NURSING CARE PLAN – Myocardial Infarction

ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

Independent:
After 8 hours of Goal met, patient
SUBJECTIVE: Pain r/t tissue Occlusion of nursing • Obtain full • Pain is a has
“Sumasakit ang ischemia (coronary coronary artery intervention the description of subjective verbalized
dibdib ko” (I’ve artery occlusion) patient will pain from experience and relief/control of chest
been experiencing Verbalize patient must be pain within
chest pains) as relief/control of including described by appropriate time
verbalized by the Decrease blood chest pain within location, patient frame for
patient flow to the appropriate time intensity (0– administered
myocardium frame for 10), duration, medications.
administered characteristics
medications. (dull/crushing),
OBJECTIVE: and radiation.
Decrease oxygen Assist patient
• Restlessness to quantify pain
supply (ischemia)
• Facial grimace by comparing it
• Pain scale of 9 to other
out of 10 experiences • Delay in
• V/S taken as reporting pain
Anaerobic
follows • Instruct patient hinders pain
metabolism
to report pain relief/may
T: 37.6 ˚C immediately. require
P: 112 increased
R: 12 dosage of
Lactic acid medication to
BP: 140/ 100
formation achieve relief
• Provide quiet
environment, • Decreases
calm activities, external
pain and comfort stimuli, which
measures may aggravate
anxiety and
cardiac strain,
limit coping
abilities and
• Assist/instruct adjustment to
in relaxation current
techniques, situation
 e.g., deep/slow
breathing, • Helpful in
distraction decreasing
behaviors, perception of/
visualization, response to
guided imagery pain. Provides
a sense of
Collaborative having some
• Administer control over
supplemental the situation,
oxygen by increase in
means of nasal positive
cannula or face attitude.
mask, as
indicated

Administer • Increases
medications as amount of
indicated: oxygen
• Antianginals, available for
e.g., myocardial
nitroglycerin, uptake and
isosorbide thereby may
dinitrate relieve
(Isordil) discomfort
associated with
tissue ischemia

• Beta-blockers, • Nitrates are

e.g., atenolol useful for pain
(Tenormin), control by
propranolol coronary
(Inderal), vasodilating
metoprolol effects, which
(Lopressor) increase
coronary blood
flow and
myocardial
perfusion.
 • Important
• Analgesics, second-line
e.g., morphine, agents for pain
meperidine control through
(Demerol) effect of
blocking
sympathetic
stimulation,
thereby
reducing heart
rate, systolic
BP, and
myocardial
oxygen
demand

• Although
intravenous
(IV) morphine
is the usual
drug of choice,
other injectable
narcotics may
be used in
acute-
phase/recurren
t chest pain
unrelieved by
nitroglycerin to
reduce severe
pain, provide
sedation, and
decrease
myocardial
workload