Nursing Assessment for Acute Myocardial Infarction (AMI) - Secondary

Nursing Assessment for Acute Myocardial Infarction (AMI)

Myocardial infarction, commonly known as a heart attack, is the irreversible necrosis of heart muscle secondary to prolonged ischemia. This usually results from an imbalance in oxygen supply and demand, which is most often caused by plaque rupture with thrombus formation in a coronary vessel, resulting in an acute reduction of blood supply to a portion of the myocardium.

Nursing Assessment for Acute Myocardial Infarction (AMI)

Secondary Assessment needs to be done on the Nursing Care Plan for Acute Myocardial Infarction (AMI) :

Activities
- Symptoms:
  - Weakness
  - Fatigue
  - Can not sleep
  - Settled lifestyle
  - No regular exercise schedule
- Signs:
  - Tachycardia
  - Dyspnea at rest or activity
Circulation
- Symptoms:
  - History of Acute Myocardial Infarction (AMI)
  - Coronary artery disease
  - Blood pressure problems
  - Diabetes mellitus.
- Signs:
  - Blood pressure: normal / up / down. Postural changes recorded from the bed to sit or stand
  - Pulse: normal, full or not strong or weak / strong quality with slow capillary filling, irregular (dysrhythmias)
  - Heart sound: an extra heart sound: S3 or S4 may indicate heart failure or decreased contractility / complaints ventricle
  - Murmur: If there are shows valve failure or dysfunction of heart muscle
  - Friction: suspected pericarditis
  - Heart rhythm can be regular or irregular
  - Edema: juguler venous distention, edema dependent, peripheral, general edema, cracles may exist with heart failure or ventricular
  - Color: Pale or cyanotic, flat nail, on mucous membranes or lips

Ego integrity
- Symptoms: an important symptom or deny the existence of conditions of 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, aggression, coma pain

Elimination
- Signs: normal, decreased bowel sounds.
Food or fluid
- Symptoms: nausea, anorexia, belching, heartburn, or burning
- Signs: decreased skin turgor, dry skin, sweating, vomiting, weight changes
Hygiene
- Symptoms or signs: difficulty perform maintenance tasks
Neuro Sensory
- Symptoms: dizziness, throbbing during sleep or while awake (sitting or resting)
- Signs: mental changes, weakness

Pain or discomfort
- Symptoms:
  - Sudden onset of chest pain (may or may not relate to activities), not relieved by rest or nitroglycerin (although most deep and visceral pain)
  - Location: Typical on the anterior chest, Substernal, precordial, can spread to the hands, jaw, face. No specific location such as epigastric, elbow, jaw, abdomen, back, neck.
  - Quality: "Crushing", narrow, heavy, settle down, depressed, as can be seen.
  - Intensity: Usually 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
Respiratory:
- Symptoms:
  - Dyspnea with or without job
  - Nocturnal dyspnea
  - Cough with or without sputum production
  - History of smoking, chronic respiratory disease.
- Signs:
  - Increased respiratory rate
  - Shortness of breath / strong
  - Pallor, cyanosis
  - Breath sounds (clean, cracles, wheezing), sputum
Social interactions
- Symptoms:
  - Stress
  - Difficulty coping with the stressors that exist eg illness, treatment in hospital
- Signs:
  - Difficulty rest - sleep
  - Response too emotional (angry constantly, fear)
  - Withdraw