Myocardial Infarction (STEMI & NSTEMI) Nursing Diagnosis & Care Plan

Myocardial infarction (MI) is commonly referred to as a “heart attack”. Myocardial ischemia is inadequate perfusion to the myocardium that occurs from a partial or complete blockage of blood and oxygen to the heart. The major cause of a heart attack is coronary artery disease. 

In an emergency, as the cells lose oxygen, ischemia (reduced blood flow) sets in. If the supply and demand of myocardial oxygen are out of balance, it can cause MI (cardiac death). 

Other causes of MI include the following:

  • Vasospasm (sudden constriction or narrowing of a coronary artery)
  • Blood clots
  • Electrolyte imbalances
  • Trauma to the coronary arteries

A prolonged lack of oxygen to the heart may result in the most common symptom which is the feeling of pressure or discomfort in the chest. This pain may radiate to the neck, jaw, shoulder, or arm. Diagnostic tests, lab results, and ECG changes may show damage to the heart.

What is an NSTEMI heart attack?

Unlike an ST-elevation myocardial infarction (STEMI), a non-ST-elevation myocardial infarction (NSTEMI) doesn’t cause a specific change in the electrical activity of the heart. These changes in electrical activity can be seen on an ECG. During an NSTEMI heart attack, the coronary artery is only partially blocked and the ST segment is not elevated. The patient may still show symptoms of a heart attack.

The Nursing Process

The nurse should immediately assess the patient to identify whether the symptoms are chest pain (angina) or myocardial infarction (MI). MIs require immediate intervention to save cardiac tissue.

As soon as an acute MI patient is brought to the emergency room, steps are taken to reduce ischemia, relieve pain, and stop progressive circulatory collapse and shock. The MONA regimen is started (morphine, oxygen, nitrates, and aspirin). The patient is placed on a cardiac monitor. IV access is established for the administration of fluids and emergency medications. Additional tests and procedures, such as cardiac catheterization or CABG, may be required.

The nurse encourages and educates the patient on medication adherence, diet and weight management, and risk factor modification after MI. Cardiac rehabilitation programs may be advised after discharge for ongoing recovery.

Nursing Care Plans Related to Myocardial Infarction

Decreased Cardiac Output Care Plan

Decreased cardiac output associated with myocardial infarction can be caused by the loss of viable heart muscle. This can result in decreased cardiac output and, in severe cases, cardiogenic shock and death.

Nursing Diagnosis: Decreased Cardiac Output

Related to:

  • Changes in heart rate and electrical conduction
  • Reduced preload
  • Reduced cardiovascular blood flow
  • Rupture of atherosclerotic plaque
  • Occluded artery
  • Altered muscle contractility

As evidenced by:

Expected outcomes:

  • Patient will maintain blood pressure within acceptable limits set by the provider
  • Patient will be able to demonstrate decreased or absent dyspnea, angina, and dysrhythmias
  • Patient will be able to verbalize an understanding of myocardial infarction and its management
  • Patient will be able to participate in activities that decrease the workload of the heart

Decreased Cardiac Output Assessment

1. Determine the patient’s risk and causative factors for decreased cardiac output.
Assess the patient’s medical history for atherosclerosis, blood clots, heart failure, and other conditions that place them at risk for decreased cardiac output and MI.

2. Determine if the condition is angina or myocardial infarction.
Stable angina is chest pain or discomfort that occurs with activity or stress but is relieved with rest or medications. MI occurs without regard to activity, lasts longer than stable angina, and is not relieved by rest or medications.

3. Closely monitor the blood pressure.
Immediately inform the provider when systolic blood pressure is less than 100 mmHg or 25 mmHg lower than the previous reading as it can lead to a cardiogenic shock. This is a complication that develops when the heart muscle deteriorates if oxygen-rich blood is not flowing to the heart.

4. Obtain ECG.
The most convenient and efficient approach for an early diagnosis of acute myocardial infarction is a 12-lead ECG. STEMI, NSTEMI, and other dysrhythmias can be detected.

5. Assess for signs of poor cardiac output.

  • Cool, diaphoretic skin
  • Weak or absent pulses
  • Decreased urine output
  • Altered mental status
  • Peripheral vasoconstriction

6. Assess cardiac enzymes.
Myoglobin, troponin, and creatine kinase are cardiac enzymes, also known as cardiac biomarkers. Cardiac troponin I or cardiac troponin T are both extremely sensitive and specific for MI.

Decreased Cardiac Output Interventions

1. Administer oxygen as ordered.
Administer oxygen to increase perfusion to the heart and other tissues.

2. Administer thrombolytic therapy as ordered.
If cardiac catheterization is not required immediately, administer thrombolytic therapy within the first 6 hours following the first symptom. Monitor for signs of bleeding.

3. Administer beta blockers as ordered.
Beta-blockers are used to lower myocardial contraction force, promote myocardial perfusion, and slow the heart rate.

4. Establish IV access.
IV access is used for the immediate administration of medication, IV fluids, and blood products.

5. Prepare for possible cardiac catheterization.
Urgent cardiac catheterization evaluates the degree and location of coronary artery blockages. A stent may be placed to restore blood flow to myocardial tissue.

6. Encourage bed rest and activity restrictions.
Bed rest lessens the workload, preventing inadequate perfusion and potential harm to the heart. Following a cardiac catheterization, the patient should be advised not to lift over 10 lbs or partake in strenuous activity.

7. Encourage cardiac rehabilitation.
Cardiac rehabilitation teaches the patient about diet modifications, exercise, and recovery following MI to improve outcomes and prevent further cardiac complications.

Acute Pain Care Plan

Acute pain associated with myocardial infarction is caused by chest pain/discomfort from inadequate blood flow to the heart.

Nursing Diagnosis: Acute Pain

Related to:

  • Blockage of coronary arteries
  • Low or no oxygen-rich blood flowing to the heart

 As evidenced by:

  • Verbal reports of chest pain, pressure, or tightness
  • Clutching the chest
  • Restlessness
  • Labored breathing and dyspnea
  • Diaphoresis
  • Changes in vital signs

Expected outcomes:

  • Patient will verbalize pain relief or control
  • Patient will rate the chest pain lower than the baseline pain scale
  • Patient will appear relaxed and able to sleep or rest appropriately
  • Patient will be able to perform daily activities without assistance

Acute Pain Assessment

1. Determine if the chest pain is angina or myocardial infarction.
Chest pain in myocardial infarction is characterized by the following:

  • Occurs without warning (usually in the early morning)
  • Crushing pain in the substernum
  • May radiate to the jaw, back, and left arm
  • Lasts for 30 minutes or longer
  • Unrelieved by rest or nitroglycerin

2. Assess pain characteristics.
Have the patient explain when the symptoms started, if they were precipitated activity or emotion, and if they took any measures to relieve the pain.

3. Obtain ECG during chest pain symptoms.
Expressions of chest pain should always be investigated using an ECG for quick results.

Acute Pain Interventions

1. Administer nitroglycerin.
When chest pain initially appears in an adult, one tablet of nitroglycerin should be placed under the tongue or in the space between the cheek and gum. Nitroglycerin dilates blood vessels.

2. Administer oxygen as ordered.
Chest pain can happen when the demand for oxygen is not being met. Supplemental oxygen administration will improve the oxygenation for the heart to function effectively.

3. Administer morphine.
Morphine may decrease the oxygen demand of the heart. It can also reduce blood pressure and slow the heart rate. Morphine will relax the patient and relieve anxiety.

4. Evaluate the effectiveness of pain control measures.
Frequently assess administered pain control measures for effectiveness.

Anxiety Care Plan

Anxiety associated with myocardial infarction can be caused by the stimulation of the sympathetic nervous system (fight or flight response). Anxiety can also be a cause of MI.

Nursing Diagnosis: Anxiety

Related to:

  • Threat of death
  • Threat to health status
  • Change to role functioning 
  • Lifestyle modification

 As evidenced by:

  • Increased tension
  • Fearful attitude
  • Apprehension
  • Expressed concerns or uncertainty
  • Restlessness
  • Dyspnea

Expected outcomes:

  • Patient will be able to verbalize the cause of their anxiety
  • Patient will verbalize an understanding of the necessary changes following myocardial infarction
  • Patient will implement individual coping mechanisms
  • Patient will display signs of reduced anxiety such as vital signs within normal limits and a calm demeanor

Anxiety Assessment

1. Observe anxiety during myocardial infarction.
Anxiety is the most common psychological symptom which is linked to a poor prognosis following MI.

2. Examine the subjective and objective cues of anxiety.
Subjective and objective cues may reflect signs of anxiety in MI patients. Patients may not complain of chest pain yet they are holding their chest. Remain aware of symptoms to intervene.

3. Assess the patient’s coping mechanisms.
Recovery following MI is a long-term process of adapting to changes in all aspects of life. Help the patient recognize and develop coping behaviors to utilize later.

Anxiety Interventions

1. Recognize that the patient’s anxieties are valid.
Encourage them to verbalize their feelings and assure them that they will not be judged because of it. With support, the patient is more likely to overcome this threat to their health.

2. Offer information and answer questions.
The nurse should provide thorough explanations of tests, procedures, and interventions to alleviate the patient’s anxiety. Allow time for patients and families to ask questions and answer honestly.

3. Include the patient in the care planning process.
Involve the patient in the care plan by allowing them to take time to prepare for scheduled treatments. Patient involvement may restore a patient’s sense of autonomy when coping with the treatment and recovery from MI.

4. Manage stress.
Stress management will lower the risk of posttraumatic stress disorder (PTSD) following MI. PTSD is linked to decreased quality of life and increased risk of recurring MI.

5. Teach ways to reduce anxiety.
In conjunction with the patient, uncover ways the patient can reduce anxiety such as through exercise, journaling, breathing, music, and medications.

References and Sources

  1. Dewit, S. C., Stromberg, H., & Dallred, C. (2017). Care of Patients With Diabetes and Hypoglycemia. In Medical-surgical nursing: Concepts & practice (3rd ed., pp. 811-817). Elsevier Health Sciences.
  2. Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nurse’s pocket guide: Diagnoses, interventions, and rationales (15th ed.). F A Davis Company.
  3. Harding, M. M., Kwong, J., Roberts, D., Reinisch, C., & Hagler, D. (2020). Lewis’s medical-surgical nursing – 2-Volume set: Assessment and management of clinical problems (11th ed., pp. 2697-2729). Mosby.
  4. Hinkle, J. L., & Cheever, K. H. (2018). Management of Patients With Coronary Vascular Disorders. In Brunner and Suddarth’s textbook of medical-surgical nursing (13th ed., pp. 1567-1575). Wolters Kluwer India Pvt.
  5. Ignatavicius, MS, RN, CNE, ANEF, D. D., Workman, PhD, RN, FAAN, M. L., Rebar, PhD, MBA, RN, COI, C. R., & Heimgartner, MSN, RN, COI, N. M. (2018). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care (9th ed., pp. 1386-1388). Elsevier.
  6. Ojha, N., & Dhamoon, A. S. (2022, May 11). Myocardial infarction – StatPearls – NCBI bookshelf. National Center for Biotechnology Information.
  7. Silvestri, L. A., Silvestri, A. E., & Grimm, J. (2022). Saunders comprehensive review for the NCLEX-RN examination (9th ed.). Elsevier Inc.
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Kathleen Salvador, MSN, RN

Kathleen Salvador is a registered nurse and a nurse educator holding a Master’s degree. She has more than 10 years of clinical and teaching experience and worked as a licensed Nursing Specialist in JCI-accredited hospitals in the Middle East. Her nursing career has brought her through a variety of specializations, including medical-surgical, emergency, outpatient, oncology, and long-term care.