NCP Myocardial Infarction

Assessment Assessment 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

Diagnosis Planning Acute (Chest) Objectives: Pain r/t Within 1 hour myocardial of nursing ischemia resulting interventions, from coronary the client will artery occlusion have improved with loss/restriction of  comfort in chest, as evidenced by: blood flow to an • States a decrease in area of the the rating of the chest myocardium and pain. necrosis of the • Is able to rest, displays myocardium reduced tension, and sleeps comfortably • Requires decrease analgesia or nitroglycerin nitroglycerin

Intervention 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 nurse’s notes. 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. 4. maintain bedrest during pain, Goal with position of comfort, The client will have an maintain relaxing environment to improved feeling promote calmness. of control as evidenced by 5. prepare for the administration verbalizing a sense of  of medications, and monitor control over present response to drug therapy. Notify situation and future outcomes within 2 days of  physician if pain does not abate nursing interventions

 Myocardial infarction

Evaluation 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. 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