XI.

NURSING CARE PLAN

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Acute (Chest) STG: INDEPENDENT: STG:

Within 1 hour 1. assess 1. pain is indication of Within 1 hour of
The client Pain r/t
of nursing characteristics of MI. assisting the client nursing intervention,
reports of chest myocardial chest pain, including
interventions, in quantifying pain the client had
pain radiating toischemia resulting location, duration,
the client will may differentiate pre- improved comfort in
the left arm and from coronary have improved quality, intensity, existing and current chest, as evidenced
neck and back. artery occlusion comfort in chest, presence of radiation, pain patterns as well by:
with as evidenced by: precipitating and as identify • States a
loss/restriction of • States a alleviating factors, and complications. decrease in the
blood flow to an decrease in as associated rating of the
Objective: the rating symptoms, have client chest pain.
area of the rate pain on a scale of
• Restlessness myocardium and of the • Is able to rest,
chest pain. 1-10 and document
• Facial necrosis of the displays
• Is able to findings in nurse’s reduced
grimacing myocardium. notes.
rest, tension, and
• Fatigue displays 2. obtain history of 2. this provides sleeps
• Peripheral reduced previous cardiac pain information that may comfortably.
tension, and familial history of help to differentiate • Requires
cyanosis cardiac problems.
and sleeps current pain from decrease
• Weak pulse previous problems and
comfortabl analgesia or
• Cold and y. complications. nitroglycerin.
clammy skin • Requires Goal was met.
3. assess respirations, 3. respirations may be
• Palpitations decrease
BP and heart rate with
analgesia increased as a result LTG:
• Shortness of each episodes of chest of pain and associate
or The client had an
breath nitroglyceri
pain. anxiety. improved feeling of
• Elevated 4. maintain bedrest 4. to reduce oxygen
n. control as evidenced
during pain, with consumption and
temperature position of comfort,
by verbalizing a
LTG: demand, to reduce sense of control over
• Pain scale of maintain relaxing competing stimuli and
The client will present situation
8/10 have an
environment to reduces anxiety. and future outcomes
promote calmness.
improved feeling within 2 days of
of control as nursing intervention.
evidenced by Goal was met.
5. prepare for the 5.pain control is a
verbalizing a
administration of priority, as it indicates
sense of control
medications, and ischemia.
over present
monitor response to
situation and
drug therapy. Notify
future outcomes
physician if pain does
within 2 days of
not abate.
nursing
interventions.
6.istruct patient in 6. to decrease
nitroglycerin SL myocardial oxygen
administration after demand and workload
hospitalization. on the heart.
Instruct patient in
activity alterations and
limitations.
7. to promote
7. instruct knowledge and
patient/family in compliance with
medication effects, therapeutic regimen
side-effects, and to alleviate fear of
contraindications and unknown.
symptoms to report.

DEPENDENT: 1. serial ECG and stat

1. obtain a 12-lead ECGs record changes
ECG on admission, that can give evidence
then each time chest of further cardiac
pain recurs for damage and location
evidence of further of MI.
infarction as
prescribed.
2. Morphine is the
2. administer drug of choice to
analgesics as ordered, control MI pain, but
such as morphine other analgesics may
sulfate, meferidine of be used to reduce
Dilaudid N. pain and reduce the
workload on the heart.

3. administer beta- 3. to block

blockers as ordered. sympathetic
stimulation, reduce
heart rate and lowers
myocardial demand.
4. administer calcium- 4. to increase
channel blockers as coronary blood flow
ordered. and collateral
circulation which can
decrease pain due to
ischemia.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
INDEPENDENT:
Subjective: Activity STG: 1. monitor heart rate, 1.changes in VS assist STG:
rhythm, respirations with monitoring
The client Intolerance Within 3 days and blood pressure for physiologic responses to
Within 3 days of
reports of r/t cardiac of nursing abnormalities. Notify increase in activity. nursing
increased dysfunction, interventions, physician of significant interventions,
work of changes in the client will be changes in VS. the client tolerated
breathing oxygen able to tolerate 2. Alleviation of factors activity without
2. Identify causative that are known to create
associated supply and activity without factors leading to intolerance can assist with
excessive dyspnea
with feelings consumption excessive intolerance of activity. development of an and had been able
of weakness as dyspnea and will activity level program. to utilize breathing
and tiredness. evidenced be able to utilize 3. encourage patient to 3. to help give the patient techniques and
by shortness breathing assist with planning a feeling of self-worth and energy
activities, with rest well-being.
Objective: of breath. techniques and periods as necessary. conservation
• Increased energy 4. instruct patient in 4. to decrease energy techniques
heart rate conservation energy conservation expenditure and fatigue. effectively.
• Increased techniques techniques. Goal was met.
effectively. 5. assist with active or 5.to maintain joint
blood passive ROM exercises mobility and muscle tone.
pressure at least QID. LTG:
• Dyspnea LTG: 6.to improve respiratory Within 5 days of
with Within 5 days 6. turn patient at least function and prevent skin nursing
of nursing every 2 hours, and prn. breakdown. interventions, the
exertion
• Pallor interventions, client increased
7. instruct patient in 7. to improve breathing
• Fatigue the client will be isometric and breathing and to increase activity and achieved
and able to increase exercises. level. desired activity
weakness and achieve level,
desired activity 8. provide 8. to promote self-worth progressively, with
• Decreased patient/family with and involves patient and
level, no intolerance
oxygen exercise regimen, with his family with self-care.
progressively, symptoms noted,
saturation written instructions.
with no such as respiratory
• Ischemic
intolerance DEPENDENT: compromise.
ECG 1.Assisst patient with 1. to gradually increase
symptoms Goal was met.
changes ambulation, as ordered, the body to compensate
noted, such as
with progressive for the increase in
respiratory increases as patient’s overload.
compromise. tolerance permits.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
INDEPENDENT:
Subjective: Deficient STG: 1. monitor patient’s 1. to promote optimal STG:
readiness to learn and learning environment
The client Knowledge r/t The client will determine best methods
The client
when patient show
verbalizes new diagnosis be able to to use for teaching. willingness to learn.
verbalized and
questions and lack of verbalize and 2. provide time for 2. to establish trust. demonstrated
regarding understanding demonstrate individual interaction with understanding of
problems and of medical understanding patient. information given
3. instruct patient on 3. to provide information regarding condition,
misconceptions condition. of information procedures that may be to manage medication
about his given regarding performed. regimen and to ensure
medications, and
condition. condition, Instruct patient on compliance. treatment regimen
medications, medications, dose, within 3 days of
Objective: and treatment effects, side effects, nursing
contraindications, and
• Lack of regimen within signs/symptoms to report interventions.
4. client may need to
improvemen 3 days of to physician. increase dietary Goal was met.
t of nursing 4. instruct in dietary potassium if placed on
previous interventions. needs and restrictions, diuretics; sodium should LTG:
such as limiting sodium be limited because of The client had
regimen
or increasing potassium. the potential for fluid
• Inadequate LTG: been able to
retention.
follow-up on The client will 5. provide printed 5. to provide reference correctly perform all
instructions able to correctly materials when possible for the patient and tasks prior to
given. perform all for patient/family to family to refer. discharge.
tasks prior to reviews. Goal was met.
• Anxiety 6. have patient
discharge. 6. to frovide information
• Lack of demonstrate all skills that that patient has gained
understan- will be necessary for a full understanding of
ding. postdischarge. instruction.
7. instruct exercises to be 7. these are helpful in
performed, and to avoid improving cardiac
overtaxing activities. function.

DEPENDENT:
1. refer patient to cardiac 1. to provide further
rehabilitation as ordered improvement and
rehabilitation
postdischarge.
.