CONCEPT MAP MYOCARDIAL INFARCTION.pptx - NURSING ASSESSMENT Sub sternal chest pain\/pressure radiating to the left arm Pain or discomfort in jaw back or

CONCEPT MAP MYOCARDIAL INFARCTION.pptx - NURSING ASSESSMENT...

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NURSING ASSESSMENT Sub sternal chest pain/pressure radiating to the left arm. Pain or discomfort in jaw, back or shoulder, or abdomen Occurring without cause, usually in the morning Relieved only by opioids Lasting 30 min or more Frequent associated symptoms: nausea/vomiting Diaphoresis Dyspnea Feeling of fear or anxiety Dysrhythmias Fatigue Palpitations Epigastric distress Anxiety Dizziness Disorientation/acute confusion Feeling “short of breath” DIAGNOSTICS Troponins T and I, creatine kinase- MB (CK-MB), and myoglobin. ECG’s, Thallium scans, contrast- enhanced cardiovascular magnetic resonance. Cardiac catherization, MANAGEMENT Oxygen, vital signs, ensure an IV access, morphine sulfate, nitroglycerin, aspirin,antiplatelet drugs, MONA- morphine,oxygen,nitrogen, aspirin, Glycoproteinf (GP) inhibitors, Beta- blockers,angiotension coveritng enzyme inhibitors or angiotensin receptor blockers, calcium channel blockers, thrombolytic therapy, primary percutaneous transluminal coronary angioplasty, increasing activity tolerance, cardiac rehabilitation, teach effective coping mechanisms, decrease cardiac ouput , ETIOLOGY Decreased oxygenation to myocardial tissue. Approximately 50% of all myocardial infarctions in the United States occur in people younger than 65 years Nursing DX #2 Decreased tissue perfusion related to decreased cardiac output as evidence chest pain, change in v/s, dyspnea, dysrhythmias Identify 5 or more Nursing Interventions: assess oxygenation, assess v/s, review laboratory data, monitor effectiveness of medications, monitor cardiac rhythm Nursing DX #3 Acute Pain related to poor tissue perfusion as evidence by chest pain, dyspnea, palpitations. Identify 5 or more Nursing Interventions: assess s/s pain, administer pain medication, assess for pain relief, assess v/s, assess oxygenation, Pathophysiology Presence of Risk Factors Coronary atherosclerosis, coronary embolism Myocardial ischemia Myocardial cell damage Catecholamine's release (Increase Heart rate, increase pain) Chest Pain Nursing DX #4 Activity intolerance related to decreased oxygenation as evidenced by fatigue and dyspnea Identify 5 or more Nursing Interventions: Identify precipitating factors, provide supplemental oxygen, note clients reports of weakness, fatigue, provide rest periods, monitor v/s Nursing DX #5 Risk for Electrolyte imbalance related to pharmacological interventions as evidence by dysrhythmias, and palpitations.
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