​ ubjective:

S
​hypertensive and was a smoker.
​have severe chest pain and sought ER ur
​after 24 hours pain persistence.
​Objective:
​* HR 90 bpm
​* Bp: 110/70 mmHg
​* Heart assessment showed a systolic
​murmur in the lower left sternal border and
​Asssess
​mitral area.
​* The initial electrocardiogram showed : HR
​of 100 bpm, sinus rhythm, 1st-degree
​atrioventricular block (PR 240 ms), low-
​voltage QRS complexes in the frontal plane,
​QRS complex electrical alternans and
​extensive ongoing anterior wall infarction
​(QS V1 to V6, ST elevation in the same leads
A 66-year-old ​and OS in the inferior wall, Il, III and aVF)
male ​1-Risk for Decreased Cardiac Output related
August 13, 2005 ​to Changes in rate, rhythm, electrical
​1-Nursing diagnosis
10 PM ​conduction evidenced by initial ECG result.
ER unit ​
possible MI ​2-Acute Pain related to Tissue ischemia
​(coronary artery occlusion) evidenced by ​2-Nursing diagnosis
​Reports of chest pain and Changes in pulse,BP.

​Maintain hemodynamic stability, e.g., BP,

​cardiac output within normal range, adequate
​1-Goal& expected Outcome
​urinary output, decreased frequency/absence
​Medical diagnosis: ​of dysrhythmias.
​Acute Myocardial ​Verbalize relief/control of chest pain wi
​Infarction ​appropriate time frame for administered
​2-Goal& expected Outcome
​medications and Display reduced tension
​relaxed manner, ease of movement.

​1-Auscultate BP. Compare both arms and obtain lying,

​sitting, and standing pressures when able.
​2-Auscultate heart sounds and Monitor heart rate and
​rhythm,Document dysrhythmias via telemetry. ​1-Interventions
​3-Measure cardiac output and other
​functional parameters as appropriate.
​

​1-Instruct patient to do relaxation techniques: deep and

​slow breathing, distraction behaviors, visualization, guided
​imagery. Assist as needed.
​2​-Interventions
​2-Perform comprehensive assessment of pain to include
​location characteristics severity(0-10 or pain scale)
​3-provide environment quiet calm activities.

​patient hemodynamic stability within

​normal range, absence of dysrhythmias and ​1-Evalution
​have adequate urinary output.

​patient verbalize relief and control of chest

​2-Evalution
​pain after medications and tension reduced.