Primary and Secondary Assessment for Myocardial Infarction

Nursing Care Plan for Acute Myocardial Infarction


Primary Assessment of Myocardial Infarction
1. Airways

• Blockage or accumulation of secretions.
• Wheezing or crackles.

2 Breathing

• Congested with light activity or rest.
• RR is more than 24 times / minute, shallow irregular rhythm.
• Ronchi, crackles.
• Expansion of the chest is not full.
• The use of accessory muscles of breath.

3 Circulation

• Weak pulse, irregular.
• Tachycardia.
• Blood pressure increases / decreases.
• Edema.
• Restless.
• Cold acral.
• Pale skin, cyanosis.
• Decreased urine output.

Secondary Assessment of Myocardial Infarction
1 Activity

• Symptoms: Weakness, fatigue, can not sleep, sedentary lifestyles, irregular exercise schedule.
• Signs: Tachycardia, dyspnea at rest or activity.

2 Circulation

• Symptoms: history of previous AMI, coronary artery disease, blood pressure problems, diabetes mellitus.
• Signs: Blood pressure; can be normal / up / down. Postural changes recorded from sleeping to sitting or standing. pulse; can be normal, full or not strong or weak / strong quality with slow capillary refill, irregular (dysrhythmias). Heart sounds; Extra heart sounds: S3 or S4 may indicate heart failure or decreased ventricular kontraktilits or complaint. murmur; when there is a demonstrated failure of valves or heart muscle dysfunction. friction; suspected pericarditis. Heart rhythm can be regular or irregular. edema; juguler venous distention, edema dependent, peripheral, generalized edema, there may be crackles with heart failure or ventricular. color; Pallor or cyanosis, flat nails, mukossa membranes or lips.

3 Ego integrity

• Symptoms: Denying important symptoms or any condition fear of dying, feeling the end is near, angry at the disease or treatment, worry about finances, work, family.
• Signs: turned, denial, anxiety, lack of eye contact, anxiety, anger, attack behavior, focus on self, pain coma.

4 Elimination

• Signs: normal, decreased bowel sounds.

5. Food or fluid

• Symptoms: nausea, anorexia, belching, heartburn or a burning sensation.
• Signs: decreased skin turgor, dry skin, sweating, vomiting, weight changes.

6 Hygiene

• Symptoms or signs: lesulitan perform maintenance tasks.

7 Neurosensory

• Symptoms: dizziness, throbbing during sleep or when you wake up (sitting or resting)
• Signs: mental changes, weakness

8 Pain or discomfort

• Symptoms: sudden onset of chest pain (may or may not be related to the activity), not relieved by rest or nitroglycerin (although mostly in and visceral pain). Location: A typical on the anterior chest, substernal, precordial, can spread to the hands, ranhang, face. No specific location such as epigastric, elbows, jaw, abdomen, back, neck. Quality: "Crushing", narrowed, weight, sedentary, depressed. Intensity: Normally 10 (on a scale of 1 -10), may experience the worst pain ever experienced.
• Note: there may be no pain in postoperative patients, diabetes mellitus, hypertension, elderly.

9 Breathing:

• Symptoms: dyspnea on exertion or at rest, nocturnal dyspnea, cough with or without sputum production, history of smoking, chronic respiratory disease.
• Signs: increased frequency of breathing, shortness of breath / strong, pale, cyanosis, breath sounds (clean, krekles, wheezing), sputum.

10. Social Interaction

• Symptoms: Stress, Difficulty coping with a stressor such as: disease, treatment in hospital.
• Signs:. Difficulty rest in peace, too emotional response (constantly angry, scared), withdrew.

Nursing Care Plan for Cardiovascular Disease : Myocardial Infarction

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