Nursing Post-MI
Question Received:
What recommendations would you give in order to deliver excellent nursing care for the patient suffering from pain and dyspnoea, post MI
Response:
What recommendations would you give in order to deliver excellent nursing care for the patient suffering from pain and dyspnoea, post MI?
1st February 2000
Nursing care and treatment for a patient who is experiencing pain and dyspnoea following a myocardial infarction (MI) will change in response to the person's changing condition. Also, patterns of care will be influenced by the Nursing Model being used within the particular practice setting. However, the stages of history-taking, assessing, planning, implementing and evaluating would be likely to form a procedural framework around which the nursing care would be delivered.
Pain
The chest pain that frequently occurs during and immediately following a myocardial infarction is both intense and frightening. Severe pain, coupled with the anxiety associated with hospital admission, leads to increased sympathetic activity. As a result myocardial oxygen demand increases and combined with the acute disturbances to the internal environment makes the heart more susceptible to dysrrhythmias. The opioid analgesics morphine or diamorphine are normally prescribed by the doctor and administered for pain relief (Grahame-Smith and Aronson, 1994). These drugs may be repeated, as prescribed, until the person is pain-free. Evaluating the person's response to these is essential since pain is such a subjective experience, and some kind of measure - a 'pain ruler' - will give a useful indication concerning the degree of relief experienced or yet to be obtained.
Opioid analgesics have the additional advantage of relieving the stress and anxiety that accompanies the illness. In addition such drugs have peripheral vasodilator properties, both venous and arteriolar, which brings about an improvement in cardiac function and relief of dyspnoea (Grahame-Smith and Aronson, 1994). Careful monitoring of the person's response is important as these preparations can produce hypotension and respiratory depression. Antiemetics are administered to treat the nausea that can accompany acute chest pain and also to counteract the side effects of opioid administration.
Dyspnoea
The presence of dyspnoea may suggest that the person is hypotensive as a result of impairment in left ventricular function. This leads to a rise in pulmonary venous and capillary pressure and an increase in blood and water volume within the lungs, i.e. pulmonary oedema. Hypotension can also occur whenever infarction provokes parasympathetic overactivity. If prescribed, oxygen will be administered either via nasal catheters (cannulae) or a close fitting mask. Note: the concentration will be modified if the person has a history of chronic obstructive airways disease. Nursing care involves assessing and recording the degree of dyspnoea that the person has, and administering prescribed drugs. Frusemide, a loop diuretic administered intravenously is an example of a diuretic commonly administered. The nurse carefully monitors the person's response. The person will need to be well supported sitting up or semi-recumbent in bed (providing they are not hypotensive). Bed rest is encouraged for at least the first 24-36hrs. and until the clinical recordings indicate that the option of sitting out in an arm chair is reasonable.
In addition to the measures outlined above, nitrates are frequently administered intravenously (via a continuous infusion pump) during the acute phase and then sublingually. Nitrates are vasodilators which affect veins mainly and arteries to a lesser extent (Smith, 1987). Vasodilation reduces pre-load (filling of the heart during diastole) and afterload (the resistance against which the heart pumps) and thus reduces the strain on the heart. Nitrates contribute towards a reduction in chest pain, and if acute left ventricular failure is present may also lessen the degree of dyspnoea present. Again the person's response to the administration of nitrates is carefully evaluated and the dose adjusted accordingly.
References
Grahame-Smith, D.G., and Aronson, J.K. (1994) The drug therapy of cardiovascular disorders - drug therapy in acute myocardial infarction. In: Oxford textbook of clinical pharmacology and drug therapy. Oxford: Oxford University Press (Chapter 23 p 272).
Smith, S. (1987) Drugs in angina and myocardial infarction. Nursing Times, 83(22), 52-54 (Jun 3).