Nursing Care Plan For Myocardial Infarction N k613n

Student Nurses’ Community

NURSING CARE PLAN ─ Myocardial Infarction ASSESSMENT Subjective: The client reports of chest pain radiating to the left arm and neck and back. Objective:  Restlessness  Facial grimacing  Fatigue  Peripheral cyanosis  Weak pulse  Cold and clammy skin  Palpitations  Shortness of breath  Elevated temperature  Pain scale of 8/10

DIAGNOSIS

PLANNING

INTERVENTION

RATIONALE

EVALUATION

Acute (Chest) Pain r/t myocardial ischemia resulting from coronary artery occlusion with loss/restriction of blood flow to an area of the myocardium and necrosis of the myocardium.

STG: Within 1 hour of nursing interventions, the client will have improved comfort in chest, as evidenced by:  States a decrease in the rating of the chest pain.  Is able to rest, displays reduced tension, and sleeps comfortably.  Requires decrease analgesia or nitroglycerin.

INDEPENDENT: 1. Assess characteristics of chest pain, including location, duration, quality, intensity, presence of radiation, precipitating and alleviating factors, and as associated symptoms, have client rate pain on a scale of 1-10 and document findings in nurse’s notes.

1. Pain is indication of MI. assisting the client in quantifying pain may differentiate preexisting and current pain patterns as well as identify complications.

STG: Within 1 hour of nursing intervention, the client had improved comfort in chest, as evidenced by:  States a decrease in the rating of the chest pain.  Is able to rest, displays reduced tension, and sleeps comfortably.  Requires decrease analgesia or nitroglycerin. Goal was met.

LTG: The client will have an improved feeling of control as

2. Obtain history of previous cardiac pain and familial history of cardiac problems. 3. Assess respirations, BP and heart rate with each episodes of chest pain. 4. Maintain bed rest during pain, with

2. This provides information that may help to differentiate current pain from previous problems and complications. 3. Respirations may be increased as a result of pain and associate anxiety. 4. To reduce oxygen consumption and demand, to reduce competing stimuli and reduces anxiety. 5. Pain control is a

LTG: The client had an improved feeling of control as evidenced by verbalizing a sense of control over present situation

Student Nurses’ Community evidenced by verbalizing a sense of control over present situation and future outcomes within 2 days of nursing interventions.

position of comfort, maintain relaxing environment to promote calmness. 5. Prepare for the istration of medications, and monitor response to drug therapy. Notify physician if pain does not abate. 6. istruct patient in nitroglycerin SL istration after hospitalization. Instruct patient in activity alterations and limitations. 7. Instruct patient/family in medication effects, side-effects, contraindications and symptoms to report. DEPENDENT: 1. Obtain a 12-lead ECG on ission, then each time chest pain recurs for evidence of further infarction as prescribed.

priority, as it indicates ischemia. 6. To decrease myocardial oxygen demand and workload on the heart. 7. To promote knowledge and compliance with therapeutic regimen and to alleviate fear of unknown. 1. Serial ECG and stat ECGs record changes that can give evidence of further cardiac damage and location of MI. 2. Morphine is the drug of choice to control MI pain, but other analgesics may be used to reduce pain and reduce the workload on the heart. 3. To block sympathetic stimulation, reduce

and future outcomes within 2 days of nursing intervention. Goal was met.

Student Nurses’ Community 2. ister analgesics as ordered, such as morphine sulfate, meferidine of Dilaudid N. 3. ister betablockers as ordered. 4. ister calcium-channel blockers as ordered.

heart rate and lowers myocardial demand. 4. To increase coronary blood flow and collateral circulation which can decrease pain due to ischemia.

Student Nurses’ Community ASSESSMENT

DIAGNOSIS

PLANNING

INTERVENTION

RATIONALE

EVALUATION

Subjective: The client reports of increased work of breathing associated with feelings of weakness and tiredness.

Activity Intolerance r/t cardiac dysfunction, changes in oxygen supply and consumption as evidenced by shortness of breath.

STG: Within 3 days of nursing interventions, the client will be able to tolerate activity without excessive dyspnea and will be able to utilize breathing techniques and energy conservation techniques effectively.

INDEPENDENT: 1. Monitor heart rate, rhythm, respirations and blood pressure for abnormalities. Notify physician of significant changes in VS.

1. Changes in VS assist with monitoring physiologic responses to increase in activity.

STG: Within 3 days of nursing interventions, the client tolerated activity without excessive dyspnea and had been able to utilize breathing techniques and energy conservation techniques effectively. Goal was met.

Objective:  Increased heart rate  Increased blood pressure  Dyspnea with exertion  Pallor  Fatigue and weakness  Decreased oxygen saturatio n  Ischemic ECG changes

LTG: Within 5 days of nursing interventions, the client will be able to increase and achieve desired activity level, progressively, with no intolerance symptoms noted, such as respiratory compromise.

2. Identify causative factors leading to intolerance of activity. 3. Encourage patient to assist with planning activities, with rest periods as necessary. 4. Instruct patient in energy conservation techniques. 5. Assist with active or ive ROM exercises at least QID. 6. Turn patient at least every 2 hours, and prn. 7. Instruct patient in isometric and breathing exercises.

2. Alleviation of factors that are known to create intolerance can assist with development of an activity level program. 3. to help give the patient a feeling of selfworth and well-being. 4. To decrease energy expenditure and fatigue. 5. To maintain t mobility and muscle tone. 6. To improve respiratory function and prevent skin breakdown. 7. To improve breathing and to increase activity level. 8. To promote self-

LTG: Within 5 days of nursing interventions, the client increased and achieved desired activity level, progressively, with no intolerance symptoms noted, such as respiratory compromise. Goal was met.

Student Nurses’ Community 8. Provide patient/family with exercise regimen, with written instructions.

DEPENDENT: 1. Assisst patient with ambulation, as ordered, with progressive increases as patient’s tolerance permits.

worth and involves patient and his family with self-care. 1. To gradually increase the body to compensate for the increase in overload.

Student Nurses’ Community ASSESSMENT

DIAGNOSIS

PLANNING

INTERVENTION

RATIONALE

EVALUATION

Student Nurses’ Community Subjective: The client verbalizes questions regarding problems and misconceptions about his condition. Objective:  Lack of improvement of previous regimen  Inadequate follow-up on instructions given.  Anxiety  Lack of understanding.

Deficient Knowledge r/t new diagnosis and lack of understanding of medical condition.

STG: The client will be able to verbalize and demonstrate understanding of information given regarding condition, medications, and treatment regimen within 3 days of nursing interventions. LTG: The client will able to correctly perform all tasks prior to discharge.

INDEPENDENT: 1. Monitor patient’s readiness to learn and determine best methods to use for teaching. 2. Provide time for individual interaction with patient. 3. Instruct patient on procedures that may be performed. Instruct patient on medications, dose, effects, side effects, contraindications, and signs/symptoms to report to physician. 4. Instruct in dietary needs and restrictions, such as limiting sodium or increasing potassium. 5. Provide printed materials when possible for patient/family to reviews. 6. Have patient demonstrate all skills that will be necessary for post discharge. 7. Instruct exercises to be performed, and to avoid overtaxing activities.

1. To promote optimal learning environment when patient show willingness to learn. 2. To establish trust. 3. To provide information to manage medication regimen and to ensure compliance. 4. Client may need to increase dietary potassium if placed on diuretics; sodium should be limited because of the potential for fluid retention. 5. To provide reference for the patient and family to refer. 6. To provide information that patient has gained a full understanding of instruction. 7. These are helpful in improving cardiac function.

STG: The client verbalized and demonstrated understanding of information given regarding condition, medications, and treatment regimen within 3 days of nursing interventions. Goal was met. LTG: The client had been able to correctly perform all tasks prior to discharge. Goal was met.

Student Nurses’ Community