Nursing Care Plan for Myocardial Infarction NCP

7/21/2019 Nursing Care Plan for Myocardial Infarction NCP

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Student Nurses’ Community

NURSING CARE PLAN Myocardial Infarction ─ ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: The client reportsof chest painradiating to the leftarm and neck andback.

Objective:• Restlessness• Facial

grimacing• Fatigue• Peripheral

c anosis• !eak pulse• "old and

clamm skin• Palpitations• Shortness of

breath• #levated

temperature• Pain scale of

$%&'

(cute )"hest*Pain r%tm ocardialischemiaresulting fromcoronar arterocclusion +ithloss%restrictionof blood ,o+ to

an area of them ocardiumand necrosis ofthem ocardium.

ST-: !ithin & hourof nursinginterventionsthe client +illhave improvedcomfort inchest asevidenced b :

• States adecrease inthe rating ofthe chestpain.• /s able torest displa sreducedtension andsleepscomfortabl .• Re0uiresdecreaseanalgesia ornitrogl cerin.

1T-: The client+ill have animprovedfeeling ofcontrol as

/23#P#23#2T:&. (ssesscharacteristics ofchest pain includinglocation duration0ualit intensitpresence ofradiationprecipitating and

alleviating factorsand as associateds mptoms haveclient rate pain on ascale of &4&' anddocument 5ndingsin nurse6s notes.

7. Obtain histor ofprevious cardiacpain and familial

histor of cardiacproblems.

8. (ssessrespirations 9P andheart rate +ith eachepisodes of chestpain.

. ;aintain bed restduring pain +ith

&. Pain is indicationof ;/. assisting theclient in 0uantif ingpain madi<erentiate pre4e=isting and currentpain patterns as+ell as identifcomplications.

7. This providesinformation thatma help todi<erentiate currentpain from previousproblems andcomplications.

8. Respirations mabe increased as a

result of pain andassociate an=iet .

. To reduce o= genconsumption anddemand to reducecompeting stimuliand reducesan=iet .

>. Pain control is a

ST-: !ithin & hour ofnursingintervention theclient hadimproved comfortin chest asevidenced b :

• States a

decrease in therating of thechest pain.• /s able to restdispla s reducedtension andsleepscomfortabl .• Re0uiresdecreaseanalgesia ornitrogl cerin.-oal +as met.

1T-: The client had animproved feelingof control asevidenced bverbali?ing a senseof control overpresent situation

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Student Nurses’ Communityevidenced bverbali?ing asense ofcontrol over

presentsituation andfutureoutcomes+ithin 7 da sof nursinginterventions.

position of comfortmaintain rela=ingenvironment topromote calmness.

>. Prepare for theadministration ofmedications andmonitor response todrug therap . 2otifph sician if paindoes not abate.

@. istruct patient innitrogl cerin S1administration afterhospitali?ation./nstruct patient inactivit alterationsand limitations.

A. /nstructpatient%famil inmedication e<ectsside4e<ectscontraindicationsand s mptoms toreport.

3#P#23#2T:&. Obtain a &74lead#"- on admissionthen each timechest pain recurs forevidence of furtherinfarction asprescribed.

priorit as itindicates ischemia.

@. To decrease

m ocardial o= gendemand and+orkload on theheart.

A. To promotekno+ledge andcompliance +iththerapeutic regimenand to alleviate fearof unkno+n.

&. Serial #"- andstat #"-s recordchanges that cangive evidence offurther cardiacdamage andlocation of ;/.

7. ;orphine is thedrug of choice tocontrol ;/ pain butother analgesicsma be used toreduce pain andreduce the+orkload on theheart.

8. To blocks mpatheticstimulation reduce

and futureoutcomes +ithin 7da s of nursingintervention.

-oal +as met.






7. (dministeranalgesics asordered such as

morphine sulfatemeferidine of3ilaudid 2.

8. (dminister beta4blockers as ordered.. (dministercalcium4channel

blockers as ordered.

heart rate andlo+ers m ocardialdemand.

. To increasecoronar blood ,o+and collateralcirculation +hichcan decrease paindue to ischemia.






ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: The clientreports ofincreased +orkof breathingassociated +ithfeelings of+eakness andtiredness.

Objective:•

/ncreasedheartrate

• /ncreasedbloodpressure

• 3 spnea+ithe=ertion

• Pallor• Fatigue and

+eakness• 3ecreased

o= gensaturation

• /schemic#"-changes

(ctivit/ntolerancer%t cardiacd sfunctionchanges ino= gensuppl andconsumptionas evidencedb shortnessof breath.

ST-: !ithin 8 da s of nursinginterventions theclient +ill be ableto tolerate activit+ithout e=cessived spnea and +illbe able to utili?ebreathingtechni0ues andenergconservationtechni0uese<ectivel .

1T-: !ithin > da s of nursinginterventions theclient +ill be ableto increase and

achieve desiredactivit levelprogressivel+ith nointolerances mptoms notedsuch asrespiratorcompromise.

/23#P#23#2T:&. ;onitor heart raterh thm respirationsand blood pressure forabnormalities. 2otifph sician ofsigni5cant changes inBS.

7. /dentif causativefactors leading tointolerance of activit .

8. #ncourage patientto assist +ith planningactivities +ith restperiods as necessar .

. /nstruct patient inenerg conservationtechni0ues.>. (ssist +ith active

or passive RO;e=ercises at least C/3.

@. Turn patient atleast ever 7 hoursand prn.

A. /nstruct patient inisometric andbreathing e=ercises.

&. "hanges in BS assist+ith monitoringph siologic responsesto increase in activit .

7. (lleviation of factorsthat are kno+n tocreate intolerance canassist +ithdevelopment of anactivit level program.8. to help give thepatient a feeling of self4+orth and +ell4being.

. To decrease energe=penditure andfatigue.

>. To maintain jointmobilit and muscletone.

@. To improverespirator function andprevent skinbreakdo+n.

A. To improve breathingand to increase activitlevel.

$. To promote self4

ST-: !ithin 8 da s ofnursinginterventions theclient toleratedactivit +ithoute=cessive d spneaand had been ableto utili?e breathingtechni0ues andenerg conservationtechni0uese<ectivel . -oal +as met.

1T-: !ithin > da s ofnursinginterventions theclient increased andachieved desiredactivit level

progressivel +ithno intolerances mptoms notedsuch as respiratorcompromise.-oal +as met.





Student Nurses’ Community$. Providepatient%famil +ithe=ercise regimen+ith +ritten

instructions.

3#P#23#2T:&. (ssisst patient +ithambulation as

ordered +ithprogressive increasesas patient6s tolerancepermits.

+orth and involvespatient and his famil+ith self4care.

&. To graduall increasethe bod tocompensate for theincrease in overload.






ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION






Subjective: The clientverbali?es

0uestionsregardingproblems andmisconceptionsabout hiscondition.

Objective:• 1ack of

improvementof previousregimen

• /nade0uatefollo+4up oninstructionsgiven.

• (n=iet• 1ack of

understan4ding.

3e5cientDno+ledge r%tne+ diagnosis

and lack ofunderstandingof medicalcondition.

ST-: The client +ill beable to verbali?e

and demonstrateunderstanding ofinformation givenregardingconditionmedications andtreatmentregimen +ithin 8da s of nursinginterventions.

1T-: The client +illable to correctlperform all tasksprior to discharge.

/23#P#23#2T:&. ;onitor patient6sreadiness to learn anddetermine best

methods to use forteaching.7. Provide time forindividual interaction+ith patient.8. /nstruct patient onprocedures that mabe performed./nstruct patient onmedications dosee<ects side e<ects

contraindications andsigns%s mptoms toreport to ph sician.. /nstruct in dietarneeds and restrictionssuch as limiting sodiumor increasingpotassium.

>. Provide printedmaterials +henpossible forpatient%famil torevie+s.@. Eave patientdemonstrate all skillsthat +ill be necessarfor post discharge.A. /nstruct e=ercises tobe performed and toavoid overta=ingactivities.

&. To promote optimallearning environment+hen patient sho+

+illingness to learn.

7. To establish trust.

8. To provideinformation tomanage medicationregimen and to ensurecompliance.

. "lient ma need to

increase dietarpotassium if placed ondiuretics sodiumshould be limitedbecause of thepotential for ,uidretention.

>. To providereference for thepatient and famil torefer.

@. To provideinformation thatpatient has gained afull understanding ofinstruction.A. These are helpful inimproving cardiacfunction.

ST-: The client verbali?edand demonstrated

understanding ofinformation givenregarding conditionmedications andtreatment regimen+ithin 8 da s ofnursing interventions.-oal +as met.

1T-: The client had been

able to correctlperform all tasks priorto discharge.-oal +as met.








Nursing Care Plan for Myocardial Infarction NCP

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