Acute Myocardial Infarct (MI) Nursing Diagnosis Nanda

Acute myocardial infarct (MI), commonly known as a heart attack, is a condition characterized by ischemic injury and necrosis of the cardiac muscle. Ischemic injury occurs when the blood supply is insufficient to meet the tissue demand for metabolism. More than two thirds of myocardial infarctions occur in lesions that are less than 60% severe.

Acute Myocardial Infarct (MI) Nursing Diagnosis Nanda

1.  Acute pain related to tissue ischemia secondary to arterial blockage

Characterized by:
  • Chest pain with / without deployment
  • facial grimacing
  • nervous
  • delirium
  • Changes in pulse, blood pressure.
  • Pain is reduced
Results Criteria:
  • Chest pain scale was reduced for example from 3 to 2, or from 2 to 1
  • Facial expression relaxed / calm, not tense
  • not anxious
  • Pulse 60-100 times / minute
  • Blood pressure of 120/80 mmHg

2. Risk for Decreased Cardiac Output related to changes in power factors, reduction miocard characteristics.

  • Cardiac output improved / stable

Results Criteria:
  • No edema
  • No dysrhythmias
  • Normal urine output
  • Vital signs within normal limits

3. Risk for excess fluid volume: extravascular related to decreased renal perfusion, increased sodium / water retention, increased hydrostatic pressure, decreased plasma proteins.

Objectives :
  • Balance the volume of fluid can be retained for nursing actions performed during the hospital
Results Criteria:
  • Blood pressure within normal limits
  • There was no distention of peripheral veins / vein and dependent edema
  • Lungs clear
  • Ideal body weight

4. Impaired gas exchange related to interruption of blood flow to the pulmonary alveoli or major failure, alveolar-capillary membrane changes (atelectasis, collapse the airway / alveolar, pulmonary edema / effusion, excessive secretion / active bleeding)

Characterized by:
  • Severe dyspnea
  • Nervous
  • Cyanosis
  • Hypoxemia

  • Oxygenation with the normal range

Expected outcomes:
  • No shortness of breath
  • Not anxious

Related Articles:

No comments:

Post a Comment