Student Nurses’ Community

NURSING CARE PLAN – Myocardial Infarction ASSESSMENT DIAGNOSIS INFERENCE PLANNING After 8 hours of nursing intervention the patient will Verbalize relief/control of chest pain within appropriate time frame for administered medications. INTERVENTION Independent: SUBJECTIVE: “Sumasakit ang dibdib ko” (I’ve
been experiencing chest pains) as

RATIONALE

EVALUATION Goal met, patient has verbalized relief/control of chest pain within appropriate time frame for administered medications.

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)

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 Instruct patient to report pain immediately. •

Pain is a subjective experience and must be described by patient

Anaerobic metabolism • Lactic acid formation Provide quiet environment, calm activities, and comfort measures •

Delay in reporting pain hinders pain relief/may require increased dosage of medication to achieve relief Decreases external stimuli, which may aggravate anxiety and cardiac strain, limit coping abilities and adjustment to current situation Helpful in decreasing perception of/ response to pain. Provides a sense of having some control over the situation,

pain

Assist/instruct in relaxation techniques, e.g., deep/slow breathing, distraction

systolic BP. Important second-line agents for pain control through effect of blocking sympathetic stimulation. guided imagery Collaborative • Administer supplemental oxygen by means of nasal cannula or face mask..g.g. propranolol (Inderal). other injectable narcotics may be used in acute- • • Beta-blockers. e. which increase coronary blood flow and myocardial perfusion.Student Nurses’ Community behaviors.. atenolol (Tenormin).g. morphine. nitroglycerin. e. metoprolol (Lopressor) • • Analgesics. meperidine (Demerol) • . 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. isosorbide dinitrate (Isordil) • increase in positive attitude. thereby reducing heart rate. as indicated Administer medications as indicated: • Antianginals.. visualization. e. and myocardial oxygen demand Although intravenous (IV) morphine is the usual drug of choice.

Student Nurses’ Community phase/recurrent chest pain unrelieved by nitroglycerin to reduce severe pain. provide sedation. and decrease myocardial workload .

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