Student Nurses Community

NURSING CARE PLAN Myocardial Infarction

ASSESSMENT

DIAGNOSIS

INFERENCE

PLANNING

INTERVENTION

RATIONALE

EVALUATION

Independent:
SUBJECTIVE:
Sumasakit ang
dibdib ko (Ive
been experiencing
chest pains) as

verbalized by the
patient

Pain r/t tissue

ischemia
(coronary
artery
occlusion)

Occlusion of
coronary artery

Decrease blood
flow to the
myocardium

OBJECTIVE:

Restlessness
Facial
grimace
Pain scale of
9 out of 10
V/S taken as
follows
T: 37.6 C
P: 112
R: 12
BP: 140/ 100

Decrease
oxygen supply
(ischemia)

After 8 hours of
nursing
intervention the
patient will
Verbalize
relief/control of
chest pain within
appropriate time
frame for
administered
medications.

Obtain full

description of pain
from patient
including location,
intensity (010),
duration,
characteristics
(dull/crushing), and
radiation. Assist
patient to quantify
pain by comparing it
to other experiences

Pain is a subjective
experience and must
be described by
patient

Instruct patient to
report pain
immediately.

Delay in reporting
pain hinders pain
relief/may require
increased dosage of
medication to
achieve relief

Provide quiet
environment, calm
activities, and
comfort measures

Decreases external
stimuli, which may
aggravate anxiety
and cardiac strain,
limit coping abilities
and adjustment to
current situation

Assist/instruct in
relaxation
techniques, e.g.,
deep/slow
breathing,
distraction

Helpful in decreasing
perception of/
response to pain.
Provides a sense of
having some control
over the situation,

Anaerobic
metabolism

Lactic acid
formation

pain

Goal met, patient

has
verbalized
relief/control of
chest pain within
appropriate time
frame for
administered
medications.

Student Nurses Community

behaviors,
visualization, guided
imagery
Collaborative
Administer
supplemental
oxygen by means of
nasal cannula or
face mask, as
indicated
Administer medications
as indicated:
Antianginals, e.g.,
nitroglycerin,
isosorbide dinitrate
(Isordil)

increase in positive
attitude.

Increases amount of
oxygen available for
myocardial uptake
and thereby may
relieve discomfort
associated with
tissue ischemia

Nitrates are useful for

pain control by
coronary vasodilating
effects, which
increase coronary
blood flow and
myocardial perfusion.

Beta-blockers, e.g.,
atenolol (Tenormin),
propranolol
(Inderal), metoprolol
(Lopressor)

Important second-line
agents for pain
control through effect
of blocking
sympathetic
stimulation, thereby
reducing heart rate,
systolic BP, and
myocardial oxygen
demand

Analgesics, e.g.,
morphine,
meperidine
(Demerol)

Although intravenous
(IV) morphine is the
usual drug of choice,
other injectable
narcotics may be
used in acute-

Student Nurses Community

phase/recurrent
chest pain unrelieved
by nitroglycerin to
reduce severe pain,
provide sedation, and
decrease myocardial
workload