Sunday, September 14, 2014

Ineffective Breathing Pattern - NCP for Acute Myocardial Infarction

Nursing Care Plan for Acute Myocardial Infarction

The term myocardial infarction pathologically denotes the death of cardiac myocytes due to extended ischemia, which may be caused by an increase in perfusion demand or a decrease in blood flow. AMI falls in the spectrum of acute coronary syndromes (ACS), which includes unstable angina (UA), non–ST-elevation myocardial infarction (NSTEMI), and ST-elevation myocardial infarction (STEMI)

Persistent elevation of the ST-segment on ECG signifies total occlusion of a coronary artery that causes necrosis of the myocardial tissue. This condition is STEMI. ACS without ST-segment elevation may either be NSTEMI or UA

NSTEMI is more severe than UA. In this condition, the ischemia in the cardiac tissue is extensive enough to release cardiac biomarkers (troponin I or T) into the blood, but the occlusion is not as complete enough to cause elevation of the ST-segment.(

Nursing Diagnosis for Acute Myocardial Infarction

Ineffective Breathing Pattern related to hyperventilation, anxiety

Goal :
Breathing pattern becomes effective

Outcomes :
  • Demonstrate effective cough and breath sounds were clean, no cyanosis and dyspnea (able to produce a sputum sample, is able to breathe easy, no pursed lips)
  • Showed a patent airway (the client does not feel suffocated, the rhythm of breath, respiratory frequency in the normal range, no abnormal breath sounds)
  • Vital signs within normal range.


Airway Management :
  • Open the airway, use techniques jaw thrust or chin lift if necessary.
  • Position the patient to maximize ventilation.
  • Identification of patients need artificial airway equipment installation.
  • Attach mayo if necessary.
  • Perform chest physiotherapy.
  • Remove the secret by coughing or suctioning.
  • Auscultation of breath sounds, note the presence of additional noise.
  • Perform suction on the mayo.
  • Give bronchodilators if necessary.
  • Give a humidifier.
  • Set intake to optimize fluid balance.
  • Monitor espirasi and O2 status.

Respiratory Monitoring :
  • Monitor the average depth, rhythm and expiratory efforts.
  • Note the movement of the chest, observe symmetry, the use of additional muscles, supraclavicular and intercostal muscle retraction.
  • Monitor breath sounds like snoring.
  • Monitor breathing patterns : bradipnea, tachypnea, kusmaul, hyperventilation, cheyne stokes, biot.
  • Note the location of the trachea.
  • Monitor the diaphragm muscle fatigue (paradoxical movement).
  • Auscultation of breath sounds , note areas of decreased / no ventilation or extra sound.
  • Determine the need auscultation suction with crakles and crackles, in the main airway.
  • Auscultation of lung sounds after the action to find the results.

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