, fear) Withdraw

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

Nursing Diagnosis for Acute Myocardial Infarction (AMI)

1. 2. 3. 4. 5. 6. 7. 8.

Acute Pain Decreased Cardiac Output related Activity Intolerance Imbalanced Nutrition: Less than Body Requirements Ineffective Tissue Perfusion Anxiety Ineffective Coping Ineffective Sexuality Patterns