nursing care plan for myocardial infarction
DESCRIPTION
Myocardial InfarctionTRANSCRIPT
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.