7 Myocardial Infarction (Heart Attack) Nursing Care Plans

Acute Pain

The classic symptom a client experience during a cardiac event is pain. It is important for the nurse to differentiate the pain of an MI or angina attack from a multitude of other pain syndromes that can mimic a coronary event. Non-cardiac chest pain may be caused by other cardiovascular issues including pericarditis, aortic aneurysm, or dissection. 

Nursing 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

• The client will verbalize relief/control of chest pain within the appropriate time frame for administered medications.
• The client will display reduced tension, a relaxed manner, and ease of movement.
• The client will demonstrate the use of relaxation techniques.

Nursing Assessment and Rationales

1. Monitor and document characteristics of pain, noting verbal reports, and nonverbal cues (moaning, crying, grimacing, restlessness, diaphoresis, and clutching of the chest).
Variations in the appearance and behavior of clients in pain may present a challenge in assessment. Most clients 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. The client may present with abdominal discomfort or jaw pain as their anginal equivalent. Women tend to present more commonly with atypical symptoms than men (Zafari, 2015).

2. Obtain a full description of pain from the client including location, intensity (using a scale of 0–10), duration, characteristics (dull, crushing, described as “like an elephant in my chest”), and radiation. Assist the client to quantify pain by comparing it to other experiences.
Pain is a subjective experience and must be described by the client. This also provides a baseline for comparison to aid in determining the effectiveness of therapy, resolution, and progression of the problem. Clients commonly describe the discomfort as crushing, oppressive, or constricting or as a pressure that may radiate to the left arm, neck, jaw, infrascapular area, or epigastric region. Transient symptoms that last less than 15 minutes and disappear at rest are classified as angina. The discomfort associated with MI typically lasts more than 30 minutes, is not relieved by rest or nitroglycerin, and may or may not be severe.

3. Review the history of previous angina, anginal equivalent, or MI pain. Discuss family history if pertinent.
A delay in reporting pain hinders pain relief and 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. A positive family history includes any first-degree male relative aged 45 years or younger or any first-degree female relative aged 55 years or younger who experienced MI (Zafari, 2015).

4. Check vital signs before and after narcotic medication.
Morphine sulfate is the analgesic of choice for anginal pain relief in STEMI and for unstable angina and NSTEMI barring contraindications (Zafari, 2015). Hypotension and respiratory depression can occur as a result of narcotic administration. These problems may increase myocardial damage in presence of ventricular insufficiency.

5. Monitor the client’s vital signs closely.
Hypertension may precipitate myocardial infarction, or it may reflect elevated catecholamine levels due to anxiety, pain, or exogenous sympathomimetics. Hypotension may indicate ventricular dysfunction due to ischemia. Impaired left ventricular diastolic function leads to pulmonary vascular congestion with shortness of breath and tachypnea and, eventually, pulmonary edema with orthopnea. Shortness of breath may be the client’s anginal equivalent or a symptom of heart failure (Zafari, 2015).

Nursing Interventions and Rationales

1. Instruct the client to report pain immediately.
Atypical presentations are common and frequently lead to misdiagnosis. Moreover, any client may present with atypical symptoms, which are considered the anginal equivalent for that client. Atypical chest pain is common, especially in older clients and clients diagnosed with diabetes. Morbidity and mortality from MI are significantly reduced if clients and bystanders recognize symptoms early, activate the emergency medical service system, and thereby shorten the time to definitive treatment (Zafari, 2015).

2. Provide a quiet environment, and calm activities, and place the client in a position of comfort. Approach the client calmly and confidently.
This decreases external stimuli, which may aggravate anxiety and cardiac strain, limiting coping abilities and adjustment to the current situation. Physical rest in bed with the backrest elevated or in a cardiac chair helps to decrease chest discomfort and dyspnea.

3. Instruct the client to do relaxation techniques such as deep and slow breathing, distraction behaviors, visualization, and guided imagery. Assist as needed.
This is helpful in decreasing perception and response to pain, provides a sense of having some control over the situation, and increases a positive attitude. Alternative therapies such as pet therapy can also help certain clients relax and reduce anxiety, therefore reducing chest pain.

4. Administer supplemental oxygen by means of a nasal cannula or face mask, as indicated.
Oxygen is administered by nasal prongs at 2 to 5 L/minute to improve oxygenation of the myocardium and other tissues. Oxygen therapy increases the amount of oxygen available for myocardial uptake and thereby may relieve discomfort associated with tissue ischemia. Administration of oxygen should be reserved for hypoxic clients as supplementary oxygen therapy increases coronary vascular resistance, and there are suggestions that its use in a non-hypoxic client is associated with higher mortality (Shah et al., 2019).

5. Administer medications as indicated. 

• 5.1. Antianginals such as nitroglycerin, isosorbide dinitrate, and mononitrate
  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. Systolic BP <90 mm Hg, HR <60 or >100, and right ventricular infarction are contraindications to nitrate use (Zafari, 2015).
  
• 5.2. Beta-blockers such as atenolol, pindolol, propranolol, nadolol, and metoprolol
  Beta-blockers are important second-line agents for pain control through the effect of blocking sympathetic stimulation, thereby reducing heart rate, systolic BP, and myocardial oxygen demand. These may be given alone or with nitrates. Metoprolol is the standard of care and is a selective beta1-adrenergic receptor blocker that decreases the automaticity of contractions. Specific contraindications to the usage of this therapy include signs of heart failure, low output state, increased risk for cardiogenic shock, pulse rate interval greater than 0.24 seconds, and active asthma (Zafari, 2015).
  
• 5.3. Analgesics such as morphine and meperidine
  Although intravenous (IV) morphine is the usual drug of choice, other injectable narcotics may be used in acute-phase and/or 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 under-perfused tissue.