About
"Heart Attack" causing a disruption of blood flow and oxygen to myocardial tissue, potentially causing tissue necrosis or death.
Assess
Pain ( tightness, burning, pressure, heartburn, radiating, neck, jaw, chest, back); VS, heart rhythm ( arrhythmia, presence of s4), anxious, cool, diaphoretic, lung sounds ( crackles, dyspnea)
Complications
Death, hypoxemia, anoxia, hypoxia, heart failure
Diagnosis
- Acute pain related to tissue ischemia
- Ineffective tissue perfusion related to interruption of myocardial blood flow
Goals
- The client will be free from pain.
- The client will verbalize understanding of treatment plan.
- The client will have adequate oxygenation.
Interventions
- Maintain NPO prior to surgery and start with clear liquids after surgery.
- Monitor electrolytes, cardiac enzymes, intake and output, ECG, pain, pulse oximetry, fluid balance, circulation, and breath sounds.
- Monitor onset, location, precipitating factors, alleviating factors, intensity of chest pain.
- Prepare for procedures ( CABG, cardiac cath, angioplasty, etc.) as indicated.
- Teach client non-pharmacological treatments including low sodium, low fat, low cholesterol diet, exercise, weight reduction, smoking cessation, avoiding alcohol.
- Teach client about medications including rationale, side effects, dosing schedule.
- Teach client how to monitor blood pressure and when to seek follow-up treatment.
- Teach client about disease and its effects on other body areas and s/s of complications.
- Teach client how to use AED if candidate for having one in the home.
- Begin cardiac rehabilitation as ordered.
- Monitor for signs/ symptoms of complications.
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