Nursing Care Plan for Myocardial Infarction NCP
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Student Nurses’ Community NURSING CARE PLAN Myocardial Infarction ─ ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION Subjective: The c lient r eports of chest pain radiating to the left arm and neck and back. Objective: • Restlessness • Facial grimacing • Fatigue • Peripheral canosis • !eak pulse • "old and clamm skin • Palpitations • Shortness of breath • #levated temperature • Pain scale of $%&' (cute )"hest* Pain r%t mocardial ischemia resulting from coronar arter occlusion +ith loss%restriction of blood ,o+ to an area of the mocardium and necrosis of the mocardium. ST-: !ithin & hour of nursing interventions the client +ill have improved comfort in chest as evidenced b: • States a decrease in the rating of the chest pain. • /s able to rest displas reduced tension and sleeps comfortabl. • Re0uires decrease analgesia or nitroglcerin. 1T-: The client +ill have an improved feeling of control as /23#P#23#2T: &. (ssess character istics of chest pain including location duration 0ualit intensit presence of radiation precipitating and alleviating factors and as associated smptoms have client rate pain on a scale of &4&' and document 5ndings in nurse6s notes. 7. Obtain histor of previous cardiac pain and familial histor of cardiac problems. 8. (ssess respirations 9P and heart rate +ith each episodes of chest pain. . ;aintain bed rest during pain +ith &. Pain is indication of ;/. assisting the client in 0uantifing pain ma di<erentiate pre4 e=isting and current pain patterns as +ell as identif complications. 7. This provides information that ma help to di<erentiate current pain from previous problems and complications. 8. Respirations ma be increased as a result of pain and associate an=iet. . To reduce o=gen consumption and demand to reduce competing stimuli and reduces an=iet. >. Pain control is a ST-: !ithin & hour of nursing intervention the client had improved comfort in chest as evidenced b: • States a decrease in the rating of the chest pain. • /s able to rest displas reduced tension and sleeps comfortabl. • Re0uires decrease analgesia or nitroglcerin. -oal +as met. 1T-: The client had an improved feeling of control as evidenced b verbali?ing a sense of control over present situation
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Nursing Care Plan for
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Student Nurses’ Community
NURSING CARE PLAN Myocardial Infarction ─ ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective: The client reportsof chest painradiating to the leftarm and neck andback.
Objective:• Restlessness• Facial
grimacing• Fatigue• Peripheral
c anosis• !eak pulse• "old and
clamm skin• Palpitations• Shortness of
breath• #levated
temperature• Pain scale of
$%&'
(cute )"hest*Pain r%tm ocardialischemiaresulting fromcoronar arterocclusion +ithloss%restrictionof blood ,o+ to
an area of them ocardiumand necrosis ofthem ocardium.
ST-: !ithin & hourof nursinginterventionsthe client +illhave improvedcomfort inchest asevidenced b :
• States adecrease inthe rating ofthe chestpain.• /s able torest displa sreducedtension andsleepscomfortabl .• Re0uiresdecreaseanalgesia ornitrogl cerin.
1T-: The client+ill have animprovedfeeling ofcontrol as
/23#P#23#2T:&. (ssesscharacteristics ofchest pain includinglocation duration0ualit intensitpresence ofradiationprecipitating and
alleviating factorsand as associateds mptoms haveclient rate pain on ascale of &4&' anddocument 5ndingsin nurse6s notes.
7. Obtain histor ofprevious cardiacpain and familial
histor of cardiacproblems.
8. (ssessrespirations 9P andheart rate +ith eachepisodes of chestpain.
. ;aintain bed restduring pain +ith
&. Pain is indicationof ;/. assisting theclient in 0uantif ingpain madi<erentiate pre4e=isting and currentpain patterns as+ell as identifcomplications.
7. This providesinformation thatma help todi<erentiate currentpain from previousproblems andcomplications.
8. Respirations mabe increased as a
result of pain andassociate an=iet .
. To reduce o= genconsumption anddemand to reducecompeting stimuliand reducesan=iet .
>. Pain control is a
ST-: !ithin & hour ofnursingintervention theclient hadimproved comfortin chest asevidenced b :
• States a
decrease in therating of thechest pain.• /s able to restdispla s reducedtension andsleepscomfortabl .• Re0uiresdecreaseanalgesia ornitrogl cerin.-oal +as met.
1T-: The client had animproved feelingof control asevidenced bverbali?ing a senseof control overpresent situation
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Student Nurses’ Communityevidenced bverbali?ing asense ofcontrol over
presentsituation andfutureoutcomes+ithin 7 da sof nursinginterventions.
position of comfortmaintain rela=ingenvironment topromote calmness.
>. Prepare for theadministration ofmedications andmonitor response todrug therap . 2otifph sician if paindoes not abate.
@. istruct patient innitrogl cerin S1administration afterhospitali?ation./nstruct patient inactivit alterationsand limitations.
A. /nstructpatient%famil inmedication e<ectsside4e<ectscontraindicationsand s mptoms toreport.
3#P#23#2T:&. Obtain a &74lead#"- on admissionthen each timechest pain recurs forevidence of furtherinfarction asprescribed.
priorit as itindicates ischemia.
@. To decrease
m ocardial o= gendemand and+orkload on theheart.
A. To promotekno+ledge andcompliance +iththerapeutic regimenand to alleviate fearof unkno+n.
&. Serial #"- andstat #"-s recordchanges that cangive evidence offurther cardiacdamage andlocation of ;/.
7. ;orphine is thedrug of choice tocontrol ;/ pain butother analgesicsma be used toreduce pain andreduce the+orkload on theheart.
8. To blocks mpatheticstimulation reduce
and futureoutcomes +ithin 7da s of nursingintervention.
-oal +as met.
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Student Nurses’ Community
7. (dministeranalgesics asordered such as
morphine sulfatemeferidine of3ilaudid 2.
8. (dminister beta4blockers as ordered.. (dministercalcium4channel
blockers as ordered.
heart rate andlo+ers m ocardialdemand.
. To increasecoronar blood ,o+and collateralcirculation +hichcan decrease paindue to ischemia.
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Student Nurses’ Community
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective: The clientreports ofincreased +orkof breathingassociated +ithfeelings of+eakness andtiredness.
Objective:•
/ncreasedheartrate
• /ncreasedbloodpressure
• 3 spnea+ithe=ertion
• Pallor• Fatigue and
+eakness• 3ecreased
o= gensaturation
• /schemic#"-changes
(ctivit/ntolerancer%t cardiacd sfunctionchanges ino= gensuppl andconsumptionas evidencedb shortnessof breath.
ST-: !ithin 8 da s of nursinginterventions theclient +ill be ableto tolerate activit+ithout e=cessived spnea and +illbe able to utili?ebreathingtechni0ues andenergconservationtechni0uese<ectivel .
1T-: !ithin > da s of nursinginterventions theclient +ill be ableto increase and
achieve desiredactivit levelprogressivel+ith nointolerances mptoms notedsuch asrespiratorcompromise.
/23#P#23#2T:&. ;onitor heart raterh thm respirationsand blood pressure forabnormalities. 2otifph sician ofsigni5cant changes inBS.
7. /dentif causativefactors leading tointolerance of activit .
8. #ncourage patientto assist +ith planningactivities +ith restperiods as necessar .
. /nstruct patient inenerg conservationtechni0ues.>. (ssist +ith active
or passive RO;e=ercises at least C/3.
@. Turn patient atleast ever 7 hoursand prn.
A. /nstruct patient inisometric andbreathing e=ercises.
&. "hanges in BS assist+ith monitoringph siologic responsesto increase in activit .
7. (lleviation of factorsthat are kno+n tocreate intolerance canassist +ithdevelopment of anactivit level program.8. to help give thepatient a feeling of self4+orth and +ell4being.
. To decrease energe=penditure andfatigue.
>. To maintain jointmobilit and muscletone.
@. To improverespirator function andprevent skinbreakdo+n.
A. To improve breathingand to increase activitlevel.
$. To promote self4
ST-: !ithin 8 da s ofnursinginterventions theclient toleratedactivit +ithoute=cessive d spneaand had been ableto utili?e breathingtechni0ues andenerg conservationtechni0uese<ectivel . -oal +as met.
1T-: !ithin > da s ofnursinginterventions theclient increased andachieved desiredactivit level
progressivel +ithno intolerances mptoms notedsuch as respiratorcompromise.-oal +as met.
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Student Nurses’ Community$. Providepatient%famil +ithe=ercise regimen+ith +ritten
instructions.
3#P#23#2T:&. (ssisst patient +ithambulation as
ordered +ithprogressive increasesas patient6s tolerancepermits.
+orth and involvespatient and his famil+ith self4care.
&. To graduall increasethe bod tocompensate for theincrease in overload.
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Student Nurses’ Community
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
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Student Nurses’ Community
Subjective: The clientverbali?es
0uestionsregardingproblems andmisconceptionsabout hiscondition.
Objective:• 1ack of
improvementof previousregimen
• /nade0uatefollo+4up oninstructionsgiven.
• (n=iet• 1ack of
understan4ding.
3e5cientDno+ledge r%tne+ diagnosis
and lack ofunderstandingof medicalcondition.
ST-: The client +ill beable to verbali?e
and demonstrateunderstanding ofinformation givenregardingconditionmedications andtreatmentregimen +ithin 8da s of nursinginterventions.
1T-: The client +illable to correctlperform all tasksprior to discharge.
/23#P#23#2T:&. ;onitor patient6sreadiness to learn anddetermine best
methods to use forteaching.7. Provide time forindividual interaction+ith patient.8. /nstruct patient onprocedures that mabe performed./nstruct patient onmedications dosee<ects side e<ects
contraindications andsigns%s mptoms toreport to ph sician.. /nstruct in dietarneeds and restrictionssuch as limiting sodiumor increasingpotassium.
>. Provide printedmaterials +henpossible forpatient%famil torevie+s.@. Eave patientdemonstrate all skillsthat +ill be necessarfor post discharge.A. /nstruct e=ercises tobe performed and toavoid overta=ingactivities.
&. To promote optimallearning environment+hen patient sho+
+illingness to learn.
7. To establish trust.
8. To provideinformation tomanage medicationregimen and to ensurecompliance.
. "lient ma need to
increase dietarpotassium if placed ondiuretics sodiumshould be limitedbecause of thepotential for ,uidretention.
>. To providereference for thepatient and famil torefer.
@. To provideinformation thatpatient has gained afull understanding ofinstruction.A. These are helpful inimproving cardiacfunction.
ST-: The client verbali?edand demonstrated
understanding ofinformation givenregarding conditionmedications andtreatment regimen+ithin 8 da s ofnursing interventions.-oal +as met.
1T-: The client had been
able to correctlperform all tasks priorto discharge.-oal +as met.
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Student Nurses’ Community
