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Student Nurses’ Community

NURSING CARE PLAN – Myocardial Infarction


ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION
Independent:
After 8 hours of Goal met, patient
SUBJECTIVE: Pain r/t tissue Occlusion of nursing • Obtain full • Pain is a subjective has
“Sumasakit ang ischemia coronary artery intervention the description of pain experience and must verbalized
dibdib ko” (I’ve (coronary patient will from patient be described by relief/control of
been experiencing artery Verbalize including location, patient chest pain within
chest pains) as occlusion) relief/control of intensity (0–10), appropriate time
verbalized by the Decrease blood chest pain within duration, frame for
patient flow to the appropriate time characteristics administered
myocardium frame for (dull/crushing), and medications.
administered radiation. Assist
medications. patient to quantify
OBJECTIVE: pain by comparing it
Decrease to other experiences
• Restlessness
oxygen supply
• Facial (ischemia) • Instruct patient to • Delay in reporting
grimace report pain pain hinders pain
• Pain scale of immediately. relief/may require
9 out of 10 increased dosage of
• V/S taken as medication to
Anaerobic
follows achieve relief
metabolism
T: 37.6 ˚C • Provide quiet • Decreases external
P: 112 environment, calm stimuli, which may
R: 12 activities, and aggravate anxiety
Lactic acid
BP: 140/ 100 comfort measures and cardiac strain,
formation
limit coping abilities
and adjustment to
current situation

pain • Assist/instruct in • Helpful in decreasing


relaxation perception of/
techniques, e.g., response to pain.
deep/slow Provides a sense of
breathing, having some control
distraction over the situation,
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behaviors, increase in positive


visualization, guided attitude.
imagery

Collaborative
• Administer • Increases amount of
supplemental oxygen available for
oxygen by means of myocardial uptake
nasal cannula or and thereby may
face mask, as relieve discomfort
indicated associated with
tissue ischemia
Administer medications
as indicated:
• Antianginals, e.g., • Nitrates are useful for
nitroglycerin, pain control by
isosorbide dinitrate coronary vasodilating
(Isordil) effects, which
increase coronary
blood flow and
myocardial perfusion.

• Beta-blockers, e.g., • Important second-line


atenolol (Tenormin), agents for pain
propranolol control through effect
(Inderal), metoprolol of blocking
(Lopressor) sympathetic
stimulation, thereby
reducing heart rate,
systolic BP, and
myocardial oxygen
demand

• Analgesics, e.g., • Although intravenous


morphine, (IV) morphine is the
meperidine usual drug of choice,
(Demerol) other injectable
narcotics may be
used in acute-
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phase/recurrent
chest pain unrelieved
by nitroglycerin to
reduce severe pain,
provide sedation, and
decrease myocardial
workload