XI. XI.
NURS NU RSIN ING G CA CAR RE PLAN PLAN
ASSESSMENT Subjective: The client reports of chest pain radiating to the left arm and neck and back.
DIAGNOSIS
Acute (Chest) Pain r/t myocardial ischemia resulting from coronary artery occlusion with loss/restriction of blood flow to an Objective: area of the Restlessness myocardium and Facial necrosis of the grimacing myocardium. • •
• •
• •
• •
•
•
Fatigue Peripheral cyanosis Weak pulse Cold and clammy skin Palpitations Shortness of breath Elevated temperature Pain scale of 8/10
PLANNING
INTERVENTION
STG: 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 comfortabl y. Requires decrease analgesia or nitroglyceri n.
INDEPENDENT: 1. assess characteristics 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.
•
•
•
LTG: The client will have an improved feeling of control as evidenced by verbalizing a sense of control over present situation and future outcomes within 2 days of nursing
RATIONALE
1. pain is indication of MI. assisting the client in quantifying pain may differentiate preexisting and current pain patterns as well as identify complications.
EVALUATION STG: 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. •
•
2. this provides information that may help to differentiate current pain from previous problems and complications.
3. assess respirations, respirations, BP and heart rate with each episodes of chest pain. 4. maintain bedrest during pain, with position of comfort, maintain relaxing environment to promote calmness.
3. respirations may be increased as a result of pain and associate anxiety. 4. to reduce oxygen consumption and demand, to reduce competing stimuli and reduces anxiety.
5. prepare for the administration of medications, and monitor response to drug therapy. Notify physician if pain does not abate.
5.pain control is a priority, as it indicates ischemia.
•
LTG: 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.
6.istruct patient in nitroglycerin nitroglycerin SL administration administration after hospitalization. Instruct patient in activity alterations and limitations. 7. instruct patient/family in medication effects, side-effects, contraindications contraindications and symptoms to report.
DEPENDENT: 1. obtain a 12-lead ECG 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 of Dilaudid N.
3. administer betablockers as ordered.
4. administer calciumchannel blockers as ordered.
6. to decrease myocardial oxygen demand and workload on the heart.
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 may be 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 which 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 STG: Within 3 days 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. LTG: Within 5 days of nursing interventions, the client will be able to increase and achieve desired activity level, progressively, with no intolerance symptoms noted, such as respiratory compromise.
INTERVENTION INDEPENDENT: 1. monitor heart rate, rhythm, respirations respirations and blood pressure for abnormalities. 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 conservation techniques. 5. assist with active or passive ROM exercises at least QID.
RATIONALE 1.changes in VS assist with monitoring physiologic responses to increase in activity.
STG: Within 3 days of nursing interventions, the client tolerated 2. Alleviation of factors activity without that are known to create excessive dyspnea intolerance can assist with and had been able development of an to utilize breathing activity level program. 3. to help give the patient techniques and a feeling of self-worth and energy well-being. conservation techniques 4. to decrease energy effectively. expenditure and fatigue. Goal was met.
5.to maintain joint mobility and muscle tone.
6. turn patient at least every 2 hours, and prn.
6.to improve respiratory function and prevent skin breakdown.
7. instruct patient in isometric and breathing exercises.
7. to improve breathing and to increase activity level.
8. provide patient/family with exercise regimen, with written instructions.
8. to promote self-worth and involves patient and his family with self-care.
DEPENDENT: 1.Assisst patient with ambulation, as ordered, with progressive progressive increases as patient’s tolerance permits.
EVALUATION
1. to gradually increase the body to compensate for the increase in overload.
LTG: Within 5 days of nursing interventions, interventions, the client increased and achieved desired activity level, progressively, with no intolerance symptoms noted, such as respiratory compromise. Goal was met.
ASSESSMENT Subjective: The client verbalizes questions regarding problems and misconceptions about his condition. Objective: Lack of improvemen t 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
INTERVENTION
STG: The client will be able to verbalize and demonstrate understanding of information given regarding condition, medications, and treatment regimen within 3 days of nursing interventions.
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, contraindications, and signs/symptoms to report to physician. 4. instruct in dietary dietary needs and restrictions, such as limiting sodium or increasing potassium.
LTG: The client will able to correctly perform all tasks prior to discharge.
5. provide printed materials when possible for patient/family to reviews. 6. have patient demonstrate all skills that will be necessary for postdischarge. 7. instruct exercises to be performed, and to avoid overtaxing activities. DEPENDENT: 1. refer patient to cardiac rehabilitation rehabilitation as ordered
.
RATIONALE
EVALUATION
1. to promote optimal learning environment when patient show willingness to learn. 2. to establish trust.
STG: The client verbalized and demonstrated understanding understanding of information given 3. to provide information regarding condition, to manage medication medications, and regimen and to ensure treatment regimen compliance. within 3 days of nursing interventions. 4. client may need to Goal was met. 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 frovide information that patient has gained a full understanding of instruction. 7. these are helpful in improving cardiac function.
1. to provide further improvement and rehabilitation postdischarge.
LTG: The client had been able to correctly perform all tasks prior to discharge. Goal was met.
