eNursing Care Plan 33-1

Patient with Acute Coronary Syndrome

Nursing Diagnosis*
Impaired Cardiac Output
Etiology: Altered contractility, altered heart rate and rhythm
Supporting data: Decrease in BP, elevation in HR, dyspnea, dysrhythmias, diminished
pulses, peripheral edema, pulmonary edema

Patient Goal
Maintains stable signs of effective cardiac output

Outcomes (NOC) Interventions (NIC) and Rationales

Tissue Perfusion: Cardiac Cardiac Care: Acute
 Angina ___  Monitor cardiac rhythm and rate and trends in BP and
 Dysrhythmia ___ hemodynamic parameters to monitor for changes in
 Tachycardia ___ cardiac output, BP, and heart rhythm, which may lead to
 Bradycardia ___ coronary hypoperfusion.
 Profuse diaphoresis ___  Auscultate lungs for crackles or other adventitious
 Nausea ___ sounds that can indicate pulmonary edema.
 Vomiting ___  Monitor effectiveness of oxygen therapy (e.g., pulse
oximetry) to determine O2 of myocardial tissue and
Measurement Scale prevent further ischemia.
1 = Severe  Monitor serum cardiac biomarkers (troponin, CK-MB
2 = Substantial levels) to determine myocardial injury and recovery.
3 = Moderate  Monitor neurologic, renal, and liver function to evaluate
4 = Mild blood perfusion to vital organs.
5 = None

Nursing Diagnosis
Acute Pain
Etiology: Imbalance between myocardial O2 supply and demand
Supporting data: Patient’s report of chest pain and tightness with radiation of pain to the
neck and arms, increased cardiac biomarkers, ECG changes supporting ST-elevation MI

Patient Goal
Reports relief of pain

Outcomes (NOC) Interventions (NIC) and Rationales

Pain Control Cardiac Care
 Uses preventive measures  Evaluate chest pain (e.g., PQRST [see Table 33-7]) to
___ accurately evaluate, treat, and prevent further ischemia.
 Uses analgesics  Monitor vital signs frequently to determine baseline and

*Nursing diagnoses listed in order of priority.

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eNursing Care Plan 33-2

Outcomes (NOC) Interventions (NIC) and Rationales

appropriately ___
 Reports uncontrolled
symptoms to health care
professional ___
 Reports pain controlled
_____
Measurement Scale
1 = Never demonstrated
2 = Rarely demonstrated
3 = Sometimes demonstrated
4 = Often demonstrated
5 = Consistently demonstrated
detect ongoing changes.
 Obtain 12-lead ECG during pain episode to help
differentiate angina from extension of MI or
pericarditis.
Pain Management
 Provide optimal pain relief with prescribed analgesics
because pain exacerbates tachycardia and increases
BP.
 Consider the type and source of pain when selecting
pain relief strategy because angina responds to opioids
and measures that increase myocardial perfusion.

Nursing Diagnosis
Anxiety
Etiology: Perceived or actual threat of death, pain, possible lifestyle changes
Supporting data: Restlessness, agitation, states concern over lifestyle changes and
prognosis, such as patient’s statement, “What if I die? Everyone relies on me”

Patient Goal
Reports decreased anxiety and increased sense of self-control

Outcomes (NOC) Interventions (NIC) and Rationales

Anxiety Level Anxiety Reduction
 Restlessness ___  Observe for verbal and nonverbal signs of anxiety to
 Verbalized apprehension identify signs of stress and intervene appropriately.
___  Identify when level of anxiety changes because anxiety
 Difficulty concentrating increases myocardial O2 consumption.
___  Use a calm, reassuring approach to avoid increasing
 Distress ___ patient’s anxiety.
 Teach patient on the use of relaxation techniques (e.g.,
Measurement Scale relaxation breathing, imagery) to enhance self-control
1 = Severe and reduce anxiety.
2 = Substantial  Encourage caregiver(s) and family member(s) to stay
3 = Moderate with patient to provide comfort and support.
4 = Mild
5 = None  Encourage verbalization of feelings, perceptions, and
fears to decrease anxiety and stress.
 Provide factual information concerning diagnosis,
treatment, and prognosis to decrease fear of the
unknown.

Acceptance: Health Status  Coping Enhancement

 Recognizes reality of health  Provide the patient with realistic choices about certain
situation ___ aspects of care to support decision making.

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eNursing Care Plan 33-3

Outcomes (NOC) Interventions (NIC) and Rationales

 Adjusts to change in health  Assist the patient in identifying positive strategies to
status ___ deal with limitations and manage needed lifestyle or
 Makes decisions about role changes.
health ___  Help the patient to grieve and work through the losses
of chronic illness to provide support.
Measurement Scale
1 = Never demonstrated
2 = Rarely demonstrated
3 = Sometimes demonstrated
4 = Often demonstrated
5 = Consistently demonstrated

Nursing Diagnosis
Activity Intolerance
Etiology: General weakness due to decreased cardiac output and poor lung and tissue
perfusion
Supporting data: Patient’s report of fatigue with minimal activity, inability to care for self
without dyspnea and/or increased heart rate

Patient Goal
Achieves a realistic program of activity that balances physical activity with energy-
conserving activities

Outcomes (NOC) Interventions (NIC) and Rationales

Activity Tolerance
 O2 saturation with activity
___
 Pulse rate with activity ___
 Ease of breathing with
activity ___
 Walking pace _____
 Ease of performing ADLs
___
Measurement Scale
1 = Severely compromised
2 = Substantially compromised
3 = Moderately compromised
4 = Mildly compromised
5 = Not compromised
Cardiac Care
 Monitor patient’s response to cardiac medications
because these drugs often affect BP and pulse.
 Encourage alternating activity and rest periods to avoid
fatigue and to increase activity tolerance without
rapidly increasing cardiac workload.
Energy Management
 Assist the patient to understand energy conservation
principles (e.g., the requirement for restricted activity
or bedrest) to conserve energy and promote healing.
 Teach patient, caregiver(s), and family member(s)
techniques of self-care that will minimize
O2consumption (e.g., self-monitoring and pacing
techniques for performance of ADLs) to promote
independence and minimize O2 consumption.

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eNursing Care Plan 33-4

Nursing Diagnosis
Lack of Knowledge
Etiology: Lack of knowledge of disease process, risk factor reduction, rehabilitation,
home activities, and medications
Supporting data: Questions about illness, management, and care after discharge

Patient Goal
Describes the disease process, measures to reduce risk factors, and rehabilitation
activities necessary to manage the therapeutic regimen

Outcomes (NOC) Interventions (NIC) and Rationales

Knowledge: Cardiac
Disease Management
 Usual course of disease
process ___
 Signs and symptoms of
worsening disease ___
 Strategies to reduce risk
factors ___
 Importance of completing
cardiac rehabilitation
program ___
 Benefits of following a
low-fat, low-cholesterol
diet ___
 Benefits of regular exercise
___
Measurement Scale
1 = No knowledge
2 = Limited knowledge
3 = Moderate knowledge
4 = Substantial knowledge
5 = Extensive knowledge
Cardiac Care: Rehabilitative
 Encourage realistic expectations for the patient,
caregiver(s), and family member(s) to promote realistic
decision making.
 Teach patient, caregiver(s), and family member(s)
about prescribed and over-the-counter drugs to promote
compliance with drug regimens.
 Teach the patient and caregiver about cardiac risk
factor modification (e.g., smoking cessation, diet,
exercise) to increase patient’s control of the illness.
 Teach the patient self-care of chest pain (e.g., take
sublingual nitroglycerin every 5 minutes three times; if
chest pain unrelieved, seek emergency medical care).
 Teach the patient and caregiver about the exercise
regimen, including warm-up, endurance, and cool-
down, to reduce cardiac risk factors.
 Teach the patient and caregiver on wound care and
precautions (e.g., sternal incision or catheterization
site), if appropriate, to prevent infection and promote
healing after invasive therapies.
 Teach the patient and caregiver how to access
emergency services available in their community to
enable them to obtain immediate care if needed.

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