Cues Nursing Diagnosis Rationale Goals / Outcome Nursing Interventions Rationale Evaluation

Criteria
Subjective: Acute pain related to Occlusion of coronary artery Within 30 mins. of nursing Independent: Goal met, after 30 minutes of
The patient reports of myocardial ischemia resulting interventions, the patient will a. Assess the intensity of the chest pain using pain rating a. To determine what nursing interventions, the
chest pain (Pain scale of from coronary artery occlusion. be able to: scale. appropriate interventions patient was able to;
9/10) and numbness of the Decreased blood flow to the  States a decrease in b. Monitor respirations, blood pressure, and heart rate will be going to apply for
left shoulder. myocardial the with each episode of chest pain. better implementation of  State a decrease in the chest
chest pain rating of 9 c. Provide patient with a quiet environment and maintain care. pain rating from 9 down to 4
out 10. bed rest during pain, with position of comfort. b. Respirations and blood as 10 is the highest.
Objective: Decreased blood supply  Maintain the vital d. Instruct patient to avoid or limit activities that cause pressure may be increased  Maintain vital signs within
Facial grimace (ischema) signs within normal to increase cardiac workload (going to the restroom) as a result of pain. normal limits.
Restlessness level. c. To reduce oxygen  Rest, displays reduced
Peripheral cyanosis  Rest, displays consumption and demand, tensions, and comfortably.
Cold and clammy skin Anaerobic metabolism reduced tension, and to reduce completing stimuli
sleeps comfortably. and reduces anxiety.
d. To prevent triggering the
Dependent
Vital sign taken as follow: Lactic acid formation heart needs of more oxygen
a. Administer Oxygen as ordered.
BP- 160 / 100 mmHg due to exertion, thus,
RR – 26 bpm limiting activities decrease
b. Administer analgesic as ordered, such as morphine
PR – 96 cpm Pain myocardial oxygen demand
sulphate.
Temp – 37.2 OC and workload on the heart.
O2 Sat – 94 % a. Increase amount of
oxygen available for
c. Administer beta blockers such as metropolol.
myocardial uptake and
thereby may relieve
discomfort associated with
Collaboration:
tissue ischemia.
b. Morphine is an opiate
analgesic and alters the
client’s perception of pain
and reduces preload time
vasoconstriction.
c. To block sympathetic
stimulation, reduce heart
rate and lowers myocardial
demand.

Patient’s Initial:
 Cues Nursing Diagnosis Rationale Goals / Outcome Criteria Nursing Interventions Rationale Evaluation

Subjective: Ineffective cardiac tissue Coronary circulation is Within 30 minutes of nursing Independent: Goal met, after 30 minutes of
The patient reports of chest perfusion related to thrombus composed of small arteries and interventions, the patient will be a. Monitor vital signs a. To establish baseline nursing interventions, the
pain and numbness of the left in coronary artery, resulting in veins that keep the heart cells able to: b. Instruct patient to maintain date. patient was able to;
shoulder. altered blood flow to supplied with fresh oxygen.  Reports beginning relief head of bed elevated, keep bed b. Physical rest reduces
myocardial tissue. With myocardial Infarction rest, and use of bed side myocardial oxygen  Reports beginning relief
of chest discomfort
of chest discomfort
Objective: plaques (fatty deposits) build  Appear comfortable and commode. consumption.
Facial grimace up, inside the lining of coronary c. Instruct patient in dietary c. Decreases coronary  Appear comfortable
free of pain.
and free of pain
Cold and clammy skin arteries. This build up can  Display adequate needs and restrictions (limiting narrowing or spasm.
partially or totally block blood high fat diet)  Display adequate
cardiac output as
flow in the large arteries of the cardiac output as
evidenced by:
heart which causes death of evidenced by:
ECG 12 lead result: - Improving 12 Lead
muscle cells. Dependent - Improved 12 Lead
Elevated ST segment ECG
a. Administer oxygen as a. Oxygen therapy ECG
- Vital signs within
prescribed. increases the oxygen - Vital signs within
Laboratory results: normal ranges
b. Administer thrombolytic supply to the normal ranges
Triglycerides - 160 mg/dL - Skin is warm & dry,
and aspirin as prescribed. myocardium. - Skin is warm & dry,
LDL - 170 mg/dL absence of
c. Obtain a 12 – lead ECG as b. Thrombolytic therapy absence of cyanosis
Cholesterol - 220 mg/dL cyanosis
Hemoglobin - 13 g/dl prescribed. can break apart the
thrombus and increase
myocardial tissue
perfusion. Aspirin
Vital sign taken as follow: reduces coronary
BP- 160 / 100 mmHg reocclusion.
RR – 26 bpm Collaboration: c. ST – segment elevation
PR – 96 cpm a. indicates myocardial
Temp – 37.2 OC tissue injury; ST- segment
O2 Sat – 94 % depression indicates
decreased myocardial
perfusion.
 Cues
Subjective:
The patient reports of chest
pain
Objective:
Cold and clammy skin
Cyanotic extremities
Decreased capillary refill
Laboratory results:
Hemoglobin - 13 g/dl
Vital sign taken as follow:
BP- 160 / 100 mmHg
RR – 26 bpm
PR – 96 cpm
Temp – 37.2 OC
O2 Sat – 94 %
Nursing Diagnosis
Risk for ineffective peripheral
tissue perfusion related to
decrease cardiac output.
Rationale
Due to decreased cardiac
output, there is decreased
preload and stroke volume thus
there is decreased blood
pumped out from the blood.
Decrease in stroke volume
decreases perfusion through
the body.
Goals / Outcome Criteria
Within 1 hour of nursing
interventions, the patient will be
able to:
 Maintain of adequate
tissue perfusion as
evidenced by:
Extremities warm, dry,
absence of cyanosis and
capillary refill <2 seconds
 Maintain the vitals
within normal level.
Nursing Interventions Rationale Evaluation
Independent: Goal met, after 1 hour of
a. Monitor vital signs, MIO and a. To have baseline data nursing interventions, the
capillary refill and to determine blood patient was able to;
b. Instruct patient to maintain circulation
bed rest and elevate of the bed b. Restricted activity  Maintain of
head to 30o reduces oxygen demands adequate tissue
c. Instruct patient to avoid of the heart and promote perfusion as
activities that increase the circulation evidenced by:
hearts’ stress. c. Activities that requires Extremities warm,
too much workload leads dry, absence of
to heart stress and cyanosis and capillary
increases oxygen refill <2 seconds
demands
 Maintain the vitals
within normal level.
Dependent:
a. Administer oxygen as a. Oxygen increase
prescribed arterial saturation.
b. Administer thrombolytic b. Thrombolytic therapy
agents e.g., alteplase as is the treatment of
prescribed. choice (when initiated
. within 6 hr) to dissolve
the clot (if that is the
cause of the MI) and
restore perfusion of the
myocardium.
Collaboration:
a. Obtain laboratory such a. Normal values indicate
haemoglobin, hematocrit and adequate tissue
RBC as prescribed. perfusion.