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Nursing Care Plan for myocardial infarction

Nursing Care Plan for myocardial infarction

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Published by mariejo

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Published by: mariejo on Feb 23, 2009
Copyright:Attribution Non-commercial

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04/15/2015

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XI.NURSING CARE PLAN
ASSESSMENTDIAGNOSISPLANNINGINTERVENTIONRATIONALEEVALUATIONSubjective:The clientreports of chestpain radiating tothe left arm andneck and back.Objective:
Restlessness
Facialgrimacing
Fatigue
Peripheralcyanosis
Weak pulse
Cold andclammy skin
Palpitations
Shortness of breath
Elevatedtemperature
Pain scale of 8/10
Acute (Chest)Pain r/tmyocardialischemia resultingfrom coronaryartery occlusionwithloss/restriction of  blood flow to anarea of themyocardium andnecrosis of themyocardium.
STG:Within 1 hourof nursinginterventions,the client willhave improvedcomfort in chest,as evidenced by:
States adecrease inthe ratingof thechest pain.
Is able torest,displaysreducedtension,and sleepscomfortably.
Requiresdecreaseanalgesiaornitroglycerin.LTG:The client willhave animproved feelingof control asevidenced byverbalizing asense of controlover presentsituation andfuture outcomeswithin 2 days of nursinginterventions.INDEPENDENT:1. assesscharacteristics of chest pain, includinglocation, duration,quality, intensity,presence of radiation,precipitating andalleviating factors, andas associatedsymptoms, have clientrate pain on a scale of 1-10 and documentfindings in nurse’snotes.2. obtain history of previous cardiac painand familial history of cardiac problems.3. assess respirations,BP and heart rate witheach episodes of chestpain.4. maintain bedrestduring pain, withposition of comfort,maintain relaxingenvironment topromote calmness.5. prepare for theadministration of medications, andmonitor response todrug therapy. Notifyphysician if pain doesnot abate.1. pain is indication of MI. assisting the clientin quantifying painmay differentiate pre-existing and currentpain patterns as wellas identifycomplications.2. this providesinformation that mayhelp to differentiatecurrent pain fromprevious problems andcomplications.3. respirations may beincreased as a resultof pain and associateanxiety.4. to reduce oxygenconsumption anddemand, to reducecompeting stimuli andreduces anxiety.5.pain control is apriority, as it indicatesischemia.STG:Within 1 hour of nursing intervention,the client hadimproved comfort inchest, as evidencedby:
States adecrease in therating of thechest pain.
Is able to rest,displaysreducedtension, andsleepscomfortably.
Requiresdecreaseanalgesia ornitroglycerin.Goal was met.LTG:The client had animproved feeling of control as evidencedby verbalizing asense of control overpresent situationand future outcomeswithin 2 days of nursing intervention.Goal was met.
 
6.istruct patient innitroglycerin SLadministration afterhospitalization.Instruct patient inactivity alterations andlimitations.7. instructpatient/family inmedication effects,side-effects,contraindications andsymptoms to report.DEPENDENT:1. obtain a 12-leadECG on admission,then each time chestpain recurs forevidence of furtherinfarction asprescribed.2. administeranalgesics as ordered,such as morphinesulfate, meferidine of Dilaudid N.3. administer beta-blockers as ordered.4. administer calcium-channel blockers asordered.6. to decreasemyocardial oxygendemand and workloadon the heart.7. to promoteknowledge andcompliance withtherapeutic regimenand to alleviate fear of unknown.1. serial ECG and statECGs record changesthat can give evidenceof further cardiacdamage and locationof MI.2. Morphine is thedrug of choice tocontrol MI pain, butother analgesics maybe used to reducepain and reduce theworkload on the heart.3. to blocksympatheticstimulation, reduceheart rate and lowersmyocardial demand.4. to increasecoronary blood flowand collateralcirculation which candecrease pain due toischemia.

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