Introduction
A myocardial infarction or a heart attack occurs when the flow of blood to the heart is blocked. The blockage is most often a buildup of fat, cholesterol, and other substances, which form a plaque in the arteries that feed the heart (coronary arteries).
Sometimes, a plaque can rupture and form a clot that blocks blood flow. The interrupted blood flow can damage or destroy part of the heart muscle.
A heart attack, also called a myocardial infarction, can be fatal, but treatment has improved dramatically over the years. It’s crucial to call 911 or emergency medical help if you think you might be having a heart attack.
This blog post discusses what myocardial infarction or heart attack is, its symptoms, nursing care plans and interventions with some examples .As you follow along, remember that our qualified writers are always ready to help in any of your nursing assignments. All you need to do is place an order with us!
Disclaimer: The information presented in this article is not medical advice; it is meant to act as a quick guide to nursing students for learning purposes only and should not be applied without an approved physician’s consent. Please consult a registered doctor in case you’re looking for medical advice.
Signs and Symptoms of Myocardial Infarction
The signs and symptoms of myocardial infarction may vary from person to person.
Others may not have any symptoms at all, while some may have warning signs before the attack occurs.
The following are the signs and symptoms which may be noted in a person having a myocardial infarction:
- Chest pain – this is the most common symptom associated with MI. The chest pain is often described as similar to the feeling of being squeezed or pressed by a heavy object on the chest. The pain may radiate to the jaw, neck, back, and arms.
- Shortness of breath
- Feeling weak, lightheaded, or both
- An overwhelming feeling of anxiety
In some cases, chest pain may not always be severe, particularly in women. It may even be mistaken for indigestion.
However, it should be noted that the severity of chest pain is not definitive and conclusive of myocardial infarction.
The chest pain should be assessed in a combination of the other symptoms to determine a heart attack.
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Causes of Myocardial Infarction
The vast majority of heart attacks occur because of a blockage in one of the blood vessels that supply your heart. This most often happens because of plaque, a sticky substance that can build up on the insides of your arteries (similar to how pouring grease down your kitchen sink can clog your home plumbing). That buildup is called atherosclerosis.
Sometimes, plaque deposits inside the coronary (heart) arteries can break open or rupture, and a blood clot can get stuck where the rupture happens. If the clot blocks the artery, this can deprive the heart muscle of blood and cause a heart attack.
Heart attacks are possible without a blockage, but this is rare and only accounts for about 5% of all heart attacks. This kind of heart attack can occur for the following reasons:
Spasm of the artery: Your blood vessels have a muscle lining that allows them to become wider or narrower as needed. Those muscles can sometimes twitch or spasm, cutting off blood flow to the heart muscle.
Rare medical conditions: An example of this would be any disease that causes unusual narrowing of blood vessels.
Trauma: This includes tears or ruptures in the coronary arteries.
Obstruction that came from elsewhere in the body: A blood clot or air bubble (embolism) that gets trapped in a coronary artery.
Electrolyte imbalances: Having too much or too little of key minerals like potassium in your blood can cause a heart attack.
Eating disorders: Over time, an eating disorder can cause damage to your heart and ultimately result in a heart attack.
Risk factors for Myocardial Infarction
Certain factors contribute to the unwanted buildup of fatty deposits (atherosclerosis) that narrow arteries throughout your body. You can improve or eliminate many of these risk factors to reduce your chances of having a first or another heart attack.
Heart attack risk factors include:
- Age. Menage 45 or older and women age 55 or older are more likely to have a heart attack than are younger men and women.
- Tobacco. This includes smoking and long-term exposure to secondhand smoke.
- High blood pressure. Over time, high blood pressure can damage arteries that lead to your heart. High blood pressure that occurs with other conditions, such as obesity, high cholesterol, or diabetes, increases your risk even more.
- High blood cholesterol or triglyceride levels. A high level of low-density lipoprotein (LDL) cholesterol (“bad” cholesterol) is most likely to narrow arteries. A high level of triglycerides, a type of blood fat related to your diet, also increases your risk of a heart attack. However, a high level of high-density lipoprotein (HDL) cholesterol (“good” cholesterol) may lower your risk.
- Obesity. Obesity is linked with high blood cholesterol levels, high triglyceride levels, high blood pressure, and diabetes. Losing just 10% of your body weight can lower this risk.
- Diabetes. Not producing enough of a hormone secreted by your pancreas (insulin) or not responding to insulin properly causes your body’s blood sugar levels to rise, increasing your risk of a heart attack.
- Metabolic syndrome. This syndrome occurs when you have obesity, high blood pressure, and high blood sugar. Having metabolic syndrome makes you twice as likely to develop heart disease than if you don’t have it.
- Family history of heart attacks. If your siblings, parents, or grandparents have had early heart attacks (by age 55 for males and by age 65 for females), you might be at increased risk.
- Lack of physical activity. Being inactive contributes to high blood cholesterol levels and obesity. People who exercise regularly have better heart health, including lower blood pressure.
- Stress. You might respond to stress in ways that can increase your risk of a heart attack.
- Illicit drug use. Using stimulant drugs, such as cocaine or amphetamines, can trigger a spasm of your coronary arteries that can cause a heart attack.
- A history of preeclampsia. This condition causes high blood pressure during pregnancy and increases the lifetime risk of heart disease.
- An autoimmune condition. Having a condition such as rheumatoid arthritis or lupus can increase your risk of a heart attack.
Complications of Myocardial Infarction
Arrhythmias. These are abnormal heart rhythms that can lead to death.
Heart failure. Significant damage to the heart can cause strain to the remaining healthy heart muscles leading to heart failure.
Cardiac arrest. While heart attack involves the lack of blood flow to the heart muscles, cardiac arrest refers to electrical disturbances in the heart rhythms, causing the heart to stop pumping.
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Diagnosis of Myocardial Infarction
Immediate treatment is necessary to prevent permanent and serious damage when a heart attack is suspected.
A series of diagnostic tests may be performed to support the diagnosis, and they will need to be performed as soon as possible so treatment can be started.
Medical history and physical examination – A detailed history and thorough medical examination are helpful in the diagnosis of myocardial infarction. The assessment will focus on the presence of risk factors and signs and symptoms. Machines will be hooked to continuously monitor the heart tracing and vital signs.
Electrocardiogram (ECG) – an ECG will be performed immediately to record the tracing of the heart.
- Partial blockage – non-ST elevation myocardial infarction (NSTEMI)
- Complete blockage – ST-elevation myocardial infarction (STEMI)
Blood tests – enzymes and protein markers such as troponin I and T and CKMB are often measured to identify muscle damage and wasting.
Additional tests may also be performed to help treat the condition:
Chest X-ray – chest x-ray will display the size of the heart and may identify the presence of fluid buildup in the lungs and other associated conditions.
Echocardiogram – This test can help identify the area of the heart damaged by the infarction.
Coronary catheterization – this procedure is done under fluoroscopy. A catheter is inserted thru an artery on the arms or the groin, which will then thread to the coronary artery. Images are taken while a contrast agent is injected.
Cardiac CT or MRI – these imaging techniques can help identify heart damage or associated heart problems.
Treatment of Myocardial Infarction
Medications
Thrombolytics – these drugs can dissolve clots to improve flow.
Antiplatelet agents – these drugs are given to prevent clots from getting worse and prevent future clot formation.
Blood thinners – other forms of blood thinners are often given to make blood less viscous.
Analgesic – pain killers may be given to help manage chest pain.
Nitroglycerin – this drug is a common treatment for angina as it promotes the dilation of blood vessels and improves flow.
Beta-blockers – these drugs help the heart pump more effectively.
ACE-inhibitors – these drugs help by lowering blood pressure and reducing the strain on the heart muscles.
Statins – these drugs help manage blood cholesterol levels.
Surgery
Coronary angioplasty stenting – this procedure involves the insertion of a balloon stent guided by fluoroscopy or ultrasound. A stent is inserted through a small catheter inserted from an artery in the arm or groin into the narrowed coronary artery to keep the vessel open.
Coronary artery bypass surgery – this procedure is more invasive, and it involves the cutting and sewing of arteries to bypass the blocked part.
Lifestyle changes
Smoking cessation, committing to low cholesterol, a low sugar diet, and stress management can help prevent MI or reduce the risk of another episode in a person who had a previous heart attack. Foods rich in omega-3 fatty acids such as fish, soybeans, and flaxseeds are recommended. Regular taking of prescribed blood pressure medications also helps control hypertension. Increasing physical activity by doing at least 150 minutes of moderate aerobic exercises will help promote an active lifestyle.
Nursing Care Plans for Myocardial Infarction Based on Diagnosis
Nursing Care Plan 1: Diagnosis – Acute Pain
May be related to tissue ischemia (coronary artery occlusion)
Possibly evidenced by:
- Reports of chest pain with/without radiation
- Facial grimacing
- Restlessness, changes in the level of consciousness
- Changes in pulse, BP
Desired outcomes
Patient will:
- Verbalize relief/control of chest pain within the appropriate time frame for administered medications.
- Display reduced tension, relaxed manner, ease of movement.
- Demonstrate the use of relaxation techniques.
| Nursing Interventions | Rationale |
| Pain Management Monitor/document characteristics of pain, noting verbal reports, nonverbal cues (e.g., moaning, crying, restlessness, diaphoresis, clutching chest, rapid breathing), and hemodynamic response (BP/heart rate changes). | Variation of appearance and behavior of patients in pain may present a challenge in assessment. Most patients with an acute MI appear ill, distracted and focused on pain. Verbal history and deeper investigation of precipitating factors should be postponed until the pain is relieved. Respirations may be increased as a result of pain and associated anxiety; the release of stress-induced catecholamines increases heart rate and BP. |
| Obtain full description of pain from patient including location, intensity (0–10),duration,characteristics(dull/crushing), and radiation. Assist patient in quantifying pain by comparing it to other experiences. | Pain is a subjective experience and must be described by the patient. Provides a baseline for comparison to aid in determining the effectiveness of therapy resolution/progression of the problem. |
| Review history of previous angina, anginal equivalent, or MI pain. Discuss family history if pertinent. | May differentiate current pain from preexisting patterns, as well as identify complications such as an extension of infarction, pulmonary embolus, or pericarditis. |
| Instruct patient to report pain immediately. | Delay in reporting pain hinders pain relief/may require an increased dosage of medication to achieve relief. In addition, severe pain may induce shock by stimulating the sympathetic nervous system, thereby creating further damage and interfering with diagnostics and relief of pain. |
| Provide a quiet environment, calm activities, and comfort measures (e.g., dry/wrinkle-free linens, backrub). Approach the patient calmly and confidently. | Decreases external stimuli, which may aggravate anxiety and cardiac strain, limit coping abilities, and adjustment to the current situation. |
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Nursing Care Plan 2: Diagnosis – Activity intolerance
May be related to:
- Imbalance between myocardial oxygen supply and demand
- Presence of ischemia/necrotic myocardial tissues
- Cardiac depressant effects of certain drugs (beta-blockers, antidysrhythmics)
Possibly evidenced by:
- Alterations in heart rate and BP with activity
- Development of dysrhythmias
- Changes in skin color/moisture
- Exertional angina
- Generalized weakness
Desired outcomes
Patient will:
- Activity Tolerance
- Demonstrate measurable/progressive increase in tolerance for activity with heart rate/rhythm and BP within patient’s normal limits and skin warm, pink, dry.
- Report absence of angina with activity.
| Nursing Interventions | Rationale |
| Energy Management Independent Record/document heart rate and rhythm and BP changes before, during, and after activity, as indicated. Correlate with reports of chest pain/shortness of breath. | Trends determine the patient’s response to activity and may indicate myocardial oxygen deprivation that may require a decrease in activity level/return to bed rest, changes in medication regimen, or use of supplemental oxygen. |
| Encourage rest (bed/chair) initially. Thereafter, limit activity on the basis of pain/ adverse cardiac response. Provide nonstress diversional activities. | Reduces myocardial workload/oxygen consumption, reducing the risk of complications (e.g., an extension of MI).Note: American Heart Association/American College of Cardiology guidelines (1996) suggest that patients with cardiac conditions should not be kept in bed longer than 24 hr. Patients with uncomplicated MI are encouraged to engage in mild activity out of bed, including short walks 12 hr after the incident. |
| Instruct patient to avoid increasing abdominal pressure, e.g., straining during defecation. | Activities that require holding the breath and bearing down (Valsalva maneuver) can result in bradycardia (temporarily reduced cardiac output) and rebound tachycardia with elevated BP. |
| Explain the pattern of graded increase of activity level, e.g., getting up to commode or sitting in a chair, progressive ambulation, and resting after meals. | The progressive activity provides a controlled demand on the heart, increasing strength and preventing overexertion. |
| Review signs/symptoms reflecting intolerance of present activity level or requiring notification of nurse/physician. | Palpitations, pulse irregularities, development of chest pain, or dyspnea may indicate the need for changes in an exercise regimen or medication. |
| Collaborative Refer to a cardiac rehabilitation program. | Provides continued support/additional supervision and participation in the recovery and wellness process. |
Nursing Care Plan 3: Diagnosis – Anxiety/Fear
May be related to:
- Threat to or change in health and socioeconomic status
- Threat of loss/death
- Unconscious conflict about essential values, beliefs, and goals of life
- Interpersonal transmission/contagion
Possibly evidenced by:
- Fearful attitude
- Apprehension, increased tension, restlessness, facial tension.
- Uncertainty, feelings of inadequacy
- Somatic complaints/sympathetic stimulation
- Focus on self, expressions of concern about current and future events
- Fight (e.g., belligerent attitude) or flight behavior
Desired outcomes
Patient will:
- Control anxiety/fear
- Recognize feelings.
- Identify causes contributing factors.
- Verbalize reduction of anxiety/fear.
- Demonstrate positive problem-solving skills.
- Identify/use resources appropriately.
| Nursing Interventions | Rationale |
| Anxiety Reduction Independent Accept but do not reinforce the use of denial. Avoid confrontations. | Denial can be beneficial in decreasing anxiety but can postpone dealing with the reality of the current situation. Confrontation can promote anger and increase the use of denial, reducing cooperation and possibly impeding recovery. |
| Orient patient/SO to routine procedures and expected activities. Promote participation when possible. | Predictability and information can decrease anxiety for the patient. |
| Answer all questions factually. Provide consistent information; repeat as indicated. | Accurate information about the situation reduces fear, strengthens the nurse-patient relationship, and assists patient/SO to deal realistically with the situation. Attention span may be short, and repetition of information helps with retention. |
| Encourage patient/SO to communicate with one another, sharing questions and concerns. | Sharing information elicits support/comfort and can relieve the tension of unexpressed worries. |
| Provide privacy for patient and SO. | Allows needed time for personal expression of feelings; may enhance mutual support and promote more adaptive behaviors. |
| Provide rest periods/uninterrupted sleep time, quiet surroundings, with patient controlling type, amount of external stimuli. | Conserves energy and enhances coping abilities. |
| Support normality of the grieving process, including the time necessary for resolution. | Can provide reassurance that feelings are a normal response to a situation/perceived changes. |
| Encourage independence, self-care, and decision-making within an accepted treatment plan. | Increased independence from staff promotes self-confidence and reduces feelings of abandonment that can accompany transfer from coronary unit/discharge from hospital. |
| Encourage discussion about post-discharge expectations. | Helps patient/SO identify realistic goals, thereby reducing the risk of discouragement in the face of the reality of limitations of condition/place of recuperation. |
| Collaborative Administer antianxiety/hypnotics as indicated, e.g., alprazolam (Xanax), diazepam (Valium), lorazepam (Ativan), flurazepam (Dalmane). | Promotes relaxation/rest and reduces feelings of anxiety. |
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Nursing Care Plan 4: Diagnosis – Risk for Decreased Cardiac Output
Risk factors may include:
- Changes in rate, rhythm, electrical conduction
- Reduced preload/increased SVR
- Infarcted/dyskinetic muscle, structural defects, e.g., ventricular aneurysm,
- septal defects
Desired outcomes
Patient will:
- Maintain hemodynamic stability, e.g., BP, cardiac output within normal range, adequate urinary output, decreased frequency/absence of dysrhythmias.
- Report decreased episodes of dyspnea angina.
- Demonstrate an increase in activity tolerance.
| Nursing Interventions | Rationale |
| Cardiac Care: Acute Independent Auscultate BP. Compare both arms and obtain lying, sitting, and standing pressures when able. | Hypotension may occur related to ventricular dysfunction, hypoperfusion of the myocardium, and vagal stimulation. However, hypertension is also a common phenomenon, possibly related to pain, anxiety, catecholamine release, and/or preexisting vascular problems. Orthostatic (postural) hypotension may be associated with complications of infarct, e.g., HF. |
| Evaluate quality and equality of pulses, as indicated. | Decreased cardiac output results in diminished weak/thready pulses. Irregularities suggest dysrhythmias, which may require further evaluation/monitoring. |
| Auscultate heart sounds: Note development of S3, S4; | S3 is usually associated with HF, but it may also be noted with mitral insufficiency (regurgitation) and left ventricular overload that can accompany severe infarction. S4 may be associated with myocardial ischemia, ventricular stiffening, and pulmonary or systemic hypertension. |
| Presence of murmurs/rubs. | Indicates disturbances of normal blood flow within the heart, e.g., incompetent valve, septal defect, or vibration of papillary muscle/chordae tendineae (a complication of MI). The presence of rub with infarction is also associated with inflammation, e.g., pericardial effusion and pericarditis. |
| Auscultate breath sounds. | Crackles reflecting pulmonary congestion may develop because of depressed myocardial function. |
| Nursing Interventions | Rationale |
| Cardiac Care: Acute Independent Monitor heart rate and rhythm. Document dysrhythmias via telemetry. | Heart rate and rhythm respond to medication, activity, and developing complications. Dysrhythmias (especially premature ventricular contractions or progressive heart blocks) can compromise cardiac function or increase ischemic damage. Acute or chronic atrial flutter/fibrillation may be seen with coronary artery or valvular involvement and may or may not be pathological. |
| Note the response to activity and promote rest appropriately. | Overexertion increases oxygen consumption/demand and can compromise myocardial function. |
| Provide small/easily digested meals. Limit caffeine intake, e.g., coffee, chocolate, cola | Large meals may increase myocardial workload and cause vagal stimulation, resulting in bradycardia/ectopic beats. Caffeine is a direct cardiac stimulant that can increase heart rate. Note: New guidelines suggest no need to restrict caffeine in regular coffee drinkers |
| Have emergency equipment/medications available. | Sudden coronary occlusion, lethal dysrhythmias, an extension of infarct, and unrelenting pain are situations that may precipitate cardiac arrest, requiring immediate life-saving therapies/transfer to CCU. |
| Collaborative Administer supplemental oxygen, as indicated | Increases the amount of oxygen available for myocardial uptake, reducing ischemia and resultant cellular irritation/dysrhythmias. |
| Measure cardiac output and other functional parameters as appropriate. | Cardiac index, preload/afterload, contractility, and cardiac work can be measured noninvasively with the thoracic electrical bioimpedance (TEB) technique. Useful in evaluating response to therapeutic interventions and identifying the need for more aggressive/emergency care. |
| Maintain IV/Hep-Lock access as indicated. | The patent line is important for the administration of emergency drugs in the presence of persistent lethal dysrhythmias or chest pain. |
| Review serial ECGs. | Provides information regarding progression/resolution of infarction, the status of ventricular function, electrolyte balance, and effects of drug therapies. |
| Review chest x-ray. | May reflect pulmonary edema related to ventricular dysfunction. |
| Monitor laboratory data, e.g., cardiac enzymes, ABGs, electrolytes. | Enzymes monitor resolution/extension of infarction. The presence of hypoxia indicates a need for supplemental oxygen. Electrolyte imbalance, e.g., hypokalemia/hyperkalemia, adversely affects cardiac rhythm/contractility. |
Nursing Care Plan 5: Diagnosis – Risk for Ineffective Tissue Perfusion
Risk factors may include:
- Reduction/interruption of blood flow, e.g., vasoconstriction, hypovolemia/shunting, and thromboembolic formation
Desired outcomes
Patient will:
- Demonstrate adequate perfusion as individually appropriate, e.g., skin warm and dry, peripheral pulses present/strong, vital signs within patient’s normal range, patient alert/oriented, balanced I&O, absence of edema, free of pain/discomfort.
| Nursing Interventions | Rationale |
| Hemodynamic Regulation Independent Investigate sudden changes or continued alterations in mentation, e.g., anxiety, confusion, lethargy, stupor. | Cerebral perfusion is directly related to cardiac output and is also influenced by electrolyte/acid-base variations, hypoxia, and systemic emboli. |
| Inspect for pallor, cyanosis, mottling, cool/clammy skin. Note the strength of the peripheral pulse. | Systemic vasoconstriction resulting from diminished cardiac output may be evidenced by decreased skin perfusion and diminished pulses. |
| Monitor respirations note work of breathing. | Cardiac pump failure and/or ischemic pain may precipitate respiratory distress; however, sudden/continued dyspnea may indicate thromboembolic pulmonary complications. |
| Monitor intake note changes in urine output—record urine-specific gravity as indicated. | Decreased intake/persistent nausea may result in reduced circulating volume, which negatively affects perfusion and organ function. Specific gravity measurements reflect hydration status and renal function. |
| Assess GI function, noting anorexia, decreased/absent bowel sounds, nausea/vomiting, abdominal distension, constipation. | Reduced blood flow to mesentery can produce GI dysfunction, e.g., loss of peristalsis. Problems may be potentiated/aggravated by the use of analgesics, decreased activity, and dietary changes. |
| Circulatory Care: Venous Insufficiency (NIC) Encourage active/passive leg exercises avoidance of isometric exercises. | Enhances venous return, reduces venous stasis, and decreases the risk of thrombophlebitis; however, isometric exercises can adversely affect cardiac output by increasing myocardial work and oxygen consumption. |
| Assess for Homans’ sign (pain in calf on dorsiflexion), erythema, edema. | Indicators of deep vein thrombosis (DVT), although DVT can be present without a positive Homans’ sign. |
| Instruct patient in application/periodic removal of an anti embolic hose when used. | Limits venous stasis, improves venous return, and reduces the risk of thrombophlebitis in a patient with limited inactivity. |
| Hemodynamic Regulation (NIC) Collaborative Monitor laboratory data, e.g., ABGs, BUN, creatinine, electrolytes, coagulation studies (PT, aPTT, clotting times). | Indicators of organ perfusion/function. Abnormalities in coagulation may occur as a result of therapeutic measures (e.g., heparin/Coumadin use and some cardiac drugs). |
| Administer medications as indicated:Antiplatelet agents, e.g., aspirin, abciximab (ReoPro), clopidogrel (Plavix); | Reduces mortality in MI patients and is taken daily. Aspirin also reduces coronary reocclusion after percutaneous transluminal coronary angioplasty (PTCA). ReoPro is an IV drug used as an adjunct to PTCA for the prevention of acute ischemic complications. |
| Anticoagulants, e.g., heparin/enoxaparin (Lovenox); | Low-dose heparin is given during PTCA and may be given prophylactically in high-risk patients (e.g., atrial fibrillation, obesity, ventricular aneurysm, or history of thrombophlebitis) to reduce the risk of thrombophlebitis or mural thrombus formation. |
| Oral anticoagulants, e.g., anisindione (Mirador), warfarin (Coumadin) | They are used for prophylaxis and treatment of thromboembolic complications associated with MI. |
| Cimetidine (Tagamet), ranitidine (Zantac), antacids; | Reduces or neutralizes gastric acid, preventing discomfort and gastric irritation, especially in the presence of reduced mucosal circulation. |
