ASSESSMENT DIAGNOSES PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Acute chest pain STG: INDEPENDENT: STG:

The clients report related to Within 1 hour of 1. Assess characteristics of chest pain including 1. Pain is indication of MI, assisting the client in Within an hour of
of severe chest myocardial nursing interventions location, duration, quality, and intensity, quantifying pain may differentiate pre existing and nursing intervention
pain. ischemia the client will have presence of radiation, precipitating and current pain patterns as well as identify had improved comfort
resulting from improved comfort in alleviating factors and as associated symptoms, complications. in chest as evidenced
coronary artery chest pain as evidence Have client rate pain from scale of 1 to 10 and by:
Objective: occlusion with by: document findings in nurse’s notes.  States
 Pain scale loss/restriction  States 2. Obtain history previous cardiac pain and decrease in
of 8/10 of blood flow to decrease in familial history of cardiac problems 2. This provides information that may help to the rate of the
 Facial an area of the the rate of the differentiate current pain from previous problems chest pain
grimacing myocardium and chest pain and complications.  Is able to rest,
 Clutching necrosis of the  Is able to rest, 3. Assess respirations, BP and heart rate with 3. Respiration may increase as a result of pain and displays
of hands to myocardium displays each episode of chest pain. associate anxiety. reduced
chest reduced 4. To reduce oxygen consumption and demand, to tension, and
 diaphoresis tension, and 4. Maintain on bed rest during pain, with reduce competing stimuli and reduces anxiety sleeps
 Shortness sleeps position of comfort, maintain relaxing 5. Pain control is a priority as it indicates ischemia. comfortably
of breath comfortably environment to promote calmness.  Requires
 Tachycardi  Requires 5. Prepare for the administration of medication 6. To decrease myocardial oxygen demand and decrease
a decrease and monitor response to drug therapy. Notify work load in the heart. analgesia
 Dizziness analgesia AP if pain does not abate. Goal was met
 Elevated LTG: 6. Instruct patient in nitroglycerine SL
body The client will have an administration after hospitalization, instruct pt. LTG:
temperatur improve feeling of in activity alteration and limitations. The client had an
e control over present improve feeling of
situation and future DEPENDENT: control over present
outcomes within 2 days 1. Obtain a 12 LEAD ECG on admission. Then 1. Serial ECG and stat ECG record changes that can situation and future
of nursing intervention each time chest pain recurs for evidence of give evidence of further cardiac damageand outcomes within 2 days
further infarction as ordered. location of MI. of nursing intervention
2. Administer analgesics as ordered, such as 2. Morphine is the drug of choice to control MI and transferred to Male
morphine sulfate or meferidine. pain but other analgesic may be used to reduce medical ward.
pain and reduce the work load of the heart. Goal was met
3. Administer beta blockers as ordered 3. To block sympathetic stimulation, reduce heart
rate and lowers myocardial demands.
ASSESSMENT DIAGNOSES PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Anxiety related STG: INDEPENDENT: STG:

to threat to/or After 3 hours of 1. Assesses client’s level of anxiety. Validate 1. Anxiety is highly individualize, normal, physical,
change in health initiating nursing observation by saying to client. “are you feeling and psychological response to internal and external After 3 hours of
status intervention patient anxious now/”. life events. initiating nursing
will be able to verbalize 2. Used presence, touch, verbalization or 2. Being supportive and approachable encourages intervention patient
Objective: absence of or decrease demeanor to remind client and to encourage communication. was able to verbalize
 Increased in subjective distress. expression or clarifications of needs, concerns, absence of or decrease
respiration unknowns and questions. in subjective distress.
 Has 3. Accepted client’s defenses, do not confront, 3. If defense are not threatened, the client may feel Goal was met
difficulty in argue and debate. safe enough to look at behavior.
sleeping 4. Allowed and reinforced clients personal 4. Talking or otherwise expressing feelings
 Increased reaction to/or pain, discomfort or threats to sometimes reduces anxiety.
heart rate LTG: well being. LTG:
 Fatigue Within 2 days of 5. helped client identify precipitants to anxiety 5. Gaining insights enables the client to reevaluate Within 2 days of
 Difficulty nursing interventions, the threat and or identify new ways to deal with nursing interventions,
concentrati the patient will be able the threat. the patient was able to
ng to demonstrate 6. Instruct patient on relaxation techniques, 6. Reduces anxiety and stress. demonstrate improve
improve concentration such as guided imagery, relaxation therapy, concentration and
and accuracy of music therapy and so forth. Provide for accuracy of thoughts.
thoughts. diversionary activities. Goal was met

DEPENDENT:
1.administer anti anxiety drugs as ordered 1. Promotes rest and reduces anxiety
ASSESSMENT DIAGNOSES PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Ineffective tissue STG: INDEPENDENT: STG:

The clients report perfusion related Within 4 hours of 1. Monitor V/S. Obtain hemodynamic values, 1. Provides information about the hemodynamics Within 4 hours of
of severe chest to tissue nursing interventions noting deviation from baseline values of the patient and facilitates early intervention for nursing and medical
pain. ischemia the client will have vital problems. intervention client’s
signs within normal 2. Auscultate heart sounds for S3 and S4 gallop, 2. May indicate presence of heart failure. V/S was within normal
parameters new murmurs, presence of jugular vein parameters evidenced
Objective: distention, or hepatojugular reflex by:
 V/S 3. Monitor oxygen status with SPO2 or with pulse 3. Provides information about the oxygenation V/S BP - 114/82
BP-190/90 oximetry. status of the patient. Continuous monitoring of HR – 65 b/m
T – 380C saturation levels provide an instant analysis of how T – 370C
HR- 110 activity affects oxygenation and perfusion for the Goal was met
 Chest pain patient.
 Shortness 4. Monitor for changes in respiratory status, 4. Decreased cardiac perfusion may result in pump
of breath LTG: increased work of breathing, dyspnea and so failure and precipitate respiratory distress and
 Dizziness The client’s ST segment forth. failure.
 ECG elevation will return to 5. Discourage any non essential activity 5. Ambulation, transfers and vasalva type-
changes( S baseline and Cardiac maneuvers can increase blood pressure and LTG:
T enzymes will normalize decrease tissue perfusion. The client’s ST segment
elevation) more rapidly as a result 6. Observe client for the development of 6. Thrombolytic drugs may create bleeding elevation returned to
of reperfusion bleeding to oral mucosa and gums, insertion complications as a result of their action baseline and Cardiac
sites, GI tracts and elsewhere. enzymes decreases
near to normal values
DEPENDENT: as a result of
1. Administer thrombolytic drugs as ordered 1. Thrombolytic drugs lyse the clot that may be reperfusion
and as per protocol specific to medication. occluding the coronary artery and promote Goal was met
restoration of oxygen and blood flow to the heart
in order to increase tissue perfusion.
2. Administer oxygen by nasal cannula as 2. Provides oxygen necessary for tissues and organ
ordered. perfusion.
3. To block sympathetic stimulation, reduce heart
rate and lowers myocardial demands.
ASSESSMENT DIAGNOSES PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Knowledge Patient will be able to 1. Determine the patient’s baseline of 1. Provides information regarding patient’s STG:
deficit related to verbalize and knowledge regarding disease process, normal understanding of condition as well as baseline from Within 4 hours of
The clients lack of demonstrate physiology and function of heart. which to base teachings nursing and medical
verbalized questions understanding of understanding of intervention client’s
regarding present medical information given 2. Monitors patient’s readiness to learn and 2. promotes optimal learning environment when V/S was within normal
health condition. condition regarding condition, determine best methods to use for teaching. patients shows willingness to learn. Family parameters evidenced
medication and Attempt to incorporate family members in members may assist with helping the patient to by:
treatment regimen. learning process. Reinstruct/reinforce make informed choices regarding his treatment. V/S BP - 114/82
information as needed. Anxiety or large volume of instruction may impede HR – 65 b/m
comprehension and limit learning. T – 370C
3. Provide time for individual interaction with 3. Establish rapport between client and nurse, and Goal was met
patient. as will as trust
Objective:
4. Instruct the patient on procedures that may 4. Provides knowledge and promotes the ability to
The clients be performed. make informed choices.
verbalized questions
regarding problems. 5. Instruct patient on medications, dose, effects, 5. Provides information to the patient to manage LTG:
side effects, contraindication and sign and medication regimen and ensure compliance. The client’s ST segment
symptoms to report to physician. elevation returned to
baseline and Cardiac
6. Instruct dietary needs and restrictions, such 6. Sodium should be limited because of the enzymes decreases
as limiting sodium, fatty foods. potential fluid retention and avoidance of fatty rich near to normal values
foods as it may aggregate or re occurrence of as a result of
occlusion as fatty deposits forming plaques and reperfusion
eventually clots. Goal was met
7. have patient demonstrate all skills that will 7. Provides information that pt has gained a full
be necessary for post discharge. understanding of instruction and is able to able to
demonstrate correct information.
 DRUG STUDY

Medication Frequency
Brand Dose
name/Generic route Action Contraindication Adverse reaction Nursing intervention
Classification
ASA (Aspirin) Stat dose 300mg 1.Decrease platelet aggregation 1.Hypersensitivity to aspirin GI bleeding, Hepatoxicity, increased Lab test consideration: monitor
Salicylates Then bleeding time, allergic reactions hepatic function tests. May cause
81mg OD 2. Decrease incidence of transient 2. bleeding disorders or including ANAPHYLAXIS AND decrease serum potassium and
Oral ischemic attacks and MI thrombocytopenia LARYNGEAL EDEMA cholesterol concentration.

Use cautiously with history of GI Monitor patient for the onset of

Indication: bleeding or ulcer disease. tinnitus, headache,
Prophylaxis of hyperventilation, agitation, mental
transient ischemic confusion, lethargy, diarrhea and
attacks and MI sweating, if these symptoms
appear, with hold medication and
inform physician (toxicity and
overdose)

Medication Frequency
Brand Dose
name/Generic route Action Contraindication Adverse reaction Nursing intervention
Classification
Plavix Stat dose 300mg Helps to reduce atherosclerotic 1.Severe liver impairment GI Bleeding, hematoma, intracranial
Clopidogrel) the 75mg OD induced events by binding to ADP bleeding, gastritis, constipation, Assess patient for signs of bleeding
Thrombolytic Oral receptors on platelets which 2. peptic ulcer and intracranial epistaxis and hemorrhage.
prevents fibrinogen from attaching hemorrhage
to the receptors and, thus, 3. Lactation Assess for evidence of additional or
preventing formation of clot. increased thrombosis.
Indication: For the
reduction of Use cautiously with patients with Monitor PTT, INR, PT and
atherosclerotic bleeding tendency’s or bleeding hematocrit and other clotting
events. disorders and hepatic impairments factors frequently during therapy
Medication Frequency
Brand Dose
name/Generic route Action Contraindication Adverse reaction Nursing intervention
Classification
Metalyse Stat dose only Activates own fibrinolytic system to 1. Bleeding disorders at present or Drop in blood pressure, increase body
(Tenecplae(TNK- 40 mg dissolve the clot and resume within 6 months, hemorrhagic temperature, bleeding, ecchymosis, Assess patient for signs of bleeding
tPA)) IV coronary blood perfusion. diatehesis, thrombocytopenia. GI bleeding, superficial bleeding and hemorrhage.
Thrombolytic 2. Major surgery or significant normally from puncture sites or
Metalyse should trauma within the past 2 months damage vessels, bleeding into Assess for evidence of additional or
be given on the urogenital tract, epistaxis, intracranial increased thrombosis.
Indication: for the basis of body Use cautiously with history of GI hemorrhage, thrombotic
thrombolytic weight with a bleeding or ulcer disease. embolisation, anaphylactoid reaction( Monitor PTT, INR, PT and
treatment of AMI maximum dose of rash, urticaria, bronchospasm, hematocrit and other clotting
10,000 U (50mg) laryngeal edema). factors frequently during therapy
(10 ml)

Medication Frequency
Brand Dose
name/Generic route Action Contraindication Adverse reaction Nursing intervention
Classification
Clexane STAT dose as per Potentiate the inhibitory effect of 1. Hypersensitivity to enoxaparin . Edema, bleeding, thrombocytopenia,
( Enoxaparin Na) hospital protocol antithrombin on factor XA and anemia, irritation, hematoma, Assess patient for signs of bleeding
Thrombolytics 30 mg IV push thrombin. It prevents the 2. Uncontrolled bleeding. erythema at injection site. and hemorrhage.
and then 40 mg conversion of prothrombin to to
Subq (according thrombin by its effects on factor XA 3. Open wounds Assess for evidence of additional or
Indication: to patients increased thrombosis.
treatment of weight) Use cautiously with patients with
unstable angina Maintenance bleeding tendency’s or bleeding Monitor PTT, INR, PT and
and non Q wave dose: disorders , severe liver and kidney hematocrit and other clotting
MI, administered BID impairments factors frequently during therapy
concurrently with 20 mg
aspirin Subq Observe injection sites for
hematomas, ecchymosis, or
 inflammation.

Medication Frequency
Brand Dose
name/Generic route Action Contraindication Adverse reaction Nursing intervention
Classification
Metoprolol Bid Block stimulation of beta1 1. Uncompensated congestive heart Fatigue, weakness, dizziness,
Antiarrhytmic, 25 mg (myocardial) adrenergic receptor. failure. depression, insomnia, memory loss, Monitor blood pressure, ECG, and
antihypertensive, PO Do not usually affect beta2 2. Pulmonary edema mental status changes, anxiety, pulse frequently during dosage and
antianginal (pulmonary, vascular, uterine) 3. Cardiogenic shock impotence, bronchospasm, adjustment period and periodically
receptor. Decrease blood pressure, 4. Bradycardia or heart block wheezing, BRADYCARDIA, throughout therapy.
decrease elevated plasma renins, CONGESTIVE HEART FAILURE, Monitor intake and output ratios
decrease heart rate, decrease PULMONARY EDEMA, hypotension, and daily weights. Assess routinely
Indication: frequency of attacks of angina . joint pain, back pain. for signs and sumptoms of
prevention of pectoris. congestive heart failure( dyspnea,
myocardial rales/crackles, weight gain,
infarction. peripheral edema, jugular vein
distention).

Medication Frequency
Brand Dose
name/Generic route Action Contraindication Adverse reaction Nursing intervention
Classification
Crestor OD (H.S.) Inhibits an enzyme, 3 – hydroxy -3 1. Hypersensitivity Dizziness, weakness, insomnia,
(Rosuvastatin Ca) 10 mg methylglutaryl-coenzyme A 2. Pregnancy or lactation constipation, flatus, heartburn, Obtain a diet history, especially
Antihperlipidaemic PO reductase, which is responsible for 3. Active Liver disease elevated liver enzyme, hepatitis, with regard to fat consumption.
Agents catalyzing an early step in the pancreatitis, rashes, pruritus, myalgia,
Indication: Primary synthesis of cholesterol. Lowering myositis, arthralgia, rhabdomyolysis Monitor Liver function test and also
Hypercholesterole of total and LDL cholesterol. may cause throid function test
mia, mixed Slowing of the progression of abnormalities
dyslipidemia and coronary artery disease with
isolated resultant decrease in MI and need If patient develops muscle
hypertriglyceridem for myocardial revascularization tenderness during therapy, CK
ia as adjunct to levels should be monitored. If CK
diet when
response to diet & levels are markedly increased or
exercise is myopathy occurs, therapy should
inadequate be discontinued.

Medication Frequency
Brand Dose
name/Generic route Action Contraindication Adverse reaction Nursing intervention
Classification
Morphine SO4 Stat Binds to opiate receptors in the 1. Hypersensitivity Sedation, confusion, headache,
Morphine 5 mg CNS. Alters the perception of and 2. Pregnancy or lactation euphoria, hallucinations, dizziness, Assess type, location and intensity
Opioid anlgesic IV response to painful stimuli, while 3. Some products contains bisulfites diplopia, blurred vision, RESPIRATORY of pain prior to and 20 mins (peak)
producing generalize CNS or alcohol and should be avoided in DEPRESSION, hypotension, following IV administration. A
Indication: depression patients with known hypersensitivity bradycardia, nausea, vomiting, repeat dose can be safely
Management of constipation, urinary retention, administered at the time of the
severe pain, sweating flushing, itching, tolerance, peak if previous dose is ineffective
management of physical dependence, psychological and side effects are minimal.
pain associated dependence
with myocardial Assess blood pressure, pulse and
infarction respiration before and periodically
ANTIDOTE: to reverse respiratory during administration. If respiratory
depression or coma, use of opioid rate is <10 assess level of sedation.
antagonist is required, naloxone Physical stimulation may be
(Narcan). Dilute the 0.4 mg ampoule sufficient to significant
in a 10 ml 0.9% NaCl and administer hypoventilation.
0.5 ml (0.02 mg) by direct IV push
every 2 mins. Assess bowel function routinely.

Medication Frequency
Brand Dose
name/Generic route Action Contraindication Adverse reaction Nursing intervention
Classification
Dormicum STAT Acts at many levels of the CNS to 1.Hypersensitivity Headache, drowsiness, agitation,
(Midazolam) 7.5 mg produce generalized CNS 2. shock blurred vision, LARYNGOSASM, Monitor blood pressure, pulse, and
Hypnotics and PO depression. Effects may be 3. comatose patients or those with broncosphasm, RESPIRATORY
sedatives mediated by gamma aminobutyric pre existing CNS depression DEPRESSION, APNEA, arrhythmias,
acid (GABA), an inhibitory 4. uncontrolled severe pain CARDIAC ARREST, hiccoughs, nausea, respiration continuously.
neurotransmitter. 5. pregnancy and lactation. vomiting, and rashes.
Indication: for Assess level of sedation and level of
sedation consciousness 6 hours following
administration.

Medication Frequency
Brand Dose
name/Generic route Action Contraindication Adverse reaction Nursing intervention
Classification
Losec OD Binds to an enzyme on gastric 1. Bleeding disorders at present or Weakness, dizziness, somnolence,
(Omeprazole) 20 mg parietal cells in the presence of within 6 months, hemorrhagic headache, somnolence, fatigue, chest Assess patient routinely for
Anti-ulcer PO acidic gastric pH, preventing the diatehesis, thrombocytopenia. pain, abdominal pain, nausea, epigastric or abdominal pain and
Gastric Pump final transport of hydrogen ions 2. Major surgery or significant vomiting, acid regurgitation, rash, frank or occult blood in stool,
inhibitor into the gastric lumen. trauma within the past 2 months itching. emesis or gastric aspirate.

Indication: Use cautiously with history of GI CBC with differential should be

prevention of bleeding or ulcer disease. monitored periodically throughout
relapse of therapy.
duodenal ulcer,
gastric ulcer and
esophagitis

Medication Frequency
Brand Dose
name/Generic route Action Contraindication Adverse reaction Nursing intervention
Classification
Plasil STAT Stimulates of the upper GI tract and 1. Hypersensitivity. Restlessness, drowsiness, fatigue,
(Metoclopramide) 10 mg accelerates gastric emptying. 2. Possible GI obstruction or extrapyramidal reactions, depression, Assess patient for nausea, vomiting,
Anti emetic, GI IV Therapeutic effect: decrease hemorrhage. tardive dyskinesia, irritability, anxiety, abdominal distention and bowel
stimulant nausea and vomiting. 3. History of seizure disorders and arrhythmias, constipation, diarrhea, sounds prior to and following
Parkinson’s disease. dry mouth, nausea and gynecomastia.
Indication:
Management of administration.
esophageal reflux.
Assess pt for extrapyramidal side
effects periodically though out
course of therapy.

Assess patient for sign of

depression

Medication Frequency
Brand Dose
name/Generic route Action Contraindication Adverse reaction Nursing intervention
Classification
Isoket Stat Produces vasodilation decreases 1. Hypersensitivity. Fatigue, malaise, headache, dizziness,
(Isosorbide 5 mg left ventricular end diastolic 2. Cross sensitivity with other azole somnolence, hypertension edema, Assess location, duration, intensity,
Dinitrate) sublingual pressure and left ventricular end – antifungals may occur. tinnitus, nausea and vomiting, and precipitating factors of angina
Vasodilator, diastolic volume (preload). Net 3. Lactation elevated liver enzymes, hepatitis, pain.
Antianginal effect is reduced myocardial oxygen . anorexia, abdominal pain, decrease
consumption. Increases coronary libido, impotence, rash, pruritus, Monitor blood pressure and pulse
Indication: blood flow by dilating arteries and hypokalemia. routinely during period of dosage
Acute treatment of improving collateral flow to and adjustment.
angina attacks, ischemic region.
long term May cause falsely decreased serum
management of cholesterol determinations
angina pectoris
and treatment of
chronic CHF

Medication Frequency
Brand Dose
name/Generic route Action Contraindication Adverse reaction Nursing intervention
Classification
Duphalac H.S. Increases water content and Patients on low galactose diet. Cramps, distention, flatulence,
(Lactulose) 30 ml softens the stool belching, diarrhea and hyperglycemia Assess patient for abdominal
Laxative PO (diabetic patients) distention, presence of bowel
(hyperosmotic) Use cautiously in: diabetes mellitus, sounds, and normal pattern of
pregnancy, lactation or children bowel functions
Indication: (safety not established). Excessive or
Treatment of prolonged used (may lead to Monitor blood glucose as it may
chronic dependence). cause increased in blood glucose in
constipation in diabetic patients
adults and elderly
and adjunct in the
management of MI

CHEST PAIN PROFILES

P Q R S T
Precipitating Quality Region and Associated signs Time and
factors Quantity radiation And symptoms Response to treatment
A.CARDIAC
1.ANGINA
Physical exertion Pressure Substernal Sweating
Emotional stress Tightness Unable to pinpoint Nausea, vomiting Gradual onset duration < 30 minutes
Environmental factors Squeezing Radiates to arms, Dyspnea relief with rest or GTN.
Eating Burning throat, jaw, back, Syncope
Mild to moderate pain upper abdomen uneasiness
2. ACUTE MYOCARDIAL
INFARCTION
Same; more likely Same description same region and Same, plus:
To occur with no Severe pain worsened by radiation Apprehension more Sudden onset duration > 30 minutes
Precipitator Fear and movement Severe no relief with rest or nitroglycerin
Extra heart sounds relief with narcotics
Pulmonary congestion
3. DISSECTING AORTIC
ANEURYSM
Hypertension Tearing sensation Substernal Dyspnnea
Excruciating pain Radiation to back Apprehension, sweating Sudden onset, no relief with rest or
Worse at onset and abdomen BP difference between arms GTN, relief with narcotics
“traveling” sensation Absence of pulse unilaterally
Hemiplegia or paraplegia
Murmur of aortic regurgitation
4. PERICARDITIS
Myocardial infarction Sharp, Stabbing, Knife like Precordial ( left of chest midline) Dyspnea
Uraemia Mild to severe deep or superficial retrosternal radiation to neck, arm or Friction Rub Sudden onset, continuous, no relief
Trauma worsened by inspiration, coughing, back with rest or GTN, relief with sitting
infections muscle movement, lying on left side forward or aspirin

P Q R S T
Precipitating Quality Region and Associated signs Time and
factors Quantity Radiation And symptoms Response to treatment
B. PULMONARY
1. PULMONARY EMBOLISM Crushing Lateral chest( over lung fields) Dyspnea, pallor or cyanosis Sudden onset, no relief with rest or
Prolonged sitting or Deep ache Radiation shoulder neck Syncope GTN, relief with narcotics
lying down Shooting Cough with Hemoptysis
Phlebitis Increased by deep Apprehension
Long bone fracture Inspiration or coughing Sinus tachycardia
Pleural rub
Fever

2. SPONTANEOUS
PNEUMOTHORAX Tearing Lateral chest Dyspnea Sudden onset
Chronic obstructive Increased by breathing Decreased breath sounds
Pulmonary disease Tachycardia
Agitation
3. PNEUMONIA
Respiratory Infection Moderate ache Over lung fields Dyspnea
Increase by coughing, inspiration and Radiation shoulder Tachycardia Gradual onset, Continuous duration
movement neck Pleural rub
Fever and relief with sitting up
Productive cough