Myocardial Infarction ASSESSMENT DIAGNOSIS Subjective: The client reports of chest pain radiating to the left arm and

neck and back. Objective: Restlessness Facial grimacing Fatigue Peripheral cyanosis Weak pulse Cold and clammy skin Palpitations Shortness of breath Elevated temperature Pain scale of 8/10 Acute (Chest) Pain r/t myocardial ischemia resulting from coronary artery occlusion with loss/restriction of blood flow to an area of the myocardium and necrosis of the myocardium.

PLANNING STG: Within 1 hour of nursing interventions, the client will have improved comfort in chest, as evidenced by: States a decrease in the rating of the chest pain. Is able to rest, displays reduced tension, and sleeps comfortably. Requires decrease analgesia or nitroglycerin. LTG: The client will have an improved feeling of control as evidenced by verbalizing a sense of control over present situation and future outcomes within 2 days of nursing interventions.

INTERVENTION INDEPENDENT: 1. assess characteristics of chest pain, including location, duration, quality, intensity, presence of radiation, precipitating and alleviating factors, and as associated symptoms, have client rate pain on a scale of 1-10 and document findings in nurses notes. 2. obtain history of previous cardiac pain and familial history of cardiac problems.

RATIONALE

EVALUATION STG: Within 1 hour of nursing intervention, the client had improved comfort in chest, as evidenced by: States a decrease in the rating of the chest pain. Is able to rest, displays reduced tension, and sleeps comfortably. Requires decrease analgesia or nitroglycerin. Goal was met. LTG: The client had an improved feeling of control as evidenced by verbalizing a sense of control over present situation and future outcomes within 2 days of nursing intervention. Goal was met.

1. pain is indication of MI. assisting the client in quantifying pain may differentiate pre-existing and current pain patterns as well as identify complications.

2. this provides information that may help to differentiate current pain from previous problems and complications. 3. respirations may be increased as a result of pain and associate anxiety. 4. to reduce oxygen consumption and demand, to reduce competing stimuli and reduces anxiety. 5.pain control is a priority, as it indicates ischemia.

3. assess respirations, BP and heart rate with each episodes of chest pain. 4. maintain bedrest during pain, with position of comfort, maintain relaxing environment to promote calmness. 5. prepare for the administration of medications, and monitor response to drug therapy. Notify physician if pain does not abate.

6.istruct patient in nitroglycerin SL administration after hospitalization. Instruct patient in activity alterations and limitations. 7. instruct patient/family in medication effects, side-effects, contraindications and symptoms to report. DEPENDENT: 1. obtain a 12-lead ECG on admission, then each time chest pain recurs for evidence of further infarction as prescribed. 2. administer analgesics as ordered, such as morphine sulfate, meferidine of Dilaudid N. 3. administer betablockers as ordered.

6. to decrease myocardial oxygen demand and workload on the heart.

7. to promote knowledge and compliance with therapeutic regimen and to alleviate fear of unknown. 1. serial ECG and stat ECGs record changes that can give evidence of further cardiac damage and location of MI. 2. Morphine is the drug of choice to control MI pain, but other analgesics may be used to reduce pain and reduce the workload on the heart. 3. to block sympathetic stimulation, reduce heart rate and lowers myocardial demand. 4. to increase coronary blood flow and collateral circulation which can decrease pain due to ischemia.

4. administer calciumchannel blockers as ordered.

ASSESSMENT Subjective: The client reports of increased work of breathing associated with feelings of weakness and tiredness. Objective: Increased heart rate Increased blood pressure Dyspnea with exertion Pallor Fatigue and weakness Decreased oxygen saturation Ischemic ECG changes

DIAGNOSIS Activity Intolerance r/t cardiac dysfunction, changes in oxygen supply and consumption as evidenced by shortness of breath.

PLANNING STG: Within 3 days of nursing interventions, the client will be able to tolerate activity without excessive dyspnea and will be able to utilize breathing techniques and energy conservation techniques effectively. LTG: Within 5 days of nursing interventions, the client will be able to increase and achieve desired activity level, progressively, with no intolerance symptoms noted, such as respiratory compromise.

INTERVENTION INDEPENDENT: 1. monitor heart rate, rhythm, respirations and blood pressure for abnormalities. Notify physician of significant changes in VS. 2. Identify causative factors leading to intolerance of activity. 3. encourage patient to assist with planning activities, with rest periods as necessary. 4. instruct patient in energy conservation techniques. 5. assist with active or passive ROM exercises at least QID. 6. turn patient at least every 2 hours, and prn. 7. instruct patient in isometric and breathing exercises. 8. provide patient/family with exercise regimen, with written instructions. DEPENDENT: 1.Assisst patient with ambulation, as ordered, with progressive increases as patients tolerance

RATIONALE 1.changes in VS assist with monitoring physiologic responses to increase in activity.

EVALUATION STG: Within 3 days of nursing interventions, the client tolerated activity without excessive dyspnea and had been able to utilize breathing techniques and energy conservation techniques effectively. Goal was met. LTG: Within 5 days of nursing interventions, the client increased and achieved desired activity level, progressively, with no intolerance symptoms noted, such as respiratory compromise. Goal was met.

2. Alleviation of factors that are known to create intolerance can assist with development of an activity level program. 3. to help give the patient a feeling of self-worth and well-being. 4. to decrease energy expenditure and fatigue. 5.to maintain joint mobility and muscle tone. 6.to improve respiratory function and prevent skin breakdown. 7. to improve breathing and to increase activity level. 8. to promote self-worth and involves patient and his family with self-care. 1. to gradually increase the body to compensate for the increase in overload.

permits.

ASSESSMENT

DIAGNOSIS

PLANNING

INTERVENTION

RATIONALE

EVALUATION

Subjective: The client verbalizes questions regarding problems and misconceptions about his condition. Objective: Lack of improvement of previous regimen Inadequate follow-up on instructions given. Anxiety Lack of understan-ding.

Deficient Knowledge r/t new diagnosis and lack of understanding of medical condition.

STG: The client will be able to verbalize and demonstrate understanding of information given regarding condition, medications, and treatment regimen within 3 days of nursing interventions. LTG: The client will able to correctly perform all tasks prior to discharge.

INDEPENDENT: 1. monitor patients readiness to learn and determine best methods to use for teaching. 2. provide time for individual interaction with patient. 3. instruct patient on procedures that may be performed. Instruct patient on medications, dose, effects, side effects, contraindications, and signs/symptoms to report to physician. 4. instruct in dietary needs and restrictions, such as limiting sodium or increasing potassium. 5. provide printed materials when possible for patient/family to reviews. 6. have patient demonstrate all skills that will be necessary for postdischarge. 7. instruct exercises to be performed, and to avoid overtaxing activities. DEPENDENT: 1. refer patient to cardiac rehabilitation as ordered .

1. to promote optimal learning environment when patient show willingness to learn. 2. to establish trust. 3. to provide information to manage medication regimen and to ensure compliance.

STG: The client verbalized and demonstrated understanding of information given regarding condition, medications, and treatment regimen within 3 days of nursing interventions. Goal was met. LTG: The client had been able to correctly perform all tasks prior to discharge. Goal was met.

4. client may need to increase dietary potassium if placed on diuretics; sodium should be limited because of the potential for fluid retention. 5. to provide reference for the patient and family to refer. 6. to frovide information that patient has gained a full understanding of instruction. 7. these are helpful in improving cardiac function. 1. to provide further improvement and rehabilitation postdischarge.