Nursing Interventions


Reducing Pain
  • Handle patient carefully while providing initial care, starting I.V. infusion, obtaining baseline vital signs, and attaching electrodes for continuous ECG monitoring.
  • Maintain oxygen saturation greater than 92%.
    • Administer oxygen by nasal cannula if prescribed
    • Encourage patient to take deep breaths -may decrease incidence of dysrhythmias by allowing the heart to be less ischemic and less irritable; may reduce infarct size, decrease anxiety, and resolve chest pain.
  • Offer support and reassurance to patient that relief of pain is a priority.
  • Administer sublingual nitroglycerin as directed; recheck BP, heart rate, and respiratory rate before administering nitrate therapy and 10 to 15 minutes after dose.
  • Administer opioids as prescribed (morphine -decreases sympathetic activity and reduces heart rate, respirations, BP, muscle tension, and anxiety).
    • Use caution when administering opioids to elderly patients and those with chronic obstructive pulmonary disease, hypotension, or dehydration.
    • Remember that meperidine is rarely used because it can have a vagolytic effect and cause tachycardia, thus increasing myocardial oxygen demands.
  • Obtain baseline vital signs before giving agents and 10 to 15 minutes after each dose. Place patient in a supine position during administration to minimize hypotension.
  • Give I.V. nitroglycerin as prescribed. Monitor BP continuously with automatic BP machine (contraindicated with antithrombolytic therapy) or intra-arterially or every 5 minutes with auscultatory method while titrating for pain relief.
  • Frequently review with patient the importance of reporting chest pain, discomfort, and epigastric distress without delay.
Alleviating Anxiety
  • Rule out physiologic etiologies for increasing or new onset anxiety before administering as needed sedatives. Physiologic causes must be identified and treated in a timely fashion to prevent irreversible adverse or even fatal outcomes; sedatives may mask symptoms, delaying timely identification, diagnosis, and treatment.
  • Assess patient for signs of hypoperfusion, auscultate heart and lung sounds, obtain a rhythm strip, and administer oxygen as prescribed. Notify the health care provider immediately.
  • Document all assessment findings, health care provider notification and response, and interventions and response.
  • Explain to patient and family reasons for hospitalization, diagnostic tests, and therapies administered.
  • Explain equipment, procedures, and need for frequent assessment to patient and significant others.
  • Discuss with patient and family the anticipated nursing and medical regimen.
    • Explain visiting hours and need to limit number of visitors at one time.
    • Offer family preferred times to phone unit to check on patient's status.
  • Observe for autonomic signs of anxiety, such as increases in heart rate, BP, respiratory rate, tremulousness.
  • Administer antianxiety agents as prescribed.
    • Explain to patient the reason for sedation: undue anxiety can make the heart more irritable and require more oxygen.
    • Assure patient that the goal of sedation is to promote comfort and, therefore, should be requested if anxious, excitable, or “jittery” feelings occur.
    • Observe for adverse effects of sedation, such as lethargy, confusion, and/or increased agitation.
  • Maintain consistency of care with one or two nurses regularly assisting patient, especially if severe anxiety is present.
  • Offer back massage to promote relaxation, reduce muscle tension, and improve skin integrity.
  • Use techniques, such as guided imagery, to relieve tension and anxiety.
Maintaining Hemodynamic Stability
  • Monitor BP every 2 hours or as directed -hypertension increases afterload of the heart, increasing oxygen demand; hypotension causes reduced coronary and tissue perfusion.
  • Monitor respirations and lung fields every 2 to 4 hours or as prescribed.
    • Auscultate for normal and abnormal breath sounds (crackles may indicate left ventricular failure; diffuse crackles indicate pulmonary edema).
    • Observe for dyspnea, tachypnea, frothy pink sputum, orthopnea - may indicate left-sided heart failure, pulmonary embolus, pulmonary edema.
  • Evaluate heart rate and heart sounds every 2 to 4 hours or as directed.
    • Compare apical heart rate with radial pulse rate, and determine the pulse deficit.
    • Auscultate heart for the presence of a third heart sound (failing ventricle), fourth heart sound (stiffening ventricular muscle due to MI), friction rub (pericarditis),

      murmurs (valvular and papillary muscle dysfunction, intraventricular septal rupture).
  • Note presence of jugular vein distention and liver engorgement.
    • Estimate right atrial pressure by determining jugular venous pressure.
    • Observe for hepatojugular reflux.
  • Evaluate the major arterial pulses (weak pulse and/or presence of pulsus alternans indicates decreased cardiac output (CO); irregularity results from dysrhythmias).
  • Take body temperature every 4 hours or as directed (most patients develop an increase in temperature within 24 to 48 hours due to tissue necrosis).
  • Observe for edema.
  • Monitor skin color and temperature (cool, clammy skin and pallor associated with vasoconstriction secondary to decreased CO).
  • Be alert to change in mental status, such as confusion, restlessness, disorientation.
  • Employ hemodynamic monitoring as indicated.
  • Evaluate urine output (30 mL/hour)-decrease in volume reflects a decrease in renal blood flow.
  • Monitor for life-threatening dysrhythmias (common within 24 hours following infarctions).
    • Be vigilant for occurrence of premature ventricular beats- may predict ventricular fibrillation or ventricular tachycardia.
    • Anticipate possibility of reperfusion dysrhythmias after thrombolytic therapy.
    • Correct dysrhythmias immediately as directed. Lidocaine (Xylocaine) may be given prophylactically to protect against ventricular fibrillation and ventricular tachycardia.
    • Monitor laboratory values such as electrolytes that could increase risk of dysrhythmias; report abnormalities promptly.
Increasing Activity Tolerance
  • Promote rest with early gradual increase in mobilization- prevents deconditioning, which occurs with bed rest.
    • Minimize environmental noise.
    • Provide a comfortable environmental temperature.
    • Avoid unnecessary interruptions and procedures.
    • Structure routine care measures to include rest periods after activity.
    • Discuss with patient and family the purpose of limited activity and visitors -to help the heart heal by lowering heart rate and BP to maintain cardiac workload at lowest level and decrease oxygen consumption.
    • Promote restful diversional activities for patient (reading, listening to music, drawing, crossword puzzles, crafts).
    • Encourage frequent position changes while in bed.
  • Assist patient with prescribed activities.
    • Assist patient to rise slowly from a supine position to minimize orthostatic hypotension.
    • Encourage passive and active range-of-motion (ROM) exercise as directed while on bed rest.
    • Measure the length and width of the unit so patients can gradually increase their activity levels with specific guidelines (walk one width [150 ft] of the unit).
    • Elevate patient's feet when out of bed in chair to promote venous return.
    • Implement a step-by-step program for progressive activity as directed. Typically can progress to the next step if they are free from chest pain and ECG changes during the activity.
Preventing Bleeding
  • Take vital signs every 15 minutes during infusion of thrombolytic agent and then hourly.
  • Observe for hematomas or skin breakdown, especially in potential pressure areas such as the sacrum, back, elbows, ankles.
  • Be alert to verbal complaints of back pain indicative of possible retroperitoneal bleeding.
  • Observe all puncture sites every 15 minutes during infusion of thrombolytic therapy and then hourly for bleeding.
  • Apply manual pressure to venous or arterial sites if bleeding occurs. Use pressure dressings for coverage of all access sites.
  • Observe for blood in stool, emesis, urine, and sputum.
  • Minimize venipunctures and arterial punctures; use heparin lock for blood sampling and medication administration.
  • Avoid I.M. injections.
  • Caution patient about vigorous tooth brushing, hair combing, or shaving.
  • Avoid trauma to patient by minimizing frequent handling of patient.
  • Monitor laboratory values: PT, International Normalized Ratio, PTT, hematocrit (HCT), and hemoglobin.
  • Check for current blood type and crossmatch.
  • Administer antacids or histamine-2 blockers as directed to prevent stress ulcers.
  • Implement emergency interventions as directed in the event of bleeding: fluid, volume expanders, blood products.
  • Monitor for changes in mental status and headache.
  • Avoid vigorous oral suctioning.
  • Avoid use of automatic BP device above puncture sites or hematoma. Use care in taking BP; use arm not being used for thrombolytic therapy.
Maintaining Tissue Perfusion
  • Observe for persistent and/or recurrence of signs and symptoms of ischemia, including chest pain, diaphoresis, hypotension - may indicate extension of MI and/or reocclusion of coronary vessel.
  • Report immediately.
  • Administer oxygen as directed.
  • Record a 12-lead ECG.
  • Prepare patient for possible emergency procedures: cardiac catheterization, bypass surgery, PCI, thrombolytic therapy.



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