NURSING CARE PLAN – Myocardial Infarction

ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

Independent:
Occlusion of After 30 minutes Goal met, patient
SUBJECTIVE: Pain r/t tissue coronary artery of nursing  Obtain full  Pain is a has
“Sumasakit ang ischemia intervention the description of subjective verbalized
dibdib ko” (I’ve (coronary artery Decrease blood patient will pain from experience relief/control of
been occlusion) flow to the Verbalize patient and must be chest pain within
experiencing myocardium relief/control of including described by appropriate time
chest pains) as chest pain within location, patient frame for
verbalized by the Decrease oxygen appropriate time intensity (0– administered
patient supply (ischemia) frame for 10), duration, medications.
administered characteristic
medications. s
(dull/crushing)
Anaerobic
, and
OBJECTIVE: metabolism
radiation.
Assist patient
 Restlessness
to quantify
 Facial grimace Lactic acid
pain by
 Pain scale of 9 formation
comparing it
out of 10 to other
 V/S taken as experiences
follows Pain
  Instruct  Delay in
T: 37.6 ˚C patient to reporting pain
P: 112 report pain hinders pain

R: 12 immediately. relief/may

BP: 140/ 100 require

increased
dosage of
medication to
achieve relief
 Provide quiet
environment,
calm  Decreases

activities, and external

comfort stimuli, which

measures may
aggravate
anxiety and
cardiac strain,
limit coping
abilities and
 Assist/instruct
adjustment to
in relaxation
current
techniques,
situation
e.g.,
deep/slow
 Helpful in
breathing,
decreasing
 distraction perception of/
behaviors, response to
visualization, pain.
guided Provides a
imagery sense of
having some
Collaborative control over

 Administer the situation,

supplemental increase in

oxygen by positive

means of attitude.

nasal cannula
or face mask,
as indicated
 Increases
Administer amount of
medications as oxygen
indicated: available for

 Antianginals, myocardial

e.g., uptake and

nitroglycerin, thereby may

isosorbide relieve

dinitrate discomfort

(Isordil) associated
with tissue
 ischemia

 Beta-  Nitrates are

blockers, e.g., useful for pain
atenolol control by
(Tenormin), coronary
propranolol vasodilating
(Inderal), effects, which
metoprolol increase
(Lopressor) coronary
blood flow
and
myocardial
perfusion.

 Important
second-line
 Analgesics,
agents for
e.g.,
pain control
morphine,
through effect
meperidine
of blocking
(Demerol)
sympathetic
stimulation,
thereby
 reducing
heart rate,
systolic BP,
and
myocardial
oxygen
demand

 Although
intravenous
(IV) morphine
is the usual
drug of
choice, other
injectable
narcotics may
be used in
acute-
phase/recurre
nt chest pain
unrelieved by
nitroglycerin
to reduce
severe pain,
provide
sedation, and
decrease
myocardial
workload