NURSING CARE PLAN

Date Assessed August 20, 2012

ASSESSMENT DIAGNOSIS SCIENTIFIC EXPLANATION

PLANNING INTERVENTION RATIONALE EVALUATION

Subjective:

The client reports of chest pain radiating to the left arm, neck and back.

P- Upon doing some exertion activities

Q- Stabbing pain R- to left arm, neck and back S- 10 out of 10 T- last more than 15 minutes

Objective:

Restlessness Facial grimacing Easy Fatigability Pallor Cold and clammy

skin With Oxygen

inhalation at 2-4 Lpm

Shortness of breath

Acute chest Pain related to Coronary

Artery occlusion secondary to

Myocardial Infarction

Occlusion of coronary artery

Decreased blood flow to the myocardium

Decreased blood supply (ischemia)

Anaerobic metabolism

Lactic Acid formation

Pain

Short Term Goal:

- After 15-30 minutes rendering care and interventions, the patient will be able to verbalized decreased/relieved pain (chest and to radiating areas)felt, AEB:

Decreased feeling of fatigue

Improve breathing

Skin is within the normal color

Vital signs within normal range:

BP=120/80 PR= 60-100bpm RR= 12-20 cpm Temp= 36.5 Pain rate scale

from 10 down to 8 as 10 is the highest

Long term Goal:

Independent:

1. Assess characteristics of chest pain (PQRST)

2. Obtain history of previous cardiac pain and familial history of cardiac problems from the S.O.

3. Assess for respirations, BP and heart rate with each episodes of chest pain.

4. Maintain bed rest during pain, with position of comfort.

1.) To determine what appropriate interventions will be going to apply for better implementation of care.

2.) It provides information that may help to differentiate current pain from previous problems and complications thus it is a big help to perform such interventions.

3.) An increase in vital signs happens as as the body compensate to pain, which can lead to other serious complications doing if continuous to increase.

4.) To reduce oxygen consumption thus decreased oxygen demand.

Short Term Goal:

- Goal Met, AEB: Patient will be able to verbalized decreased/relieved pain (chest and to radiating areas)felt, AEB:

Decreased feeling of fatigue

Improve breathing Skin is within the

normal color Vital signs within

normal range: BP=120/80

PR= 60-100bpm RR= 12-20 cpm Temp= 36.5 Pain rate scale

from 10 down to 8 as 10 is the highest

Long term Goal:

- Goal Met, AEB:Patient experienced an improved feeling of control and comfort

Vital signs taken as:BP=150/90

PR=109 bpm RR= 26 cpm Temp= 35.0

- After 1 hour of rendering care and interventions, the patient will be able to have an improved feeling of control and comfort AEB:

Able to sleep and rest comfortably

Improve breathing

Vital signs within normal range:

BP=120/80 PR= 60-100bpm RR= 12-20 cpm Temp= 36.5 Pain rate scale

from 10 down to 2 as 10 is the highest

5. Maintain relaxing environment conducive for rest.

6. Instruct patient to avoid/limit activities that causes to increase cardiac workload ( lifting heavy objects, running, stressful task)

7. Instruct patient/family in medication effects, side-effects, contraindications and symptoms that need to report

Collaborative: - Administration of medications and oxygen supplementation:

1.Administer oxygen

5.) To promote calmness, reduce competing stimuli and reduces anxiety thus it decreases oxygen demand.

6.) To prevent triggering the heart to the need of more oxygen due to exertion, thus, limiting activities decrease myocardial oxygen demand and workload on the heart.

7.) To promote knowledge and compliance with the said therapeutic regimen and for better action.

1.) To promote adequate oxygen supply

AEB: Able to sleep and

rest comfortably Improve breathing Vital signs within

normal range: BP=120/80

PR= 60-100bpm RR= 12-20 cpm Temp= 36.5 Pain rate scale

from 10 down to 2 as 10 is the highest

2. Administer analgesics as ordered, such as morphine sulfate

3. Administer beta-blockers such as metropolol as ordered.

4. Perform a 12-lead ECG and monitor for cardiac changes

2.) Morphine Sulfate is the drug of choice to control MI pain, it decreases the afterload and preload (workload) of the heart, decrease oxygen demand, Thus, reduces pain

3.) To block sympathetic stimulation, reduce heart rate and lowers myocardial demand.

4.) ECG record changes that can give evidence of further cardiac damage and location of MI, thus ECG monitoring is important for better prevention of damage due to MI.

Date Assessed August 22, 2012

ASSESSMENT DIAGNOSIS SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION

EXPLANATION

Subjective:

- “Mabilis akong mapagod at manghina, simpleng Gawain lng nakakramdam na ako ng hirap sa paghinga” as verbalized by the patient

Objective:

Weak in appearance

Pallor Experience

shortness of breathing

Needs assistance in doing minimal activities

Easy fatigability With Oxygen

inhalation at 2-4 Lpm

Vital signs taken as: BP=130/90

PR=90 bpm RR= 20 cpm

Activity Intolerance related to Imbalance

between oxygen Supply and Demand

secondary to Myocardial Infarction

Deficient oxygen in the coronary arteries

↓Use of anaerobic

pathway to for ATP production

↓↓ Oxygen to the

myocardium↓

Inadequate amounts of oxygen to the

tissues↓

Imbalance between oxygen Supply and

Demand↓

Activity Intolerance

Short Term Goal:

- After 5-8 hours shift duty of rendering care and interventions, the patient will be able to verbalized understanding about her condition, AEB: Reduced feeling

of fatigue and weakness

Able to mention and apply ways on how managed her condition

Participate to interventions

Vital signs within normal limits upon performing limited activities:

BP=120/80 PR= 60-100bpm RR= 12-20 cpm Temp= 36.5

Long term Goal:

- After 1 to 2 weeksof intervention, the patient will report measurable increase

Independent:

1. Establish rapport both to patient and S.O.

2. Monitor vital signs, before and after doing such activities.

3. Encourage patient to verbalize her feelings and concerns regarding her present condition and limitations.

4. Maintain stressful activity restrictions and assist patient with self care activities as needed.

5. Provide frequent rest periods, especially after meals.

1.) To gain their trust and for better intervention participation.

2.) For baseline data and to determine the of other complication in relation to increase vital signs if possible.

3.) Informing her about her condition and limitations prevents her to develop further complication and it will be a help to manage properly her condition.

4.) Reduces physical stress and tension, it decreases the demand of oxygen thus decreases also the workload of the heart.

5.) Resting decreases the oxygen demand of the heart. Large meals may increase

Short Term Goal:

Goal Met: Patient was able to verbalized understanding about her condition, AEB: Reduced feeling

of fatigue and weakness

Able to mentioned and apply ways on how managed her condition

Vital signs within normal limits upon performing limited activities:

BP=120/80 PR= 60-100bpm RR= 12-20 cpm Temp= 36.5

Long term Goal:Goal Met, Patient showed measurable increase in activity tolerance, AEB:

Reduced feeling of fatigue and weakness

Demonstrate a decrease in

Temp= 37.8 Functional Level

Classification: Level III – means, walk no more than 50 ft on level without stopping; unable to climb one flight of stairs without stopping.

in activity tolerance, AEB:

Reduced feeling of fatigue and weakness

Demonstrate a decrease in physiological signs of intolerance

Vital signs within normal limits upon performing limited activities:

BP=120/80 PR= 60-100bpm RR= 12-20 cpm Temp= 36.5 Perform ADL’s

without the need of assistance and able to do it comfortably

6. Encourage rest periods between care activities.

Collaborative:

1. Administer beta-blockers such as metoprolol, as ordered.

myocardial workload and causes vagal stimulation thus increases the demand of oxygen.

6.) Postural hypotension/ cerebral hypoxia may cause dizziness, fainting, and increased risk of injury

1.) It blocks sympathetic stimulation, thus, reduces heart rate and lowers myocardial demand.

physiological signs of intolerance

Vital signs within normal limits upon performing limited activities:

BP=120/80 PR= 60-100bpm RR= 12-20 cpm Temp= 36.5 Perform ADL’s

without the need of assistance and able to do it comfortably.

ASSESSMENT DIAGNOSIS SCIENTIFIC EXPLANATION

PLANNING INTERVENTION RATIONALE EVALUATION

Subjective:

“Hindi ko maipaliwanag nararamdaman ko,malala ba kondisyon ko?hindi pa ako handa” as vervalized by the patient.

Objective:

Usually staring at the wall or ceiling.

Unexplained facial expression

Poor eye contact Confusion irritability Restlessness Ask questions Decreased

interaction to the family/S.O

Anxiety (moderate) related to Actual

Threats topresent condition

Secondary to Myocardial Infarction

Experienced chest pain

↓Myocardial ischemia

reported↓

Diagnosed as myocardial infarction

↓Frequent monitoring

needed↓

Conscious, irritable, poor eye contact,

restless↓

Confusion↓

Anxiety

Short Term Goal:

- After the 8 hrs shift of duty of rendering care and interventions, the patient will be able to understand the complications about his condition and able to control his anxiety through proper explanation in her present situation, AEB: Verbalized

awareness of feelings of anxiety

Actively interacts to family

Open to his conditions and ask questions for security and reassurance

With eye contact Decreased

irritability, restlessness and confusion.

Long term Goal:

- After 3-5 days of rendering care and interventions, the patient will be able to accept the reality about his condition and readily participates in activities, AEB: Appeared relax

and report

Independent:

1. Establish rapport

2. Provide continuity of care

3. Encourage the patient and family to ask questions and bring up common concerns.

4. Encourage patient and S.O to verbalize concerns and fears.

5. Inform them that frequent assessment are routinely done to monitor her condition and don’t necessarily imply a deteriorating condition.

6. Repeat the information as necessary because patient and family may reduce their

1.) To have a trusted nurse to patient relationship and to have a therapeutic communication.

2.) Continuity of care promotes security and development of rapport.

3.) Accurate information about his condition reduces fear , strengthens the nurse-patient relationship and assist the patient and familt to face the situation realistically.

4.) Sharing information elicits support and comfort and can relieve tension and unexpressed worries.

5.) To reassure the patient that frequent monitoring may prevent him to develop of more serious complications.

6.) Anxiety decreases learning and attention.

Short Term Goal:

Goal Met: Patient already understand the complications about his condition and able to control his anxiety through proper explanation in her present situation, AEB: Verbalized

awareness of feelings of anxiety

Actively interacts to family

Open to his conditions and ask questions for security and reassurance

With eye contact Decreased

irritability, restlessness and confusion.

Long Term Goal :

Goal Met: Patient was able to accept the reality about his condition and readily participates in activities, AEB: Appeared relax

and report anxiety is reduced to manageable level

Open to his conditions and

Date Assessed August 20, 2012

ASSESSMENT DIAGNOSIS SCIENTIFIC EXPLANATION

PLANNING INTERVENTION RATIONALE EVALUATION

Subjective:

“ Mabuti naman na pakiramdam ko, hindi na sumasakit ang dibdib ko,minsan minsan na lang pero hindi na kagaya noon” as verbalized by the patient.

Objective:

Experience easy fatigability

Experience dizziness and shortness of breath upon doing minimal activities ( Standing)

Experiences

Risk for Decrease cardiac output related to increase vascular

resistance as evidenced by narrowing of

coronary arteries secondary to Myocardial Infarction

Deposits from a large atherosclerotic plaque cause in increase in

size and bulge into the artery

Endothelial lining of coronary

activation of coagulation cascade arteries will rupture

Plaque protrudes in lumen of the vessels

Thrombus may dislodge from a broken plaque

Narrowed blood vessels/impedes blood

flow

Short Term Goal:

- After 8 hours shift of duty and rendering patient care and nursing interventions, the patient will verbalized understanding about his risk for decrease cardiac output and promote appropriate actions to promote patient’s condition AEB: Able to

participate in medication regimen and in restrictions regarding to her condition.

Identify signs and symptoms of

Independent:

1. Establish rapport both to patient and to the S.O

2. Monitor patient’s vital signs, noting blood pressure changes.

3. Provide a calm and restful surroundings

4. Maintain activity restrictions and assisted patient with self care

1.) In order to have a trusting relationship on them.

2.) Tachycardia may be present because of pain and anxiety and reduced cardiac output. Changes may also occur in BP (hypertension or hypotension) because of cardiac response.

3.) It promotes comfort and relaxation.

4.) Reduces physical stress and tension. Conserves energy, reduces

Short Term Goal:

Goal Met: Patient verbalized understanding about his risk for decrease cardiac output and able to promote appropriate actions to promote patient’s condition AEB: Participates in

medication regimen and in restrictions regarding to her condition.

Identify signs and symptoms of cardiac decompression and able to seek attention if occur

Reported

chest pain, nausea and vomiting, and epigastric pain.

Restlessness With an Oxygen

inhalation at 2-4 Lpm

Vital signs taken as:BP=150/90

PR=109 bpm RR= 26 cpm Temp= 35.0

Decreased cardiac output

cardiac decompression and able to seek attention if occur

Report of continuous disappearance of minimal occurrence of chest pain being intermittently felt.

Vital signs are within normal limits.

Long term Goal:

- After 3-5 days of rendering patient care and interventions, the patient will report feeling of comfort and lessen the possible signs and symptoms of being in risk for decrease cardiac output through the proper management and participation to intervention and medication regimens AEB: Display a

hemodynamic Stability Shows proper

activities as needed.

5. Provided comfort measures (ex. Back massage and elevation of head)

6. Encouraged to do relaxation techniques such as distraction

7. Maintain head elevated approximately 30 degrees.

8. Instruct patient to avoid activities that create a Valsalva response (e.g. straining to have a bowel movement, holding breath while moving up in bed)

9. Maintain on bed rest or semi fowlers

cardiac workload.

5.) Decreases discomfort and may reduce sympathetic stimulation.

6.) Can reduce stressful stimuli and produce a calming effect.

7.) To promote optimal cerebral perfusion.

8.) Valsalva maneuver causes vagal stimulation, reducing heart rate (bradycardia), which may be followed by rebound tachycardia, which causes to impair cardiac output.

9.) Decreases oxygen consumption/dem

continuous disappearance of minimal occurrence of chest pain being intermittently felt.

Vital signs are within normal limits.

Long term Goal:

Goal partially Met: Patient reported feeling of comfort and lessen signs and symptoms being felt and observed through the proper management and participation to intervention and medication regimens AEB: -Display an

improvement in hemodynamic

Stability Shows proper

breathing pattern but still have the need to use an oxygen therapy for support.

breathing pattern and no need to use an oxygen therapy for support.

can perform basic activities without experiencing dizziness and easy fatigability

will improved into an active body tolerance.

Adequate cardiac outputAEB: stable/improving ECG result after performing PTCA done on the same day.

position.

Collaborative:

1. Administer Administer beta-blockers such as metoprolol, as ordered.

2. Administer supplemental oxygen as needed.

3. Perform surgical intervention such as PTCA as needed.

and, reducing myocardial workload

1.) It blocks sympathetic stimulation, thus, reduces heart rate and lowers myocardial demand.

2.) Increases oxygen available for myocardial uptake to improve contractility, reduce ischemia, and reduce lactic acid levels.

3) It helps to improve the condition of the patient and it contributes patients’ wellness and danger.

Able to perform basic activities without experiencing dizziness and minimally experience fatigability.

Adequate cardiac output, AEB: stable/improving ECG result after performing PTCA done on the same day.

Date Assessed August 21, 2012

ASSESSMENT DIAGNOSIS SCIENTIFIC EXPLANATION

PLANNING INTERVENTION RATIONALE EVALUATION

Subjective:

The patient reports of difficulty of breathing and chest discomfort.

Objective: restlessness irritability easy fatigability Diaphoresis Dizziness Cold clammy

skin Pale in

appearance With an

Oxygen inhalation at 2-4 Lpm

Vital signs taken as:BP=150/90

PR=109 bpm RR= 26 cpm Temp= 35.0

Ineffective Cardiac Tissue Perfusion

related to Reduced Coronary Blood

Flow Secondary to Myocardial Infarction

Deposits from a large atherosclerotic

plaque cause in increase in size and bulge into

the artery

Endothelial lining of coronary

activation of coagulation cascade arteries will rupture

Plaque protrudes in lumen of the vessels

Thrombus may dislodge from a broken plaque

Narrowed blood vessels/impedes

blood flow

Decreased cardiac output

Ineffective Tissue Perfusion

Short Term Goal:

- After 8 hours of rendering nursing intervention the patient will show adequate coronary perfusion and reported feeling of relieved from discomforts, AEB: decrease restlessness decrease irritability decrease feeling of

fatigability Skin warm and dry and

in normal color Vital signs within

normal range Relieved chest

discomfort Improve breathing

discomfort

Long Term Goal: - After 3 Days of nursing intervention the patient will be free from the signs and symptoms of ineffective cardiac tissue perfusion AEB:

Reported a comfortable feeling

Free of pain and other signs and symptoms ineffective tissue

Independent:

1. Monitor vital signs especially blood pressure.

2. Asses for restlessness fatigue, changes of level of consciousness appearance of skin color.

3. Provides period of undisturbed rest and calming environment

4. Instruct patient in a complete bed rest.

1.) For baseline data and to monitor or determine for further myocardial ischemia, thus preventing the occurrence of other potential complications

2.) It is the signs and symptoms of inadequate systemic perfusion which can affect cardiac function

3.) To reduce myocardial oxygen demand and work load

4.) It promotes decreases oxygen demand, thus promoting adequate oxygen circulation.

Short Term Goal:

Goal Met, Patient will showed adequate coronary perfusion and reported feeling of relieved from discomforts, AEB:

decrease restlessness

decrease irritability

decrease feeling of fatigability

Skin warm and dry and in normal color

Vital signs within normal range

Relieved chest discomfort

Improve breathing discomfort

Long Term Goal:

Goal Met, Patient was observed as free from the signs and symptoms of ineffective cardiac tissue perfusion and showed feeling of

perfusion VS within normal limits Adequate cardiac output

AEB:stable/improving ECG result

Collaborative:

1. Administer medication regimens as ordered such as:

Morphine sulfate

Administer beta-blockers as ordered.

2. Perform a 12-lead ECG and monitor for cardiac changes

Morphine Sulfate is the drug of choice to control MI pain, it decreases the afterload and preload (workload) of the heart, decrease oxygen demand, Thus, reduces pain

To block sympathetic stimulation, reduce heart rate and lowers myocardial demand.

2.) It helps in determining cardiac insufficiency and it helps to monitor the cardiac electrical activity.

wellness AEB:

Reported a comfortable feeling

Free of pain and other signs and symptoms ineffective tissue perfusion

VS within normal limits

Adequate cardiac outputAEB: stable/improving ECG result after performing PTCA done on the same day.

3. Administer Oxygen as ordered

4. Administer intravenous fluids as routinely ordered

5. Perform surgical intervention such as PTCA as needed.

3.) In order to improve or maintain cardiac and systemic tissue perfusion

4.) To maintain systemic circulation and optimal cardiac function.

5.) It helps to improve the condition of the patient and it contributes patients’ wellness and danger.