Nursing Care Plan (NCP) for Myocardial Infarction (MI)

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Myocardial Infarction Interventions (Picmonic)
Myocardial Infarction Assessment (Picmonic)
Inferior MI (Cheat Sheet)
Anterior MI (Cheat Sheet)

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Hey guys, in this lesson, we are going to take a look at the care plan for myocardial infarction or MI. So in this lesson, we will talk about the pathophysiology and etiology of an MI. We'll also take a look at subjective and objective data your patient may present with as well as nursing interventions and rationales for this issue. 


So myocardial Infarction is cardiac muscle tissue death from lack of blood flow, which is super important because blood carries nutrients and oxygen to the cells. If this doesn't occur, cell necrosis occurs. So, this causes them an MI, including narrowing or occlusion of cardiac vessels, DVT that has broken off or is an embolus and it lands in the heart. So, the desired outcome would be reperfusion to cardiac muscle and return of cardiac muscle functionality. 


Let's take a look at some of the subjective and objective data that your patient with an MI may present with. Now, remember subjective data are going to be things that are based on your patient's opinions or feelings. So for an MI, this may include chest pain or chest pressure and squeezing, and feeling of impending doom, or shortness of breath. 


So guys for objective data, be sure to do a pain assessment. For example, the PQRST assessment for pain objective data can include ST elevation on the EKG and this is called a STEMI, decreased oxygenation, signs of left ventricular failure like crackles in the lungs or S3 heart sounds, tachycardia, elevated cardiac enzymes, or with an inferior MI, bradycardia can be seen. 


Let's take a look at the nursing interventions included with the MI care plan. Mona, which stands for medicine, for pain, oxygen, nitroglycerin, and aspirin, is the initial treatment for acute coronary syndrome. Remember, Mona is not the correct order of administration, just an easy way to remember the components of this treatment. So, I just want to mention that “M” used to be for morphine, if both aspirin and nitroglycerin did not relieve the chest pain, but morphine isn't really used anymore as it increases mortality. So, for the “M” in Mona, think medicine, because some type of medicine will be given for pain. Now, oxygen reminds you to check oxygenation for chest pain. If the patient is short of breath, or has a SAT of less than 94%, you're going to apply two liters of nasal cannula, but remember, only administer oxygen if clinically necessary.


Nitroglycerin is the initial medication that is given along with aspirin. Nitroglycerin works as a dilator to help a low blood flow that might be disrupted. So, you're going to give 0.4 milligram sublingual, wait five minutes, and if chest pain isn't relieved, administer another dose, but no more than three doses. Make sure the patient's blood pressure is being monitored and hold the dose if the systolic blood pressure is less than 90 millimeters of mercury. Aspirin is given because it decreases mortality by thinning the patient's blood. A single dose of 325 milligrams can be given, or for baby aspirin, which are 81 milligrams each, can be given a total of 324 milligrams. Also a 12 lead EKG should be completed immediately on anyone who is complaining of chest pain to determine if there is an ST elevated MI occurring. 


If it is, this patient needs to go to the cath lab stat. Now, if the 12 lead is normal sinus or a rhythm that is not of concern, place the patient on a three or five lead cardiac monitor to frequently assess, because we are most definitely worried about a worsening condition or cardiac arrest. Also, a right-sided 12 lead EKG shows the right side of the heart to assess for right ventricular ischemia. Remember, inferior MI's need to be treated differently. 


I already mentioned that if the patient has a STEMI, they must be taken to the cath lab quickly to locate the clot and have a stent placed to regain blood flow to the heart. I also want to mention that it is definitely possible for the patient to go to the cath lab without having a STEMI and a clot may still be located, although most non STEMI's are treated without catheterization. Patients who are coming in must definitely have their BP monitored closely. The values or limits are going to be determined by the provider. It's measured by the MAP, or mean arterial pressure, or systolic BP within the arterial line. And, why is this important? Well, the higher the blood pressure, the more pressure on a blood clot, and it isn't terribly uncommon for a patient to have more than one clot, which could definitely break free with a high blood pressure. 


Heparin is an important intervention as this drug is an anticoagulant, and breaks up clots, as well as prevents them. With heparin administration, something like a PTT needs to be monitored every six hours to adjust the dose to keep the levels therapeutic. For a STEMI, there are different values such as 60 unit per kilo bolus is given with a max of 4,000 units and then a continuous fusion of 12 units per kilo/ per hour. For a non-STEMI a 60 to 70 unit per kilos bolus is given with a max of 5,000 units and then a continuous infusion of 12 to 15 units per kilo/ per hour. Remember to always follow your facility's protocol. 


IV access is critical to administer medications and also to draw initial cardiac enzymes, which are important to rule out an MI and can also indicate how much damage has occurred. Not only do we draw cardiac enzymes, but they also need to be monitored. Troponin 1 is an enzyme that helps with the interaction of myosin and actin in the cardiac muscle. So, Troponin can become elevated two to four hours after an ischemic event and can stay elevated for up to 14 days. When we talk about CK-MB, this is an enzyme that is found in cardiac muscle, so when cardiac muscle cells are damaged, this enzyme is released into the bloodstream. CK-MB should be measured at admission and then every eight hours after. 


Here's a look at the completed care plan for an MI. Let's do a quick review. An MI occurs from cardiac muscle tissue death from lack of blood flow. Causes include narrowing of cardiac vessels, DVT, or an embolus. Subjective data includes chest pain, pressure, squeezing, impending doom, and shortness of breath. Objective data includes ST Elevation, decreased O2, crackles, being tachycardic, and elevated cardiac enzymes. Nursing interventions include a 12 lead EKG, Mona or medicine for pain, oxygen, nitroglycerin, aspirin, starting a large bore IV, and drawing initial cardiac enzymes. BP monitoring and the continuation of monitoring of cardiac enzymes is important in managing the patient. Also, preparing for the cath lab If a STEMI is present. Following your facility's nomogram for heparin administration and adjustment is critical. 


Alright guys, that is it on this care plan. We love you guys. Now, go out and be your best self today and as always, happy nursing!

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