MI-Nursing Diagnosis and Interventions: Acute Chest Pain

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Assess for characteristics of AMI pain:
a.) Client may experience crushing substernal pain
b.) Pain may radiate to the jaw, back, and left arm
c.) Pain may occur without cause, primarily early in the morning
d.) Pain is unrelieved by rest or nitroglycerin and is relieved only by narcotics
e.) Pain last 30 minutes or longer

Rationale: Assist identification of AMI to provide early treatment

Note time since onset of first episode of chest pain; if less than 6 hours, patient may be a candidate for thrombolytic therapy

Rationale: Provide timely intervention

Assess prior treatments of pain; patient may have taken sublingual nitroglycerin and a single dose of aspirin before arriving to hospital

Rationale: Assess response to prior treatment; assess needs for aspirin as part of treatment protocol

Monitor VS: HR, BP during pain episodes and during medication administration

Rationale: Assess nonverbal indicators of pain and response to treatment

Assess baseline ECG for signs of MI: T- and ST changes and development of Q waves

Rationale:Identify ischemia, injury, evolving MI

Monitor serial cardiac markers

Rationale:Assist in diagnosis and confirmation of MI

Continually reassess chest pain and response to medication; ongoing chest pain signifies prolonged myocardial ischemia and warrants immediate intervention

Rationale:Assess response to treatment ; ensure that pain is controlled

Asssess for contraindications to thrombolytic agents; absolute contraindications include active internal bleeding, bleeding diathesis, or history of hemmorhagic stroke or intracranial hemorrhage

Rationale: Ensure that the medication is administered safely when warranted. Prevent complications associated with the medication

Maintain bed rest during periods of pain

Rationale: Reduce oxygen demand of the heart

Administer oxygen therapy at 4-6 L/min; maintain oxygen saturation above 90%

Rationale: Ensure adequate oxygenation to the myocardium to prevent further damage

Initiate IV nitrates according to protocol

Rationale: Nitrates are both coronary dilators and peripheral vasodilators causing hypotension

Administer morphine sulfate according to unit protocol

Rationale: Reduce workload on the heart through venodilation and relieve chest pain

Administer IV Beta-Blockers according to unit protocol

Rationale: to slow the heart rate and increase myocardial perfusion while reducing the force of myocardial contraction

Administer oral aspirin

Rationale:Decrease platelet aggregation to improve to improve mortality

Administer angiotensin-converting enzyme inhibitors

Rationale: Reduce progression to heart failure and death in patients with large transmural MIs with LV dysfunction and in diabetic patients having an MI

Administer thromolytic agents within the first 6 hours of coronary event according to unit protocol

Rationale: Restore perfusion

Assess for signs of bleeding

Rationale:Assess for complications of thrombolytic therapy so that treatment can be initiated as needed

Assess for intracranial bleeding by frequent monitoring of neurological status

Rationale: Assess for complications of intracranial bleeding associated with thrombolytic therapy

Administer IV Heparin according to unit protocol, adjust aPTT dose to 1.5 to 2 times normal

Rationale: Maintain vessel patency after thrombolysis

Prepare for possible (1) cardiac catheterization (2) percutaneous transluminal coronary angioplasty (PTCA) or (3) coronary bypass graft surgery if signs of reperfusion are not evident and infarction evolves

Rationale: Facilitate rapid intervention to restore coronary artery perfusion

Monitor the BP closely after administration of medications. If the BP is lower than 100 mm Hg systolic or 25 mm HG lower than the previius reading, lower the head of the bed and notify the physician

Rationale: Early intervention to prevent hypotension associated with medications to lower BP

MI Nursing Diagnosis

Acute Chest Pain

Patient Outcomes for Acute Chest Pain

(1) Verbalize relief of pain
(2) Appears comfortable

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