ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

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.
Short-term goal:
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.
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.
2. Obtain history of previous
cardiac pain and familial history
of cardiac problems.
3. Assess respirations, BP and
heart rate with each episodes
of chest pain.
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.
Short-term goal:
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.

4. Maintain bed rest during 4. To reduce oxygen

pain, with position of comfort, consumption and demand, to
maintain relaxing environment reduce competing stimuli and
to promote calmness. reduces anxiety.

5. Prepare for the 5. Pain control is a priority, as it

administration of medications, indicates ischemia.
and monitor response to drug
therapy. Notify physician if pain
does not abate.

6. Instruct patient in 6. To decrease myocardial

nitroglycerin SL administration oxygen demand and work load
after hospitalization. Instruct on the heart.
patient inactivity alterations and
limitations.
7. Instruct patient/family in
medication effects, side-effects,
and contraindications and
symptoms to report.
DEPENDENT:
1. Obtain a 12-leadECG 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 or Dilaudid
N.
3. Administer beta-blockers as
ordered.
4. Administer calcium-channel
blockers as ordered.
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 maybe 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
that can decrease pain due to
ischemia.
 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
Short-term goal:
Within 8 hours 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.
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.
RATIONALE EVALUATION
Short-term goal:
1. Changes in VS assist with Within 8hours of nursing
monitoring physiologic interventions, the client
responses to increase in tolerated activity without
activity. excessive dyspnea and had
been able to utilize breathing
techniques and energy
2. Alleviation of factors that are conservation techniques
known to create intolerance can effectively.
assist with development of an
activity level program. Goal was met.
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.
DEPENDENT:
1. Assist patient with 1. To gradually increase the
ambulation, as ordered, with body to compensate for the
progressive increases as increase in overload.

patient’s tolerance permits.

 ASSESSMENT
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 understanding.
DIAGNOSIS
Deficient Knowledge r/t new
diagnosis and lack of
understanding of medical
condition.
PLANNING
Short-term goal:
The client will be able to
verbalize and demonstrate
understanding of information
given regarding condition,
medications, and treatment
regimen within 1 hour of
nursing interventions.
INTERVENTION
INDEPENDENT:
1. Monitor patient’s 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
post discharge.
7. Instruct exercises to be
performed, and to avoid
overtaxing activities.
RATIONALE EVALUATION
Short-term goal:
1. To promote optimal learning The client verbalized and
environment when patient show demonstrated understanding of
willingness to learn. information given regarding
condition, medications, and
2. To establish trust. treatment regimen within 1 hour
of nursing interventions.
3. To provide information to Goal was met.
manage medication regimen
and to ensure compliance.
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 provide information that
patient has gained a full
understanding of instructions.
7. These are helpful in
improving cardiac function.
DEPENDENT:
1. Refer patient to cardiac 1. To provide further
rehabilitation as ordered. improvement and rehabilitation
post discharge.