MI refers to a dynamic process by which one or more regions of the
heart experience a severe and prolonged decrease in oxygen supply because of
insufficient coronary blood flow; subsequently, necrosis or “death†to the
myocardial tissue occurs. The onset of the MI process may be sudden or gradual,
and the progression of the event to completion takes approximately 3 to 6 hours.
MI is one manifestation of ACS.
Pathophysiology and Etiology
-
Acute coronary thrombosis (partial or total)—associated with 90% of MIs.
-
Severe CAD (greater than 70% narrowing of the artery) precipitates thrombus formation.
-
The first step in thrombus formation involves plaque rupture. Platelets adhere to the damaged area.
-
Activation of the exposed platelets causes expression of glycoprotein IIb/IIIa receptors that bind fibrinogen.
-
Further platelet aggregation and adhesion occurs, enlarging the thrombus and occluding the artery.
-
-
Other etiologic factors include coronary artery spasm, coronary artery embolism, infectious diseases causing arterial inflammation, hypoxia, anemia, and severe exertion or stress on the heart in the presence of significant CAD (ie, surgical procedures or shoveling snow).
-
Different degrees of damage occur to the heart muscle (see Figure 13-1):FIGURE 13-1 Different degrees of damage occur to the heart muscle after a myocardial infarction. The diagram shows the zones of necrosis, injury, and ischemia.
-
Zone of necrosis—death to the heart muscle caused by extensive and complete oxygen deprivation; irreversible damage
-
Zone of injury—region of the heart muscle surrounding the area of necrosis; inflamed and injured, but still viable if adequate oxygenation can be restored
-
Zone of ischemia—region of the heart muscle surrounding the area of injury, which is ischemic and viable; not endangered unless extension of the infarction occurs
-
-
According to the layers of the heart muscle involved, MIs can be classified as:
-
Transmural (Q wave) infarction—area of necrosis occurs throughout the entire thickness of the heart muscle.
-
Subendocardial (nontransmural/non–Q-wave) infarction—area of necrosis is confined to the innermost layer of the heart lining the chambers.
-
-
Location of MI is identified as the location of the damaged heart muscle within the left ventricle: inferior, anterior, lateral, and posterior or right ventricle.
-
Left ventricle is a common and dangerous location for an MI, because it is the main pumping chamber of the heart.
-
Right ventricular infarctions commonly occur in conjunction with damage to the inferior and/or posterior wall of the left ventricle.
-
-
Region of the heart muscle that becomes damaged—determined by the coronary artery that becomes obstructed (see Figure 13-2).FIGURE 13-2 Diagram of the coronary arteries arising from the aorta and encircling the heart. Some of the coronary veins also are shown.
-
The amount of heart muscle damage and the location of the MI—determine prognosis.
NURSING ALERT
A subendocardial infarction is considered a
potential uncompleted MI; monitor carefully for signs and symptoms of extension
of heart muscle damage.
Clinical Manifestations
-
Chest pain
-
Severe, diffuse steady substernal pain of a crushing and squeezing nature
-
Not relieved by rest or sublingual vasodilator therapy, but requires opioids
-
May radiate to the arms (usually the left), shoulders, neck, back, and/or jaw
-
Continues for more than 15 minutes
-
May produce anxiety and fear, resulting in an increase in heart rate, BP, and respiratory rate
-
-
Diaphoresis, cool clammy skin, facial pallor
-
Hypertension or hypotension
-
Bradycardia or tachycardia
-
Premature ventricular and/or atrial beats
-
Palpitations, severe anxiety, dyspnea
-
Disorientation, confusion, restlessness
-
Fainting, marked weakness
-
Nausea, vomiting, hiccups
-
Atypical symptoms: epigastric or abdominal distress, dull aching or tingling sensations, shortness of breath, extreme fatigue
NURSING ALERT
Many patients do not have symptoms; these are
“silent MIs.†Nevertheless, there still is resultant damage to the heart.
Women usually present with atypical and/or vague complaints (eg, epigastric
pain, “gas,†feeling tired).
GERONTOLOGIC ALERT
Elderly patients are more likely to experience
silent MIs or have atypical symptoms, such as hypotension, low body temperature,
vague complaints of discomfort, mild perspiration, strokelike symptoms,
dizziness, change in sensorium.
Diagnostic Evaluation
ECG Changes
-
Generally occur within 2 to 12 hours, but may take 72 to 96 hours.
-
Necrotic, injured, and ischemic tissue alter ventricular depolarization and repolarization.
-
ST segment depression and T wave inversion indicate a pattern of ischemia.
-
ST elevation indicates an injury pattern.
-
Q waves (see Figure 13-3) indicate tissue necrosis and are permanent. A pathologic Q wave is one that is greater than 3 mm in depth or greater than one-third the height of the R wave.FIGURE 13-3 Abnormal Q wave.
-
-
Location of the infarction (anterior wall, anteroseptal) is determined by the leads in which the ischemic changes are seen.
NURSING ALERT
A normal ECG does not rule out the possibility
of infarction, as ECG changes can be subtle and obscured by underlying
conditions (bundle branch blocks, electrolyte
disturbances).
Cardiac Markers
-
Nonspecific markers
-
All muscle cells, including cardiac muscle cells contain protein enzymes or biochemical markers that leak out into the bloodstream when muscle cells are damaged.P.387
-
A rise in a cardiac marker confirms cardiac cell death; however, nonspecific markers can increase from damage in other organs and are therefore not routinely helpful in the diagnosis of MI.
-
These include lactate dehydrogenase, aspartate aminotransferase, and myoglobin.
-
-
Specific cardiac markers
-
Troponin—is a contractile protein of the muscle cell and has three subunits, troponin C, troponin I and troponin T. Troponin I and T are cardiac-specific. Troponin I is assessed more commonly because the test is readily available.
-
Single elevation exceeding the normal range in the first 24 hours after an acute coronary event is considered diagnostic for myocardial ischemia without further testing.
-
Due to its cardiac specificity, troponin has replaced the CK-MB as the standard in MI diagnosis.
-
-
Creatine kinase (CK)—is a nonspecific marker, but is more specific when broken down into its subunits.
-
CK-MB-is the CK isoenzyme found in the heart.
-
Drawbacks to use of this maker include false positive results due to skeletal muscle injury or chronic muscle diseases.
-
-
-
Cardiac markers are not diagnostic of an acute MI with a single elevation; serial markers are drawn.
-
Markers are usually drawn on admission and every 6 to 24 hours until three samples are obtained. Marker elevation is then correlated to the extent of heart muscle damage (see page 329).
-
Characteristic elevation over several days confirms an MI (see Figure 13-4).
-
FIGURE 13-4 Release of cardiac markers
after acute myocardial infarction (AMI). Following AMI, myoglobin and CK-MB
levels rise, but the increases last only a few days. Levels of troponin T can be
sustained for 4 to 10 days following AMI, allowing for more accurate diagnosis.
All results are normalized to the upper reference limit. (Wu AHB. Cardiac
troponins T and I in coronary artery diseases. Endocrinology
and Metabolism In-Service Training and Continuing Education, 13:81, 1995.
© American Association for Clinical Chemistry,
Inc.)
|
Other Findings
-
Elevated CRP and lipoprotein(a) due to inflammation in the coronary arteries.
-
Abnormal coagulation studies (prothrombin time [PT], partial thromboplastin time [PTT]).
-
Elevated white blood cell (WBC) count and sedimentation rate due to the inflammatory process involved in heart muscle cell damage.
-
Radionuclide imaging allows recognition of areas of decreased perfusion.
-
PET determines the presence of reversible heart muscle injury and irreversible or necrotic tissue; extent to which the injured heart muscle has responded to treatment can also be determined.
-
Cardiac muscle dysfunction noted on echocardiography.
P.388
Management
The American College of Cardiology and the AHA issued “Guidelines
for the Management of Patients with Unstable Angina and non-ST-Segment Elevation
MI.†These guidelines call for clinicians to begin treatment for acute chest
pain immediately, based on risk level and ECG changes, rather than waiting for
cardiac marker results, which was the traditional approach to diagnosis and
treatment of MI.
Therapy is aimed at reversing ischemia to preserve cardiac muscle
function, reduce the infarct size, and prevent death. Innovative modalities
provide early restoration of coronary blood flow. The use of pharmacologic
agents improves oxygen supply and demand, reduces and prevents dysrhythmias, and
inhibits the progression of CAD. Immediate reperfusion is desirable.
NURSING ALERT
Prompt identification of MI as well as ACS and
initiation of therapy is important. Time is muscle.
Oxygen Therapy
-
Usually given by nasal cannula.
-
Improves oxygenation to ischemic heart muscle.
Pain Control
Endogenous catecholamine release during pain imposes an increased
workload on the heart muscle, thus causing an increase in oxygen demand.
-
Morphine is used to relieve pain, to improve cardiac hemodynamics by reducing preload and afterload, and to provide anxiety relief.
-
Vasodilator therapy consists of nitroglycerin administered sublingually, via I.V., or transdermally.
-
Benzodiazepines are used with analgesics when anxiety complicates chest pain and its relief.
Pharmacologic Therapy
See Table 13-1.
TABLE 13-1 ACS Medications at a
Glance
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|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
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Other Medications
-
Thrombolytic agents, such as tissue plasma activator (Activase), streptokinase (Streptase), and reteplase (Retavase), reestablish blood flow in coronary vessels by dissolving thrombus.
-
No effect on the underlying stenosis that precipitated the thrombus to form
-
Administered I.V. or intracoronary
-
-
Antiarrhythmics, such as lidocaine (Xylocaine), decrease the ventricular irritability that occurs after MI.
Percutaneous Coronary Interventions
-
Mechanical opening of the coronary vessel can be performed during an evolving infarction.
-
Percutaneous coronary interventions (PCI), including percutaneous transluminal coronary angioplasty, coronary stenting, and arthrectomy can be used instead of or as an adjunct to thrombolytic therapy (see Percutaneous Transluminal Coronary Angioplasty, page 366).
Surgical Revascularization
-
Emergency CABG surgery can be performed within 6 hours of evolving infarction.
-
Definite treatment of the stenosis and less scar formation on the heart are the benefits of this therapy.
Complications
-
Rhythm disturbances
-
Sudden cardiac death due to ventricular arrhythmias
-
Infarct expansion (thinning and dilation of the necrotic zone)
-
Infarct extension (additional heart muscle necrosis occurring after 24 hours of acute infarction)
-
Heart failure (with 20% to 35% left ventricle damage)
-
Cardiogenic shock (see page 398)
-
Reinfarction
-
Ischemic cardiomyopathy
-
Cardiac rupture
-
Papillary muscle rupture
-
Ventricular mural thrombus
-
Thromboemboli
-
Ventricular aneurysm
-
Cardiac tamponade
-
Pericarditis (2 to 3 days after MI)
-
Psychiatric problems—depression, personality changes
Nursing Assessment
-
Gather information regarding the patient's chest pain:
-
Nature and intensity—describe the pain in patient's own words and compare it with pain previously experienced.
-
Onset and duration—exact time pain occurred as well as the time pain relieved or diminished (if applicable).
-
Location and radiation—point to the area where the pain is located and to other areas where the pain seems to travel.
-
Precipitating and aggravating factors—describe the activity performed just before the onset of pain and if any maneuvers and/or medications alleviated the pain.
-
-
Question patient about other symptoms experienced associated with the pain. Observe patient for diaphoresis, facial pallor, dyspnea, guarding behaviors, rigid body posture, extreme weakness, and confusion.
-
Evaluate cognitive, behavioral, and emotional status.
-
Question patient about prior health status with emphasis on current medications, allergies (opiate analgesics, iodine, shellfish), recent trauma or surgery, nonsteroidal anti-inflammatory drug (NSAID) ingestion, peptic ulcers, fainting spells, drug and alcohol use.
-
Analyze information for contraindications for thrombolytic therapy and PCI.
-
Gather information about presence or absence of cardiac risk factors.
-
Identify patient's social support system and potential caregivers.
-
Identify significant other's reaction to the crisis situation.
P.389
Nursing Diagnoses
See also Nursing Care Plan 13-1, pages 390
and 391.
-
Acute Pain related to oxygen supply and demand imbalance
-
Anxiety related to chest pain, fear of death, threatening environment
-
Decreased Cardiac Output related to impaired contractility
-
Activity Intolerance related to insufficient oxygenation to perform activities of daily living, deconditioning effects of bed rest
-
Risk for Injury (bleeding) related to dissolution of protective clotsP.390
P.391
P.392
-
Ineffective Tissue Perfusion (myocardial) related to coronary restenosis, extension of infarction
-
Ineffective Coping related to threats to self-esteem, disruption of sleep-rest pattern, lack of significant support system, and loss of control
NURSING
CARE PLAN 13-1
Caring for a Patient with Acute MI
Mr. M. is a 60-year-old male admitted to your unit with a diagnosis
of an acute inferior wall myocardial infarction (MI). From your assessment and
knowledge of acute MI, you develop your care plan.
Subjective data: Mr. M. is complaining of
severe crushing chest pain unrelieved by rest, which has lasted for 2 hours. The
pain is substernal and does not radiate. He tells you that he smokes two packs
of cigarettes per day, is a manager at an electronics firm, and that his father
died at age 59 from a heart attack.
Objective data: Vital signs: pulse 110
and irregular, blood pressure (BP) 90/68, respirations 28. His cardiac monitor
shows sinus tachycardia with frequent premature ventricular contractions (PVCs)
and his 12-lead electrocardiogram (ECG) shows ST elevation in leads II, III, and
AVF. He has no significant Q waves at this time. His heart sounds are
normal except for the irregularity, and his lungs are clear. He is pale,
diaphoretic, and holding his chest.
NURSING DIAGNOSIS
Pain related to an imbalance in oxygen supply
and demand
GOAL (EXPECTED OUTCOME)
Pain will be reduced.
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NURSING DIAGNOSIS
Decreased Cardiac Output related to decreased
cardiac contractility and dysrhythmias
GOAL (EXPECTED OUTCOME)
Cardiac output will improve.
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NURSING DIAGNOSIS
Anxiety related to chest pain, fear of death,
threatening environment, invasive therapies, and uncertain
prognosis
GOAL (EXPECTED OUTCOME)
Anxiety will be alleviated.
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Nursing Interventions
Reducing Pain
-
Handle patient carefully while providing initial care, starting I.V. infusion, obtaining baseline vital signs, and attaching electrodes for continuous ECG monitoring.
-
Maintain oxygen saturation greater than 92%.
-
Administer oxygen by nasal cannula if prescribed
-
Encourage patient to take deep breaths—may decrease incidence of dysrhythmias by allowing the heart to be less ischemic and less irritable; may reduce infarct size, decrease anxiety, and resolve chest pain.
-
-
Offer support and reassurance to patient that relief of pain is a priority.
-
Administer sublingual nitroglycerin as directed; recheck BP, heart rate, and respiratory rate before administering nitrate therapy and 10 to 15 minutes after dose.
-
Administer opioids as prescribed (morphine—decreases sympathetic activity and reduces heart rate, respirations, BP, muscle tension, and anxiety).
-
Use caution when administering opioids to elderly patients and those with chronic obstructive pulmonary disease, hypotension, or dehydration.
-
Remember that meperidine is rarely used because it can have a vagolytic effect and cause tachycardia, thus increasing myocardial oxygen demands.
-
-
Obtain baseline vital signs before giving agents and 10 to 15 minutes after each dose. Place patient in a supine position during administration to minimize hypotension.
-
Give I.V. nitroglycerin as prescribed. Monitor BP continuously with automatic BP machine (contraindicated with antithrombolytic therapy) or intra-arterially or every 5 minutes with auscultatory method while titrating for pain relief.
-
Frequently review with patient the importance of reporting chest pain, discomfort, and epigastric distress without delay.
GERONTOLOGIC ALERT
Elderly patients are extremely susceptible to
respiratory depression in response to opioids. Analgesic agents with less
profound effects on the respiratory center should be used. Anxiolytic agents
should also be used with caution.
DRUG ALERT
I.V. administration is the preferred route for
analgesic medication, because I.M. injections can cause elevations in serum
enzymes, resulting in an incorrect diagnosis of
MI.
Alleviating Anxiety
-
Rule out physiologic etiologies for increasing or new onset anxiety before administering as needed sedatives. Physiologic causes must be identified and treated in a timely fashion to prevent irreversible adverse or even fatal outcomes; sedatives may mask symptoms, delaying timely identification, diagnosis, and treatment.
-
Assess patient for signs of hypoperfusion, auscultate heart and lung sounds, obtain a rhythm strip, and administer oxygen as prescribed. Notify the health care provider immediately.
-
Document all assessment findings, health care provider notification and response, and interventions and response.
-
Explain to patient and family reasons for hospitalization, diagnostic tests, and therapies administered.
-
Explain equipment, procedures, and need for frequent assessment to patient and significant others.
-
Discuss with patient and family the anticipated nursing and medical regimen.
-
Explain visiting hours and need to limit number of visitors at one time.
-
Offer family preferred times to phone unit to check on patient's status.
-
-
Observe for autonomic signs of anxiety, such as increases in heart rate, BP, respiratory rate, tremulousness.
-
Administer antianxiety agents as prescribed.
-
Explain to patient the reason for sedation: undue anxiety can make the heart more irritable and require more oxygen.
-
Assure patient that the goal of sedation is to promote comfort and, therefore, should be requested if anxious, excitable, or “jittery†feelings occur.
-
Observe for adverse effects of sedation, such as lethargy, confusion, and/or increased agitation.
-
-
Maintain consistency of care with one or two nurses regularly assisting patient, especially if severe anxiety is present.
-
Offer back massage to promote relaxation, reduce muscle tension, and improve skin integrity.
-
Use techniques, such as guided imagery, to relieve tension and anxiety.
Maintaining Hemodynamic Stability
-
Monitor BP every 2 hours or as directed—hypertension increases afterload of the heart, increasing oxygen demand; hypotension causes reduced coronary and tissue perfusion.
-
Monitor respirations and lung fields every 2 to 4 hours or as prescribed.
-
Auscultate for normal and abnormal breath sounds (crackles may indicate left ventricular failure; diffuse crackles indicate pulmonary edema).
-
Observe for dyspnea, tachypnea, frothy pink sputum, orthopnea—may indicate left-sided heart failure, pulmonary embolus, pulmonary edema.
-
-
Evaluate heart rate and heart sounds every 2 to 4 hours or as directed.
-
Compare apical heart rate with radial pulse rate, and determine the pulse deficit.
-
-
Note presence of jugular vein distention and liver engorgement.
-
Estimate right atrial pressure by determining jugular venous pressure.
-
Observe for hepatojugular reflux.
-
-
Evaluate the major arterial pulses (weak pulse and/or presence of pulsus alternans indicates decreased cardiac output (CO); irregularity results from dysrhythmias).
-
Take body temperature every 4 hours or as directed (most patients develop an increase in temperature within 24 to 48 hours due to tissue necrosis).
-
Observe for edema.
-
Monitor skin color and temperature (cool, clammy skin and pallor associated with vasoconstriction secondary to decreased CO).
-
Be alert to change in mental status, such as confusion, restlessness, disorientation.
-
Employ hemodynamic monitoring as indicated.
-
Evaluate urine output (30 mL/hour)—decrease in volume reflects a decrease in renal blood flow.
-
Monitor for life-threatening dysrhythmias (common within 24 hours following infarctions).
-
Be vigilant for occurrence of premature ventricular beats—may predict ventricular fibrillation or ventricular tachycardia.
-
Anticipate possibility of reperfusion dysrhythmias after thrombolytic therapy.
-
Correct dysrhythmias immediately as directed. Lidocaine (Xylocaine) may be given prophylactically to protect against ventricular fibrillation and ventricular tachycardia.
-
Monitor laboratory values such as electrolytes that could increase risk of dysrhythmias; report abnormalities promptly.
-
NURSING ALERT
Auscultation of clear lungs in the presence of
cool, clammy skin, jugular vein distention, and hypotension may indicate right
ventricular infarction.
Increasing Activity Tolerance
-
Promote rest with early gradual increase in mobilization—prevents deconditioning, which occurs with bed rest.
-
Minimize environmental noise.
-
Provide a comfortable environmental temperature.
-
Avoid unnecessary interruptions and procedures.
-
Structure routine care measures to include rest periods after activity.
-
Discuss with patient and family the purpose of limited activity and visitors—to help the heart heal by lowering heart rate and BP to maintain cardiac workload at lowest level and decrease oxygen consumption.
-
Promote restful diversional activities for patient (reading, listening to music, drawing, crossword puzzles, crafts).
-
Encourage frequent position changes while in bed.
-
-
Assist patient with prescribed activities.
-
Assist patient to rise slowly from a supine position to minimize orthostatic hypotension.
-
Encourage passive and active range-of-motion (ROM) exercise as directed while on bed rest.
-
Measure the length and width of the unit so patients can gradually increase their activity levels with specific guidelines (walk one width [150 ft] of the unit).
-
Elevate patient's feet when out of bed in chair to promote venous return.
-
Implement a step-by-step program for progressive activity as directed. Typically can progress to the next step if they are free from chest pain and ECG changes during the activity.
-
Preventing Bleeding
-
Take vital signs every 15 minutes during infusion of thrombolytic agent and then hourly.
-
Observe for hematomas or skin breakdown, especially in potential pressure areas such as the sacrum, back, elbows, ankles.
-
Be alert to verbal complaints of back pain indicative of possible retroperitoneal bleeding.
-
Observe all puncture sites every 15 minutes during infusion of thrombolytic therapy and then hourly for bleeding.
-
Apply manual pressure to venous or arterial sites if bleeding occurs. Use pressure dressings for coverage of all access sites.
-
Observe for blood in stool, emesis, urine, and sputum.
-
Minimize venipunctures and arterial punctures; use heparin lock for blood sampling and medication administration.
-
Avoid I.M. injections.
-
Caution patient about vigorous tooth brushing, hair combing, or shaving.
-
Avoid trauma to patient by minimizing frequent handling of patient.
-
Monitor laboratory values: PT, International Normalized Ratio, PTT, hematocrit (HCT), and hemoglobin.
-
Check for current blood type and crossmatch.
-
Administer antacids or histamine-2 blockers as directed to prevent stress ulcers.
-
Implement emergency interventions as directed in the event of bleeding: fluid, volume expanders, blood products.
-
Monitor for changes in mental status and headache.
-
Avoid vigorous oral suctioning.
-
Avoid use of automatic BP device above puncture sites or hematoma. Use care in taking BP; use arm not being used for thrombolytic therapy.
Maintaining Tissue Perfusion
-
Observe for persistent and/or recurrence of signs and symptoms of ischemia, including chest pain, diaphoresis, hypotension—may indicate extension of MI and/or reocclusion of coronary vessel.
-
Report immediately.
-
Administer oxygen as directed.
-
Record a 12-lead ECG.
-
Prepare patient for possible emergency procedures: cardiac catheterization, bypass surgery, PCI, thrombolytic therapy.
P.394
Strengthening Coping Abilities
-
Listen carefully to patient and family to ascertain their cognitive appraisals of stressors and threats.
-
Assist patient to establish a positive attitude toward illness and progress adaptively through the grieving process.
-
Manipulate environment to promote restful sleep by maintaining patient's usual sleep patterns.
-
Be alert to signs and symptoms of sleep deprivation—irritability, disorientation, hallucinations, diminished pain tolerance, aggressiveness.
-
Minimize possible adverse emotional response to transfer from the intensive care unit to the intermediate care unit:
-
Introduce the admitting nurse from the intermediate care unit to the patient before transfer.
-
Plan for the intermediate care nurse to answer questions the patient may have and to inform patient what to expect relative to physical layout of unit, nursing routines, and visiting hours.
-
Patient Education and Health Maintenance
Goals are to restore patient to optimal physiologic, psychological,
social, and work level; aid in restoring confidence and self-esteem; develop
patient's self-monitoring skills, and assist in managing cardiac problems;
modify risk factors.
-
Inform the patient and family about what has happened to heart.
-
Explain basic cardiac anatomy and physiology.
-
Identify the difference between angina and MI.
-
Describe how the heart heals and that healing is not complete for 6 to 8 weeks after infarction.
-
Discuss what the patient can do to assist in the recovery process and reduce the chance of future heart attacks.
-
-
Instruct patient on how to judge the body's response to activity.
-
Introduce the concept that different activities require varying expenditures of oxygen.
-
Emphasize the importance of rest and relaxation alternating with activity.
-
Instruct patient how to take pulse before and after activity as well as guidelines for the acceptable increases in heart rate that should occur.
-
Review signs and symptoms indicative of a poor response to increased activity levels: chest pain, extreme fatigue, shortness of breath.
-
-
Design an individualized activity progression program for patient as directed.
-
Determine activity levels appropriate for patient as prescribed and by predischarge low-level exercise stress test.
-
Encourage patient to list activities he enjoys and would like to resume.
-
Establish the energy expenditure of each activity (ie, which are most demanding on the heart), and rank activities from lowest to highest.
-
Instruct patient to move from one activity to another after the heart has been able to manage the previous workload as determined by signs and symptoms and pulse rate.
-
-
Give patient specific activity guidelines, and explain that activity guidelines will be reevaluated after heart heals:
-
Walk daily, gradually increasing distance and time as prescribed.
-
Avoid activities that tense muscles, such as weight lifting, lifting heavy objects, isometric exercises, pushing and/or pulling heavy loads, all of which can cause vagal stimulation.
-
Avoid working with arms overhead.
-
Gradually return to work.
-
Avoid extremes in temperature.
-
Do not rush; avoid tension.
-
Advise getting at least 7 hours of sleep each night and take 20- to 30-minute rest periods twice per day.
-
Advise limiting visitors to three to four daily for 15 to 30 minutes and shorten phone conversations.
-
-
Tell patient that sexual relations may be resumed on advice of health care provider, usually after exercise tolerance is assessed.
-
If patient can walk briskly or climb two flights of stairs, he can usually resume sexual activity with familiar partner; resumption of sexual activity parallels resumption of usual activities.
-
Sexual activity should be avoided after eating a heavy meal, after drinking alcohol, or when tired.
-
-
Advise eating three to four small meals per day rather than large, heavy meals. Rest for 1 hour after meals.
-
Advise limiting caffeine and alcohol intake.
-
Driving a car must be cleared with health care provider at a follow-up visit.
-
Teach patient about medication regimen and adverse effects.
-
Instruct the patient to notify the health care provider when the following symptoms appear:
-
Chest pressure or pain not relieved in 15 minutes by nitroglycerin or rest
-
Shortness of breath
-
Unusual fatigue
-
Swelling of feet and ankles
-
Fainting, dizziness
-
Very slow or rapid heart beat
-
-
Assist patient to reduce risk of another MI by risk factor modification.
-
Explain to patient the major risk factors that can increase chances for having another MI.
-
Instruct patient in strategies to modify risk factors.
-
-
For additional information and support refer to AHA: http://www.americanheart.org, and the American College of Cardiology: http://www.acc.org.
Evaluation: Expected Outcomes
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