Patient X

50 yrs old

Myocardial Infarction

SOAPIE CHARTING
SUBJECTIVE

 Chest pain as evidenced by clenching his fist against his chest.

OBJECTIVE

 BP: 140/88
 PR: 110bpm (sinus tachycardia)
 Anxious
 Diaphoretic

ASSESSMENT

 Acute chest pain related to coronary artery occlusion.

PLANNING

 After 7 hrs of nursing intervention, the client will verbalize relief of chest pain.

INTERVENTION

 Administered oxygen therapy to balance the myocardial oxygen supply.

 Administered medication as prescribed (2 mg morphine sulfate via IV) to reduce pain
and also to dilate vein and to reduce cardiac preload and after load.
 Encouraged physical rest in bed with the head of the bed to decrease chest discomfort
and dyspnea.
 Monitored vital signs especially blood pressure and pulse. Elevated blood pressure
may indicate cardiogenic shock and irregular pulse may indicate atrial fibrillation.
 Monitored urinary output. Decreased urinary output may indicate cardiogenic shock.

EVALUATION

 Goal met. After 7hrs of nursing intervention, the client verbalized relief of chest pain by
decreasing pain to 3 out of 10.