Acute Myocardial Infarction (AMI) - Primary and Secondary Nursing Assessment

Acute Myocardial Infarction (AMI) is a sudden loss of blood supply to an area of the heart, causing permanent heart damage or death. There are different types of AMI, classified by the location of the actual event in the heart (e.g., inferior wall vs. anterior wall) or the type of changes seen on an electrocardiogram (ST elevation or non-ST elevation).

Primary Nursing Assessment

Airways

• Blockage or accumulation of secretions
• Wheezing or crackles

Breathing

• Shortness of breath with mild activity or rest
• Respiration more than 24 x / min, irregular rhythm shallow
• Ronchi, crackles
• The expansion of the chest is not full
• Use of auxiliary respiratory muscles

Circulation

• Weak pulse, irregular
• Tachycardia
• Blood pressure increase / decrease
• Edema
• Nervous
• Acral cold
• Pale skin, cyanosis
• Decreased urine output

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Secondary Nursing Assessment

1. Activities
Symptoms:

• Weakness
• Fatigue
• Can not sleep
• Settled lifestyle
• No regular exercise schedule

Signs:

• Tachycardia
• Dyspnea at rest or activity

2. 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

3. 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

4. Elimination
Signs:

• Normal, decreased bowel sounds.

5. Food or fluid
Symptoms:

• Nausea, anorexia, belching, heartburn, or burning

Signs:

• Decreased skin turgor, dry skin, sweating, vomiting, weight changes

6. Hygiene
Symptoms or signs:

• Difficulty perform maintenance tasks

7. Neurosensory
Symptoms:

• Dizziness, throbbing during sleep or while awake (sitting or resting)

Signs:

• Mental changes, weakness

8. 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

9. 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

10. 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

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