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1.Acute Pain related to ischemia of the myocardium resulting from coronary occlusion with loss/restriction of blood flow to an area of the myocardium and necrosis of myocardium
2.Ineffective Tissue Perfusion (cardiopulmonary) related to altered blood flow to myocardial tissue. 3.Risk for Decreased Cardiac Output related to negative inotropic changes in the heart

4.Impaired Gas Exchange related to decreased cardiac output 5.Risk for Fluid Volume Deficit related to excessive losses through diaphoresis. 6.Risk for Activity Intolerance related to an imbalance between oxygen supply and demand 7.Anxiety and Fear related to threat of death, threat of change in health status and role functioning of lifestyle.

8.Powerlessness related to near experience and anticipated lifestyle.

death

9.Risk for Ineffective therapeutic management related to lack of knowledge 10.Risk for sedentary lifestyle related to lack of resources, lack of knowledge/training of specific exercise exercise needs, safety concerns/fear of injury.

ND 1:Acute Pain related to ischemia of the myocardium resulting from coronary occlusion with loss / restriction of blood flow to an area of the myocardium and necrosis of myocardium as evidenced by RR-30 bpm, diaphoresis, severe chest pain and epigastric pain.

Goal

Within 30 minutes of nursing intervention, client will experience improved comfort in the chest, as evidenced by a decreased in the pain rating scale 3/10.

Interventions

Independent:
1.Assess the characteristics of chest pain, including location, duration, quality, intensity, presence of radiation, precipitating and alleviating factors and associated manifestations. Have the client rate pain on a scale of 0-10, and document findings in nurses notes. R: Pain is an indication of myocardial ischemia. Assisting the client in qualifying pain may differentiate pre existing and current pin patterns as well as identify complications

2. Assess respirations, blood pressure, heart rate with each episode of chest pain. R: Respirations may be increased as a result of pain and associated anxiety. Released of induced catecholamine increases heart rate and blood pressure.

3.Monitor the response of the drug therapy. Notify physician if pain dos abate within 30 minutes. R: Pain control is a priority because it indicates ischemia.

Closely monitor for complications. R: MI can result to arrythmia, heart failure, cardiogenic shock and pericarditis.

5. Provide care in a calm, efficient manner that reassures the client and minimizes anxiety. Stay with the client until discomfort is relieved. R: External stimuli may worsen anxiety and increase cardiac workload as well as limit coping abilities.
6. Maintain client in bedrest without bathroom privileges. R: To reduce oxygen demand on the heart.

Limit Visitors as the client request. R: Limiting visitors prevents overstimulation ad promote rest.

Allay clients anxiety. R: Anxiety increases oxygen demand.

Dependent:
1. Administer Morphine Sulfate as ordered. R: Opiates analgesic and alters clients perception of pain and reduces preload time vasoconstriction. 2. Administer nitroglycerin as ordered. R: Nitrates relax the smooth muscle of coronary blood vessels, decreasing ischemia and hence decreasing pain.

3. Obtain a 12 lead electrocardiogram on admission and then each time chest pain recurs for evidence of further infarction.
R: Serial ECGs and stat ECGs record changes that can give evidence of further cardiac damage and location of myocardial ischemia.

4. Administer oxygen via face mask.

R: Improves oxygen supply to heart muscle.

Interdependent:
Refer to dietician for low fat and lowsalt diet. R: To meet increase metabolic demands, and reduce fluid retention and cholesterol levels.
1.

Collaborate with physician and medical technologist for request of the following laboratories: CK-MB (Troponin I) and ECG.
R: To detect myocardial damage, electrolyte abnormalities, drug levels and coagulation,

Expected Outcome