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Myocardial Infarction Nursing Care Plan

myocardial infarction nursing care plan

Myocardial infarction (MI) is caused by a marked reduction/loss of blood flow through one or more of the coronary arteries, resulting in cardiac muscle ischemia and necrosis. Prolonged ischemia lasting for more than 30 to 45 minutes produces irreversible damage and necrosis of the myocardium.



   The reduced blood flow usually results from the blockage of a thrombus in the coronary artery. This may also transpire due to the following events:

  • Spasm of the coronary artery
  • Embolism in the coronary artery
  • A sudden drop in the blood pressure during a surgical procedure.

Another instance of myocardial infarction can be brought about by too much demand for oxygen. This implies that the need of the heart for oxygen is more than what the blood flow can provide. The increase in demand can be caused by the following cases:

  • Heavy exertion
  • Cocaine abuse
  • Stress
  • Increase in catecholamine levels
  • A sudden increase in blood pressure

Risk Factors

  • Family History – Increases the individual’s risk of atherosclerosis and MI
  • Tobacco Use – Tobacco components are known to damage blood vessel walls. The body reacts to these chemicals by the formation of atherosclerosis, increasing the risk for MI
  • Hypertension – Increase in the blood pressure’s systolic and diastolic is associated with increased risk for MI. Hypertension control and management have shown to reduce the risk for MI significantly.
  • Diabetes Mellitus – It increases the rate of atherosclerotic progression.
  • Hyperlipidemia – Elevated cholesterol levels are associated with increased risk of coronary atherosclerosis and MI.
  • Age – Risk for MI onsets for men in their 45 years old and in women in their 55 years.
  • Gender – Common in males
  • Sedentary Lifestyle
  • Stress – Studies show that the development of atherosclerosis is highly affected by stress
  • Alcohol– The risk of heart attack is affected by prolonged exposure to increased quantities of alcohol


  • Smoking, of any amount
  • High LDL Cholesterol Levels
  • High Blood Pressure
  • Diabetes
  • Chronic Kidney Disease
  • Advancing age
  • Physical exertion
  • Psychological stress


  • Chest Pain – The crushing, severe, prolonged, unrelieved by rest or nitroglycerine often radiating to arms, the neck and the back.
    • Levine’s Sign – Hand clutching over the chest. It is the universal sign for distress in heart attacks. It usually last for more than 30 minutes
    • Anxiety and apprehension
  • Shock
    • Hypotension
    • Lethargic / restlessness
    • Confusion/ disorientation
    • Diaphoresis
    • Peripheral cyanosis
    • Tachycardia / bradycardia
    • Palpitation
  • Nausea, vomiting and hiccups
  • Dizziness
  • Epigastics pain or abdominal distress
  • Dull aching or tingling sensation
  • Dyspnea – Shortness of breath
  • Feeling of impending doom
  • Lightheadedness

Difference of the Pain of Angina and Myocardial Infarction

Source: Balita, C. (2008). Ultimate learning guide to nursing review. Manila, Philippines: Tri-Mega Printing

  Angina Pectoris Myocardial Infarction
Predisposing/ Precipitating Factors Exertion, especially in colds; emotional stress; heavy meals

May transpire during rest

Quality Pressing, tight, squeezing, viselike heavy occasionally burning Pressing, tight, squeezing, viselike heavy occasionally burning
Region/ Radiation Substernal or retrosternal, which may radiate to shoulder, arms, neck, lower jaw, or upper abdomen slight to the left side. Substernal or retrosternal, which may radiate to shoulder, arms, neck, lower jaw, or upper abdomen slight to the left side.
Severity Mild to moderate, rarely to be described as severe More severe
Timing Pain usually is 1 to 3 minutes up to 10 minutes long, or may even last up to 15 to 20 minutes. This pain can be relieved by rest or Nitroglycerin (vasodilator) Pain usually last for 20 minutes or even hours. This type of pain is not relieved by rest or Nitroglycerin, but could be addressed by Morphine Sulfate (narcotic analgesic).
Associated Symptoms Dyspnea, nausea and vomiting, sweating, and weakness. Dyspnea, nausea and vomiting, sweating, and weakness.
Pathophysiology A temporary myocardial ischemia which is usually secondary coronary atherosclerosis. A prolonged myocardial ischemia which leads to an irreversible myocardial damage or necrosis.

Diagnostic Studies

  • Blood Tests
    • Cardiac enzymes and isoenzymes: CPK-MB(isoenzyme in cardiac muscle): Elevates within 4–8 hr, peaks in 12–20 hr, returns to normal in 48–72 hr.
      • LDH:Elevates within 8–24 hr, peaks within 72–144 hr, and may take as long as 14 days to return to normal. An LDH1 greater than LDH2 (flipped ratio) helps confirm/diagnose MI if not detected in acute phase.
      • Troponins:Troponin I (cTnI) and troponin T (cTnT): Levels are elevated at 4–6 hr, peak at 14–18 hr, and return to baseline over 6–7 days. These enzymes have increased specificity for necrosis and are therefore useful in diagnosing postoperative MI when MB-CPK may be elevated related to skeletal trauma.
      • Creatinine Kinase (CK-MB): Increased in over 90% of MI patients. Time sequence after MI: Begins to rises 4-6 hours, Peaks 24 hours, returns to normal after 2 days.
    • Myoglobin: A heme protein of small molecular weight that is more rapidly released from damaged muscle tissue with elevation within 2hr after an acute MI, and peak levels occurring in 3–15 hr.
    • Electrolytes: Imbalances of sodium and potassium can alter conduction and compromise contractility.
    • WBC: Leukocytosis (10,000–20,000) usually appears on the second day after MI because of the inflammatory process.
    • ESR: Rises on second or third day after MI, indicating inflammatory response.
    • C-Reactive protein (CRP) – Is the marker of acute of acute inflammation. Patients without evidence of myocardial necrosis but with elevated CRP are at increased risk of MI.
    • Chemistry profiles: May be abnormal, depending on acute/chronic abnormal organ function/perfusion.
    • ABGs/pulse oximetry: May indicate hypoxia or acute/chronic lung disease processes.
    • Lipids (total lipids, HDL, LDL, VLDL, total cholesterol, triglycerides, phospholipids):Elevations may reflect arteriosclerosis as a cause for coronary narrowing or spasm.
  • Diagnostics Tests
    • ECG: ST elevation signifying ischemia; peaked upright or inverted T wave indicating injury; development of Q waves signifying prolonged ischemia or necrosis.
    • Chest x-ray: May be normal or show an enlarged cardiac shadow suggestive of HF or ventricular aneurysm.
    • Two-dimensional echocardiogram: May be done to determine dimensions of chambers, septal/ventricular wall motion, ejection fraction (blood flow), and valve configuration/function.
    • Nuclear imaging studies: Persantine or Thallium:Evaluates myocardial blood flow and status of myocardial cells, e.g., location/extent of acute/previous MI. Cardiac blood imaging/MUGA: Evaluates specific and general ventricular performance, regional wall motion, and ejection fraction. Technetium: Accumulates in ischemic cells, outlining necrotic area(s).
    • Coronary angiography: Visualizes narrowing/occlusion of coronary arteries and is usually done in conjunction with measurements of chamber pressures and assessment of left ventricular function (ejection fraction). Procedure is not usually done in acute phase of MI unless angioplasty or emergency heart surgery is imminent.
    • Digital subtraction angiography (DSA): Technique used to visualize status of arterial bypass grafts and to detect peripheral artery disease.
    • Magnetic resonance imaging (MRI): Allows visualization of blood flow, cardiac chambers/intraventricular septum, valves, vascular lesions, plaque formations, areas of necrosis/infarction, and blood clots.
    • Exercise stress test: Determines cardiovascular response to activity (often done in conjunction with thallium imaging in the recovery phase).


  • Promote oxygenation and tissue perfusion
  • Pain Control (Balita, C., 2008)
    • Opiate analgesic therapy – Morphine, Meperidine (Demerol)
    • Vasodilator therapy – Nitroglycerin (sublingual, IV, paste)
    • Anxiolytic therapy – Benzodiazepines
  • Pharmacologic Therapy
    • Antiplatelet agents: provides a strong mortality benefit, however, it also has a significant risk of bleeding in situation such as emergency coronary artery bypass graft (CABG).
    • Antithrombotic agents: averts the development of thrombi which is associated to myocardial infarction. In addition, it also halts platelet function through blocking cyclooxygenase and subsequent platelet aggregation.
    • Glycoprotein IIb/IIIa Inhibitors: deter acute cardiac ischemic complications on cases such as unstable angina that is unresponsive to conventional therapy.
    • Vasodilators: enhance myocardial oxygen supply which provides alleviation from chest discomfort. Aside from this, this also in return dilates the pericardial and collateral vessels, thus, improving the blood supply to the ischemic myocardium.
    • Beta-adrenergic blockers: These medications can potentially subdue ventricular ectopy brought by ischemia or excess catecholamines.
    • Angiotensin-Converting Enzyme Inhibitors: reduces the aldosterone secretion through averting the conversion of angiotensin I to angiotensin II, which is a potent vasoconstrictor.
    • Nitrates: IV nitrates are administered to MI patients and congestive heart failure persistent ischemia and hypertension.
    • Angiotensin-receptor blockers: can be used as an alternative for Angiotensin-Converting Enzyme Inhibitors.
    • Thrombolytics: restores the circulation through rapid and complete removal of a pathologic intraluminal thrombus or embolus which was failed to be dissolved by the endogenous fibrinolytic system.
    • Other Medical Therapy: Percutaneous Coronary Intervention (establishes coronary reperfusion), or Coronary Artery Bypass Graft Surgery.
  • Percutanous Transluminal Coronary Angioplasty
  • Surgical Revascularization


  • Rhythm disturbances
  • Congestive Heart Failure
  • Cardiogenic Shock
  • Rapture of the Myocardium
  • Infarct Extension – the affected heart tissue has extended
  • Papillary muscle rupture
  • Ventricular mural thrombus
  • Thromboembolism
  • Ventricular aneurysm
  • Cardiac tamponade
  • Pericarditis (2 to 3 days after MI)
  • Psychiatric problems – depression, personality changes

Myocardial Infarction Nursing Care Plan (Based on NANDA)

Nursing diagnosis:

Pain, Acute

May be related to

  • Tissue ischemia (coronary artery occlusion)

Possibly evidenced by

  • Subjective
    • Reports of chest pain with/without radiation
  • Objective
    • Restlessness, changes in level of consciousness
    • Changes in pulse, BP
  • Demonstrates the Levine’s sign
  • Observed evidence of pain
  • Facial mask; sleep disturbance (eyes lack luster, beaten look, fixed or scattered movement, grimace)
  • Expressive behavior (e.g., restlessness, moaning, crying, vigilance, irritability, sighing)
  • Distraction behavior (e.g., pacing, seeking out other people and/or activities, repetitive activities)
  • Change in muscle tone (may span from listless [flaccid] to rigid)
  • Diaphoresis; change in blood pressure/heart rate/respiratory rate; pupillary dilation

Desired outcomes/evaluation criteria—patient will:

  • Report pain is relieved/ controlled.
  • Follow prescribed pharmacological regimen.
  • Verbalize non-pharmacologic methods that provide relief.
  • Demonstrate use of relaxation skills and diversional activities, as indicated, for individual situation
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 pain is relieved. Respirations may be increased as a result of pain and associated anxiety; 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 to quantify pain by comparing it to other experiences. Pain is a subjective experience and must be described by patient. Provides baseline for comparison to aid in determining effectiveness of therapy, resolution/progression of 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 extension of infarction, pulmonary embolus, or pericarditis.
Instruct patient to report pain immediately. Delay in reporting pain hinders pain relief/may require 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 quiet environment, calm activities, and comfort measures (e.g., dry/wrinkle-free linens, backrub). Approach patient calmly and confidently. Decreases external stimuli, which may aggravate anxiety and cardiac strain, limit coping abilities and adjustment to current situation.
Nursing Interventions Rationale
Pain Management


Assist/instruct in relaxation techniques, e.g., deep/slow breathing, distraction behaviors, visualization, guided imagery.

Helpful in decreasing perception of/ response to pain. Provides a sense of having some control over the situation, increase in positive attitude.
Check vital signs before and after narcotic medication. Hypotension/respiratory depression can occur as a result of narcotic administration. These problems may increase myocardial damage in presence of ventricular insufficiency.

Administer supplemental oxygen by means of nasal cannula or face mask, as indicated.

Increases amount of oxygen available for myocardial uptake and thereby may relieve discomfort associated with tissue ischemia.
Administer medications as indicated:

Antianginals, e.g., nitroglycerin (Nitro-Bid, Nitrostat, Nitro-Dur), isosorbide denitrate (Isordil), mononitrate (Imdur)

Nitrates are useful for pain control by coronary vasodilating effects, which increase coronary blood flow and myocardial perfusion. Peripheral vasodilation effects reduce the volume of blood returning to the heart (preload), thereby decreasing myocardial workload and oxygen demand.
Beta-blockers, e.g., atenolol (Tenormin), pindolol(Visken), propranolol (Inderal), nadolol (Corgard), metoprolol (Lopressor) Important second-line agents for pain control through effect of blocking sympathetic stimulation, thereby reducing heart rate, systolic BP, and myocardial oxygen demand. May be given alone or with nitrates. Note: beta-blockers may be contraindicated if myocardial contractility is severely impaired, because negative inotropic properties can further reduce contractility.
Analgesics, e.g., morphine, meperidine (Demerol) Although intravenous (IV) morphine is the usual drug of choice, other injectable narcotics may be used in acute-phase/recurrent chest pain unrelieved by nitroglycerin to reduce severe pain, provide sedation, and decrease myocardial workload. IM injections should be avoided, if possible, because they can alter the CPK diagnostic indicator and are not well absorbed in underperfused tissue.

Nursing 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)
    • Therapeutic restrictions (isolation/bedrest)

Possibly evidenced by:

  • Subjective
    • Verbal report of fatigue/weakness
    • Exertional discomfort/dyspnea
  • Objective
    • Abnormal heart rate/blood pressure response to activity
    • Electrocardiographic changes reflecting arrhythmias/or ischemia [Pallor, cyanosis]
    • Changes in skin color/moisture
    • Exertional angina
    • Generalized weakness


Functional Level Classification (Gordon, 1987):

  • Level I: Walk, regular pace, on level indefinitely; one flight or more but more short of breath than normally
  • Level II: Walk one city block [or] 500 ft on level; climb one flight slowly without stopping
  • Level III: Walk no more than 50 ft on level without stopping; unable to climb one flight of stairs without stopping
  • Level IV: Dyspnea and fatigue at rest

Desired outcomes/evaluation criteria—patient will:

Activity Tolerance (NOC)

  • 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.
  • Identify negative factors affecting activity tolerance and eliminate or reduce their effects when possible.
  • Use identified techniques to enhance activity tolerance.
  • Participate willingly in necessary/desired activities.
Nursing Interventions Rationale
Energy Management


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. (Refer to ND: Cardiac Output, risk for decreased.)

Trends determine patient’s response to activity and may indicate myocardial oxygen deprivation that may require decrease in activity level/return to bedrest, changes in medication regimen, or use of supplemental oxygen.
Encourage rest (bed/chair) initially. Thereafter, limit activity on basis of pain/ adverse cardiac response. Provide nonstress diversional activities. Reduces myocardial workload/oxygen consumption, reducing risk of complications (e.g., 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 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 pattern of graded increase of activity level, e.g., getting up to commode or sitting in chair, progressive ambulation, and resting after meals. 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 need for changes in exercise regimen or medication.

Refer to cardiac rehabilitation program.

Provides continued support/additional supervision and participation in recovery and wellness process.

Nursing diagnosis: 

Anxiety [specify level]/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
  • Situational/maturational crises
  • Stress
  • Familial association; heredity
  • Threat to self-concept [perceived or actual]; [unconscious conflict]
  • Unmet needs
  • Exposure to toxins

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/evaluation criteria—patient will:

Anxiety/Fear Control (NOC)

  • Appear relaxed and report anxiety is reduced to a manageable level.
  • Identify healthy ways to deal with and express anxiety.
  • Identify causes, contributing factors.
  • Verbalize reduction of anxiety/fear.
  • Demonstrate positive problem-solving skills.
  • Identify/use resources appropriately.
Nursing Interventions Rationale
Anxiety Reduction


Identify and acknowledge patient’s perception of threat/situation. Encourage expressions of, and do not deny feelings of, anger, grief, sadness, fear.

Coping with the pain and emotional trauma of an MI is difficult. Patient may fear death and/or be anxious about immediate environment. Ongoing anxiety (related to concerns about impact of heart attack on future lifestyle, matters left unattended/unresolved, and effects of illness on family) may be present in varying degrees for some time and may be manifested by symptoms of depression.
Note presence of hostility, withdrawal, and/or denial (inappropriate affect or refusal to comply with medical regimen). Research into survival rates between type A and type B individuals and the impact of denial has been ambiguous; however, studies show some correlation between degree/
expression of anger or hostility and an increased risk for MI.
Maintain confident manner (without false reassurance). Patient and SO can be affected by the anxiety/uneasiness displayed by health team members. Honest explanations can alleviate anxiety.
Observe for verbal/nonverbal signs of anxiety, and stay with patient. Intervene if patient displays destructive behavior. Patient may not express concern directly, but words/actions may convey sense of agitation, aggression, and hostility. Intervention can help patient regain control of own behavior.
Nursing Interventions Rationale
Anxiety Reduction


Accept but do not reinforce 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 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 patient.
Answer all questions factually. Provide consistent information; repeat as indicated. Accurate information about the situation reduces fear, strengthens nurse-patient relationship, and assists patient/SO to deal realistically with 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 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 grieving process, including time necessary for resolution. Can provide reassurance that feelings are normal response to situation/perceived changes.
Encourage independence, self-care, and decision making within 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 postdischarge expectations. Helps patient/SO identify realistic goals, thereby reducing risk of discouragement in face of the reality of limitations of condition/pace of recuperation.

Administer antianxiety/hypnotics as indicated, e.g., alprazolam (Xanax), diazepam (Valium), lorazepam (Ativan), flurazepam (Dalmane).

Promotes relaxation/rest and reduces feelings of anxiety.

Nursing diagnosis: 

Cardiac Output, risk for decreased

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

Possibly evidenced by

  • Subjective
    • Palpitations
    • Fatigue
    • Difficulty of breathing
    • Anxiety
  • Objective
    • Dysrhythmias; tachycardia; bradycardia
    • ECG changes
    • Distended jugular vein; edema; weight gain; increased/decreased central venous pressure (CVP); increased/decreased pulmonary artery wedge pressure (PAWP); murmurs
    • Dyspnea; clammy skin; skin color changes [cyanosis, pallor]; prolonged capillary refill
    • Crackles; cough
    • Restlessness

Desired outcomes/evaluation criteria—patient will:

Cardiac Pump Effectiveness (NOC)

  • Maintain hemodynamic stability, e.g., BP, cardiac output within normal range, adequate urinary output, and decreased frequency/absence of dysrhythmias.
  • Report decreased episodes of dyspnea, angina.
  • Demonstrate an increase in activity tolerance. Display hemodynamic stability (e.g., blood pressure, cardiac output, renal perfusion/urinary output, peripheral pulses).
  • Verbalize knowledge of the disease process, individual risk factors, and treatment plan.
  • Participate in activities that reduce the workload of the heart
  • Identify signs of cardiac decompensation, alter activities, and seek help appropriately.
Nursing Interventions Rationale
Cardiac Care: Acute


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 the 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 (complication of MI). Presence of rub with an 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


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 response to activity and promote rest appropriately. (Refer to ND: Activity intolerance.) 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, extension of infarct, and unrelenting pain are situations that may precipitate cardiac arrest, requiring immediate life-saving therapies/transfer to CCU.

Administer supplemental oxygen, as indicated

Increases 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 thoracic electrical bioimpedance (TEB) technique. Useful in evaluating response to therapeutic interventions and identifying need for more aggressive/emergency care.
Maintain IV/Hep-Lock access as indicated. Patent line is important for administration of emergency drugs in presence of persistent lethal dysrhythmias or chest pain.
Review serial ECGs. Provides information regarding progression/resolution of infarction, 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. Presence of hypoxia indicates need for supplemental oxygen. Electrolyte imbalance, e.g., hypokalemia/hyperkalemia, adversely affects cardiac rhythm/contractility.
Nursing Interventions Rationale
Cardiac Care: Acute


Administer antidysrhythmic drugs as indicated. (Refer to CP: Dysrhythmias.)

Dysrhythmias are usually treated symptomatically, except for PVCs, which are often treated prophylactically. Early inclusion of ACE inhibitor therapy (especially in presence of large anterior MI, ventricular aneurysm, or HF) enhances ventricular output, increases survival, and may slow progression of HF. Note: Use of routine lidocaine is no longer recommended.
Assist with insertion/maintain pacemaker, when used. Pacing may be a temporary support measure during acute phase or may be needed permanently if infarction severely damages conduction system, impairing systolic function. Evaluation is based on echocardiography or radionuclide ventriculography.

Nursing diagnosis:

Tissue Perfusion, ineffective

Risk factors may include

  • Reduction/interruption of blood flow, e.g., vasoconstriction, hypovolemia/shunting, and thromboembolic formation
  • Decreased hemoglobin concentration in blood; enzyme poisoning
  • Altered affinity of hemoglobin for oxygen; impaired transport of oxygen
  • Hypoventilation

Possibly evidenced by

  • Subjective
    • Cardiopulmonary
    • Chest pain
    • Dyspnea
    • Sense of “impending doom”
    • Gastrointestinal
    • Nausea
    • Abdominal pain or tenderness
    • Peripheral
    • Claudication
  • Objective
    • Altered blood pressure outside of acceptable parameters
    • Oliguria; anuria; hematuria
    • Elevation in BUN/creatine ratio
    • Restlessness
    • Extremity weakness; paralysis
    • Changes in pupillary reactions
    • Difficulty in swallowing
    • Cardiopulmonary
    • Arrhythmias
    • Capillary refill >3 sec
    • Chest retraction; nasal flaring
    • Bronchospasms
    • Abnormal arterial blood gases
    • Hypoactive/absent bowel sounds
    • Abdominal distention
    • Paleness of the skin
    • Edema
    • Delayed healing
    • Positive Homans’ sign

Desired outcomes/evaluation criteria—patient will:

Cardiac Pump Effectiveness (NOC)

  • 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.
  • Verbalize understanding of condition, therapy regimen, side effects of medications, and when to contact healthcare provider
  • Demonstrate behaviors/lifestyle changes to improve circulation (e.g., cessation of smoking, relaxation techniques, exercise/ dietary program).
Nursing Interventions Rationale
Hemodynamic Regulation


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 strength of 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 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 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 antiembolic hose, when used. Limits venous stasis, improves venous return, and reduces risk of thrombophlebitis in patient who is limited in activity.
Hemodynamic Regulation (NIC)


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 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 risk of thrombophlebitis or mural thrombus formation.
Oral anticoagulants, e.g., anisindione (Miradon), warfarin (Coumadin) 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 presence of reduced mucosal circulation.
Nursing Interventions Rationale
Hemodynamic Regulation


Assist with reperfusion therapy:

Administer thrombolytic agents, e.g., alteplase (Activase, rt-PA), reteplase (Retavase), streptokinase (Streptase), anistreplase (Eminase), urokinase, (Abbokinase);

Thrombolytic therapy is the treatment of choice (when initiated within 6 hr) to dissolve the clot (if that is the cause of the MI) and restore perfusion of the myocardium.
Prepare for PTCA (balloon angioplasty), with/without intracoronary stents; This procedure is used to open partially blocked coronary arteries before they become totally blocked. The mechanism includes a combination of vessel stretching and plaque compression. Intracoronary stents may be placed at the time of PTCA to provide structural support within the coronary artery and improve the odds of long-term patency.
Transfer to critical care. More intensive monitoring and aggressive interventions are necessary to promote optimum outcome.

Nursing diagnosis: 

Fluid Volume, risk for excess

Risk factors may include

  • Decreased organ perfusion (renal)
  • Increased sodium/water retention
  • Increased hydrostatic pressure or decreased plasma proteins (sequestering of fluid in interstitial space/tissues)

Possibly evidenced by

  • Subjective
    • Orthopnea [difficulty breathing]
    • Anxiety
  • Objective
    • Edema; anasarca; weight gain over short period of time
    • Intake exceeds output; oliguria
    • Adventitious breath sounds [rales or crackles]; changes in respiratory pattern; dyspnea
    • Increased central venous pressure; jugular vein distention; positive hepatojugular reflex
    • Pulmonary congestion, pleural effusion, pulmonary artery pressure changes; blood pressure changes
    • Changes in sensorium

Desired outcomes/evaluation criteria—patient will:

Fluid Balance (NOC)

  • Maintain fluid balance as evidenced by BP within patient’s normal limits.
  • Be free of peripheral/venous distension and dependent edema, with lungs clear and weight stable.
  • Verbalize understanding of individual dietary/fluid restrictions.
  • Demonstrate behaviors to monitor fluid status and reduce recurrence of fluid excess.
  • List signs that require further evaluation
Nursing Interventions Rationale
Fluid Management


Auscultate breath sounds for presence of crackles.

May indicate pulmonary edema secondary to cardiac decompensation.
Note JVD, development of dependent edema. Suggests developing congestive failure/fluid volume excess.
Nursing Interventions Rationale
Fluid Management 


Measure I&O, noting decrease in output, concentrated appearance. Calculate fluid balance.

Decreased cardiac output results in impaired kidney perfusion, sodium/water retention, and reduced urine output.
Weigh daily. Sudden changes in weight reflect alterations in fluid balance.
Maintain total fluid intake at 2000 mL/24 hr within cardiovascular tolerance. Meets normal adult body fluid requirements, but may require alteration/restriction in presence of cardiac decompensation.

Provide low-sodium diet/beverages.

Sodium enhances fluid retention and should therefore be restricted during active MI phase and/or if heart failure is present.
Administer diuretics, e.g., furosemide (Lasix), spironolactone with hydrochlorothiazide (Aldactazide), hydralazine (Apresoline). May be necessary to correct fluid overload. Drug choice is usually dependent on acute/chronic nature of symptoms.
Monitor potassium as indicated. Hypokalemia can limit effectiveness of therapy and can occur with use of potassium-depleting diuretics.

Nursing diagnosis: 

Knowledge, deficient [Learning Need] regarding cause/treatment of condition, self-care, and discharge needs

May be related to

  • Lack of information/misunderstanding of medical condition/therapy needs
  • Unfamiliarity with information resources
  • Lack of recall
  • Information misinterpretation/lack of recall
  • Information misinterpretation [inaccurate/incomplete information presented]
  • Cognitive limitation
  • Lack of interest in learning [client’s request for no information]

Possibly evidenced by

  • Questions; statement of misconception
  • Failure to improve on previous regimen
  • Development of preventable complications
  • Inappropriate/exaggerated behaviors (e.g., hysterical, hostile, agitated, apathetic)

Desired outcomes/evaluation criteria—patient will:

  • Verbalize understanding of condition, potential complications, individual risk factors, and function of pacemaker (if used).
  • Relate signs of pacemaker failure.
  • Verbalize understanding of therapeutic regimen.
  • List desired action and possible adverse side effects of medications.
  • Correctly perform necessary procedures and explain reasons for actions.
  • Participate in learning process.
  • Identify interferences to learning and specific action(s) to deal with them.
  • Exhibit increased interest/assume responsibility for own learning by beginning to look for information and ask questions.
  • Identify relationship of signs/symptoms to the disease process and correlate symptoms with causative factors.
  • Initiate necessary lifestyle changes and participate in treatment regimen.
Nursing Interventions Rationale
Teaching: Individual


Assess patient/SO level of knowledge and ability/desire to learn.

Necessary for creation of individual instruction plan.

Reinforces expectation that this will be a “learning experience.” Verbalization identifies misunderstandings and allows for clarification.

Be alert to signs of avoidance, e.g., changing subject away from information being presented or extremes of behavior (withdrawal/euphoria). Natural defense mechanisms, such as anger or denial of significance of situation, can block learning, affecting patient’s response and ability to assimilate information. Changing to a less formal/structured style may be more effective until patient/SO is ready to accept/deal with current situation.
Present information in varied learning formats, e.g., programmed books, audiovisual tapes, question-and-answer sessions, group activities. Using multiple learning methods enhances retention of material.
Cardiac Care: Rehabilitation


Reinforce explanations of risk factors, dietary/activity restrictions, medications, and symptoms requiring immediate medical attention.

Provides opportunity for patient to retain information and to assume control/participate in rehabilitation program.

Note: Routine use of supplements/herbal remedies (e.g., ginkgo biloba, garlic, vitamin E) can result in alterations in blood clotting, especially when anticoagulant/ASA therapy is prescribed.

Encourage identification/reduction of individual risk factors, e.g., smoking/alcohol consumption, obesity. These behaviors/chemicals have direct adverse effects on cardiovascular function and may impede recovery, increase risk for complications.
Warn against isometric activity, Valsalva maneuver, and activities requiring arms positioned above head. These activities greatly increase cardiac workload and myocardial oxygen consumption and may adversely affect myocardial contractility/output.
Review programmed increases in levels of activity. Educate patient regarding gradual resumption of activities, e.g., walking, work, recreational and sexual activity. Provide guidelines for gradually increasing activity and instruction regarding target heart rate and pulse taking, as appropriate. Gradual increase in activity increases strength and prevents overexertion, may enhance collateral circulation, and allows return to normal lifestyle. Note: Sexual activity can be safely resumed once patient can accomplish activity equivalent to climbing two flights of stairs without adverse cardiac effects.
Identify alternative activities for “bad weather” days, such as measured walking in house or shopping mall. Provides for continuing daily activity program.
Review signs/symptoms requiring reduction in activity and notification of healthcare provider. Differentiate between increased heart rate that normally occurs during various activities and worsening signs of cardiac stress (e.g., chest pain, dyspnea, palpitations, increased heart rate lasting more than 15 min after cessation of activity, excessive fatigue the following day). Pulse elevations beyond established limits, development of chest pain, or dyspnea may require changes in exercise and medication regimen.
Nursing Interventions Rationale
Cardiac Care: Rehabilitation


Stress importance of follow-up care, and identify community resources/support groups, e.g., cardiac rehabilitation programs, “coronary clubs,” smoking cessation clinics.

Reinforces that this is an ongoing/continuing health problem for which support/assistance is available after discharge. Note: After discharge, patients encounter limitations in physical functioning and often incur difficulty with emotional, social, and role functioning requiring ongoing support.
Emphasize importance of contacting physician if chest pain, change in anginal pattern, or other symptoms recur. Timely evaluation/intervention may prevent complications.
Stress importance of reporting development of fever in association with diffuse/atypical chest pain (pleural, pericardial) and joint pain. Post-MI complication of pericardial inflammation (Dressler’s syndrome) requires further medical evaluation/intervention.
Encourage patient/SO to share concerns/feelings. Discuss signs of pathological depression versus transient feelings frequently associated with major life events. Recommend seeking professional help if depressed feelings persist. Depressed patients have a greater risk of dying 6–18 mo following a heart attack. Timely intervention may be beneficial. Note: Selective serotonin reuptake inhibitors (SSRIs), e.g., paroxetine (Paxil), have been found to be as effective as tricyclic antidepressants but with significantly fewer adverse cardiac complications.


  1. Balita, C. (2008). Ultimate learning guide to nursing review. Manila, Philippines: Tri-Mega Printing
  2. Myocardial infarction: An incredibly easy miniguide. (2000). Springhouse, PA: Springhouse Corporation.
  3. Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2006). Nurse’s pocket guide: Diagnoses, prioritized interventions, and rationales. Philadelphia, PA: F.A. Davis.
  4. Canobbio, M. (2006). Mosby’s handbook of patient teaching. Elsevier Health Sciences
  5. Leukemia. (2015). Canadian Cancer Society. Retrieved October 27, 2015 from http://www.cancer.ca/en/cancer-information/cancer-type/leukemia/leukemia/?region=on.

This page was last edited on 9 June 2020

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