Typical Complaint in Patients with Acute Myocardial Infarction (AMI)


Typical complaint is retrosternal chest pain, such as squeezing, pressure, plugging, heat or crushed heavy objects. The pain may spread to the arms (usually the left), shoulders, neck, jaw and even to the back and epigastrium. The pain lasts longer than angina pectoris and unresponsive to nitroglycerin. Sometimes, especially in diabetic patients, and the elderly, found no pain at all. The pain can be accompanied by nausea, vomiting, spasms, dizziness, sweating, palpitations or syncope. Patients often looked frightened. Although AMI can be the first manifestation of coronary heart disease, but if history is done carefully it is often actually been preceded by complaints of angina, an uneasy feeling in the chest or epigastric.

Abnormalities on physical examination no specific and can be normal. Can be found the S2 heart sounds are broken, paradoxical and gallop rhythm. Crepitation basal showed lung dam. Tachycardia, pallor, cold and hypotension are found in relatively more severe cases, sometimes found pulsation dyskinetic-looking or are in the inferior wall of the chest at the IMA.

Although the majority of individuals do not show obvious signs of myocardial infarction, clinical manifestations usually include:
  • Sudden chest pain.
  • Nausea and vomiting.
  • Feeling weak.
  • Cold and pale skin.
  • A decrease of urine.
  • Tachycardia due to the increase.
  • Sympathetic stimulation of the heart.
  • Anxious.
  • The pain may spread to the arms (generally to the left), shoulders, neck, jaw, and even to the back and epigastrium.
  • The pain lasts longer than usual angina pectoris and unresponsive to nitroglycerin.

Anyone who had a heart attack will feel the complaints are of course different, but generally a person will feel some specific things like:
  1. Chest pain, muscle where lack of blood supply (called ischemia conditions) that affect the need of oxygen by the muscles is reduced. The result is excessive metabolism causing cramps or spasms. Pain is felt in the center of the chest, it can spread to the back of the chest, to the left of the base of the neck, shoulders and upper arms and left hand. Some patients may experience abdominal pain upper part (the base of the center rib and even part of the stomach), where the pain is more severe and does not disappear despite being rested or given cardiac pain medication (nitroglycerin). This is called angina, patients feel uneasy with tightness in the chest and like to feel chest knead.
  2. Shortness of breath, usually felt by people who have heart failure. Tightness is a result of the entry of fluid into the air cavities in the lungs (pulmonary congestion or pulmonary edema).
  3. Fatigue or tiredness, Abnormalities of the heart can cause heart pumping that was not optimal. As a result, the blood supply to the muscles of the body while doing the activity will be reduced, This causes the patient to feel weak and tired. Such symptoms are mild, people just trying to reduce its activity and assume that it is only the aging process.
  4. There is a feeling of pounding (palpitations).
  5. Dizziness and fainting, It can be an early symptom of patients with coronary heart disease. Where decreased blood flow due to rate or abnormal heart rhythm or for worse pumping ability, can cause dizziness and fainting.
  6. Bluish on the lips, fingers and toes as a sign of inadequate blood flow throughout the body.
  7. Sudden cold sweat, and others such as nausea and anxiety.

Signs of a heart attack:
  1. Sense depressed (feels crushed heavy burden, pain, pinched and burning) that causes shortness of breath and choking on the neck.
  2. The pain may radiate to the left arm, neck and back.
  3. The pain can last about 15-20 minutes and occurs continuously.
  4. Arise cold sweat, body weakness, heart palpitations and even unconscious.
  5. The pain can be reduced when taking a break, but will gain weight if the patient is on the move.

Nursing Diagnosis for Diabetes Mellitus : Fluid Volume Deficits

Diabetes mellitus (or diabetes) is a chronic, lifelong condition that affects your body's ability to use the energy found in food. There are three major types of diabetes: type 1 diabetes, type 2 diabetes, and gestational diabetes.



Fluid Volume Deficits Definition : Decreased intravascular fluid, interstitial or intracellular.

Defining characteristics :
  • Thirsty.
  • Decreased skin turgor and tongue.
  • Decreased venous filling.
  • Skin and mucous membranes dry.
  • Increased heart rate, decreased blood pressure, decreased volume and pulse pressure.
  • Weight loss is sudden (except the 3rd room).
  • Weakness.

Related factors:
  • Loss of fluid volume.
  • Failure mechanisms of regulation (diabetes insipidus, hyperaldosteronisme).

Goal :
After nursing actions 2x24 hours, expected the patient does not experience pain with indicator :
  • Maintain urine output in accordance with the age and weight, normal urine specific gravity.
  • Blood pressure, pulse, body temperature within normal limits.
  • No signs of dehydration, elasticity good skin turgor, mucous membranes moist, no excessive thirst.
  • Orientation to time and place well.
  • The number and the respiratory rhythm within normal limits.
  • Electrolytes, hemoglobin, Hmt within normal limits.
  • urine pH within normal limits.
  • Intake of oral and intravenous adequate.


NOC :
  • The patient will have a normal urine concentration.
  • The patient had a hemoglobin and hematocrit within normal limits for the patient.
  • The patient did not experience abnormal thirst.
  • The patient has a balance of intake and output balance within 24 hours.
  • The patient show good hydration.
  • The patient had oral fluid / intravenous adequate.
NIC :
  • Maintain records accurate intake and output.
  • Monitor the status of hydration (moisture mucous membranes, adequate pulse, orthostatic blood pressure), if necessary.
  • Monitor vital signs every 15 minutes - 1 hour.
  • Collaboration of IV fluids.
  • Monitor nutritional status.
  • Give oral fluids.
  • Encourage families to help patients eat.
  • Collaboration with doctor if signs of excess fluid appears to worsen.
  • Attach the catheter if necessary.
  • Monitor intake and urine output every 8 hours.

Source :
http://nurse-books.blogspot.com/2015/01/fluid-volume-deficits-related-to.html

Ineffective Airway Clearance related to Rhinosinusitis

Rhinosinusitis or sinusitis is inflammation of the paranasal sinuses. It can be due to infection, allergy, or autoimmune problems. Most cases are due to a viral infection and resolve over the course of 10 days.

Rhinosinusitis or sinusitis is defined as an inflammation of the mucous membrane that lines the paranasal sinuses and is classified chronologically into several categories:
  • Acute rhinosinusitis — a new infection that may last up to four weeks and can be subdivided symptomatically into severe and non-severe;
  • Recurrent acute rhinosinusitis — four or more separate episodes of acute sinusitis that occur within one year;
  • Subacute rhinosinusitis — an infection that lasts between four and 12 weeks, and represents a transition between acute and chronic infection;
  • Chronic rhinosinusitis — when the signs and symptoms last for more than 12 weeks; and
  • Acute exacerbation of chronic rhinosinusitis — when the signs and symptoms of chronic rhinosinusitis exacerbate, but return to baseline after treatment.
All these types of sinusitis have similar symptoms, and are thus often difficult to distinguish. Acute sinusitis is very common. Roughly ninety percent of adults have had sinusitis at some point in their life.


Nursing Diagnosis for Rhinosinusitis : Ineffective Airway Clearance related to excessive mucus.

NOC :
  • Respiratory status : Ventilation
  • Respiratory status : Airway patency
  • Aspiration Control
Expected outcomes :
  • Demonstrate effective cough and breath sounds were clean, no cyanosis and dyspnea (able to produce a sputum sample, was able to breathe easily, no pursed lips).
  • Indicates that a patent airway (the client does not feel suffocated, the rhythm of breathing, respiratory frequency in the normal range , no abnormal breath sounds).
  • Being able to identify and prevent the factors that can inhibit airway.


NIC :

Airway Management
  • Open the airway, use techniques chin lift or jaw thrust if necessary.
  • Position the patient to maximize ventilation.
  • Identification of the patient's need for installation tools artificial airway.
  • Installing mayo if necessary.
  • Perform chest physiotherapy if necessary.
  • Remove secretions by coughing or suctioning.
  • Auscultation of breath sounds, note the presence of additional noise.
  • Perform suction on the mayo.
  • Give bronchodilators if necessary.
  • Give humidifier wet gauze, with NaCl moist.
  • Set intake to optimize fluid balance.
  • Monitor respiration and O2 status.

Airway Suction
  • Ensure the needs of oral / tracheal suctioning.
  • Auscultation of breath sounds before and after suctioning.
  • Inform the client and family about suctioning.
  • Ask the client a deep breath before suction done .
  • Give O2 by using a nasal, to facilitate nasotracheal suction.
  • Use sterile tools every action.
  • Instruct the patient to rest and deep breath, after the catheter is removed from the nasotracheal.
  • Monitor the status of the patient oxygen.
  • Teach the patient's family, how to perform suction.
  • Stop suction and administer oxygen if the patient showed bradycardia, increase in O2 saturation, etc.
Source :
http://nurse-books.blogspot.com/2015/01/nursing-care-plan-for-ineffective.html

Nursing Care Plan for Hyperthermia related to Dengue Hemorrhagic Fever (DHF)


Dengue hemorrhagic fever is a severe and sometimes fatal infection that occurs tropical regions. The dengue virus is transmitted by mosquitoes. A more severe version of the infection called dengue hemorrhagic fever can involve significant bleeding and a drop in blood pressure that can cause shock and death. This condition is sometimes known as dengue shock syndrome.

Dengue hemorrhagic fever can occur when a person is bitten by a mosquito and exposed to blood infected with the dengue virus. Those who are repeatedly exposed to the dengue virus often experience more acute symptoms and are at risk for dengue hemorrhagic fever.


Nursing Diagnosis : Hyperthermia related to disease process (viremia)

Goal :
Patient 's body temperature can be reduced.

Outcome :
  • Comfortable body condition.
  • Temperature 36,80C-37,50C.
  • Blood pressure : 120/80 mmHg.
  • Respiration : 16-24 x / mnt.
  • Pulse : 60-100 x / mnt.

Intervention :
  • Assess the onset of fever.
  • Observation of vital signs (temperature, pulse, blood pressure, respiration) every 3 hours.
  • Instruct the patient to drink (2.5 liters / 24 hours).
  • Give warm compresses.
  • Suggest to not wear thick blankets and clothing.
  • Give intravenous fluid therapy and medications as ordered.

Rationale :
  • To identify patterns of fever.
  • Vital Signs is a reference to determine the patient's general condition.
  • The increase in body temperature results in increased evaporation body so it needs to be balanced with a high fluid intake.
  • With vasodilation can increase evaporation which accelerates the decline in body temperature.
  • Clothing thin body helps reduce evaporation.
  • Fluid administration is very important for patients with a high temperature.

Source :

http://nursing-diagnosis-intervention.blogspot.com/2014/10/hyperthermia-and-acute-pain-related-to.html

Impaired Gas Exchange and Activity Intolerance related to Heart Failure

Nursing Care Plan for Heart Failure

Heart failure or chronic heart failure (CHF), occurs when the heart is unable to pump sufficiently to maintain blood flow to meet the needs of the body. The terms congestive heart failure (CHF) or congestive cardiac failure (CCF) are often used interchangeably with chronic heart failure. Signs and symptoms commonly include shortness of breath, excessive tiredness, and leg swelling. The shortness of breath is usually worse with exercise, when lying down, and at night while sleeping. There is often a limitation on the amount of exercise people can perform, even when well treated.

Heart failure symptoms are traditionally and somewhat arbitrarily divided into "left" and "right" sided, recognizing that the left and right ventricles of the heart supply different portions of the circulation. However, heart failure is not exclusively backward failure (in the part of the circulation which drains to the ventricle).

There are several other exceptions to a simple left-right division of heart failure symptoms. Additionally, the most common cause of right-sided heart failure is left-sided heart failure. The result is that patients commonly present with both sets of signs and symptoms.

Nursing Diagnosis :

1. Impaired Gas Exchange related to changes in the alveolar capillary membrane.
characterized by; dyspnea, orthopneu.

Goal: more effective gas exchange, the results; analysis of blood gases within normal limits and the patient was free from respiratory distress.

Interventions :
  • Auscultation of breath sounds, crackles, wheezing.
  • Instruct the patient to cough effectively and breathe deeply.
  • Keep sitting or bed rest with semifowler position.
  • Collaboration to monitor blood gas analysis and pulse oximetry.
  • Collaboration for the provision of supplemental oxygen as indicated.
  • Collaboration for diuretics and bronchodilators.
Rationale :
  • Monitor the presence of pulmonary congestion for further intervention.
  • Cleaning airway and facilitate the flow of oxygen.
  • Lowers oxygen consumption and maximize lung development.
  • Can be severe hypoxemia during pulmonary edema.
  • Increasing alveolar oxygen concentration to improve tissue hypoxemia.
  • Diuretics can reduce congestion and improve the alveolar gas exchange. Broncodilator for airway dilatation.

Nursing Diagnosis : 

Activity Intolerance related to imbalance between oxygen supply / needs, weaknesses.
characterized by; The patient said wearily continuously throughout the day, shortness of breath on exertion, changes in vital signs during activity.

Goal: Activity achieve optimal limit, as indicated by the patient participating in a desired activity and is able to meet the needs of their own care.

Interventions :
  • Check vital signs before and after the activity.
  • Note the cardiopulmonary response to activity, tachycardia, dysrhythmias, dyspnea, sweating, pale.
  • Provide assistance in self-care activities as indicated. Interspersed periods of activity with periods of rest.
  • Collaboration to implement a cardiac rehabilitation program.
Rationale :
  • Orthostatic hypotension can occur with activity due to the effects of the drug, fluid shifts, influence heart function.
  • The inability of the myocardium, increasing stroke volume during exercise, can increase heart rate, oxygen consumption and increased fatigue.
  • Self care needs without affecting the stress myocardial / excessive oxygen demand.
  • Gradual increase in the activity of the heart and avoid excessive oxygen consumption.

Source :
http://nandacareplan.blogspot.com/2014/11/heart-failure-5-nursing-diagnosis-and.html

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