Nursingcrib.com Nursing Care Plan - Myocardial Infarction

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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

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