Student Nurses’ Community NURSING CARE PLAN – Myocardial Infarction ASSESSMENT
DIAGNOSIS
INFERENCE
PLANNING
INTERVENTION
RATIONALE
EVALUATION
Independent: SUBJECTIVE: “Sumasakit ang dibdib ko” (I’ve been experiencing chest pains) as
verbalized by the patient
Pain r/t tissue ischemia (coronary artery occlusion)
Occlusion of coronary artery
Decrease blood flow to the myocardium
OBJECTIVE: • • • •
Restlessness Facial grimace Pain scale of 9 out of 10 V/S taken as follows T: 37.6 ˚C P: 112 R: 12 BP: 140/ 100
Decrease oxygen supply (ischemia)
After 8 hours of nursing intervention the patient will Verbalize relief/control of chest pain within appropriate time frame for administered medications.
•
Obtain full • description of pain from patient including location, intensity (0–10), duration, characteristics (dull/crushing), and radiation. Assist patient to quantify pain by comparing it to other experiences
Pain is a subjective experience and must be described by patient
•
Instruct patient to report pain immediately.
•
Delay in reporting pain hinders pain relief/may require increased dosage of medication to achieve relief
•
Provide quiet environment, calm activities, and comfort measures
•
Decreases external stimuli, which may aggravate anxiety and cardiac strain, limit coping abilities and adjustment to current situation
•
Assist/instruct in relaxation techniques, e.g., deep/slow breathing, distraction
•
Helpful in decreasing perception of/ response to pain. Provides a sense of having some control over the situation,
Anaerobic metabolism
Lactic acid formation
pain
Goal met, patient has verbalized relief/control of chest pain within appropriate time frame for administered medications.
Student Nurses’ Community behaviors, visualization, guided imagery Collaborative • Administer supplemental oxygen by means of nasal cannula or face mask, as indicated Administer medications as indicated: • Antianginals, e.g., nitroglycerin, isosorbide dinitrate (Isordil)
increase in positive attitude.
•
Increases amount of oxygen available for myocardial uptake and thereby may relieve discomfort associated with tissue ischemia
•
Nitrates are useful for pain control by coronary vasodilating effects, which increase coronary blood flow and myocardial perfusion.
•
Beta-blockers, e.g., atenolol (Tenormin), propranolol (Inderal), metoprolol (Lopressor)
•
Important second-line agents for pain control through effect of blocking sympathetic stimulation, thereby reducing heart rate, systolic BP, and myocardial oxygen demand
•
Analgesics, e.g., morphine, meperidine (Demerol)
•
Although intravenous (IV) morphine is the usual drug of choice, other injectable narcotics may be used in acute-
Student Nurses’ Community phase/recurrent chest pain unrelieved by nitroglycerin to reduce severe pain, provide sedation, and decrease myocardial workload