Page 1702 - Saunders Comprehensive Review For NCLEX-RN

c. Pain may occur without cause,
primarily early in the morning.
d. Pain is unrelieved by rest or
nitroglycerin and is relieved only by
opioids.
e. Pain lasts 30 minutes or longer.
2. Nausea and vomiting
3. Diaphoresis
4. Dyspnea
5. Dysrhythmias
6. Feelings of fear and anxiety, impending doom
7. Pallor, cyanosis, coolness of extremities
F. Complications of MI (Box 52-6)

G. Interventions, acute stage

Pain relief increases oxygen supply to the myocardium; administer morphine as

a priority in managing pain in the client having an MI.
1. Obtain a description of the chest discomfort.
2. Administer oxygen and institute pain relief measures
(morphine, nitroglycerin as prescribed).
3. Assess vital signs and cardiovascular status and
maintain cardiac monitoring.
4. Assess respiratory rate and breath sounds for signs of
heart failure, as indicated by the presence of crackles
or wheezes or dependent edema.
5. Ensure bed rest and place the client in a semi-Fowler’s
position to enhance comfort and tissue oxygenation;
stay with the client.
6. Establish an IV access route.
7. Obtain a 12-lead ECG.
8. Monitor laboratory values.
9. Monitor for cardiac dysrhythmias, because
tachycardia and PVCs frequently occur in the first few
hours after MI; administer antidysrhythmics as
prescribed.
10. Administer thrombolytic therapy, which may be
prescribed within the first 6 hours of the coronary
event if cardiac catheterization is not to be done
emergently; monitor for signs of bleeding if the client
is receiving thrombolytic therapy.
11. Assess distal peripheral pulses and skin temperature,
because poor cardiac output may be identified by cool
diaphoretic skin and diminished or absent pulses.
12. Monitor the BP closely after the administration of
medications; if the systolic pressure is lower than

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