Patient’s Name: N/A Patient’s age: 50 years old

Cues Nursing Diagnosis Rationale Goals / Outcome Nursing Interventions Rationale Evaluation
Criteria

Subjective: Acute pain related to Occlusion of Within 30 minutes of Independent:

The patient reports of myocardial ischemia coronary artery nursing interventions, the patient a. Assess the intensity of the chest pain a.To determine what appropriate Goal met, after 30 minutes of
chest pain (Pain scale of resulting from coronary will be able to: using pain rating scale. interventions will be going to apply for nursing interventions, the
7/10) and numbness of the artery occlusion. b. Monitor respirations, blood pressure, better implementation of care. patient was able to;
left shoulder. Decreased blood  States a decrease in the and heart rate with each episode of chest pain. b. Respirations and blood pressure may be
flow to the chest pain rating of 7 out 10. c. Provide patient with a quiet increased as a result of pain. State a decrease in the chest
myocardial environment and maintain bed rest during c.To reduce oxygen consumption and pain rating from 7 down to
Objective: pain, with position of comfort. demand, to reduce completing stimuli and 4 as 10 is the highest.
 Maintain the vital signs
Facial grimace d. Instruct patient to avoid or limit reduces anxiety.
within normal range.
Restlessness Decreased blood activities that cause to increase cardiac d. To prevent triggering the heart needs of  Maintain vital signs within
Peripheral cyanosis supply (ischema) workload (going to the restroom) more oxygen due to exertion, thus, limiting normal limits.
Cold and clammy  Rest, displays reduced activities decrease myocardial oxygen
skin tension, and sleeps demand and workload on the heart.
Anaerobic comfortably. Rest, displays reduced
metabolism Dependent tensions, and comfortably.
Vital sign taken as follow: a. Administer Oxygen as ordered.
BP- 160 / 100 mmHg a. Increase amount of oxygen available for
RR – 26 bpm Lactic acid b. Administer analgesic as ordered, such as myocardial uptake and thereby may relieve
PR – 96 cpm formation morphine sulphate. discomfort associated with tissue ischemia.
Temp – 37.2 OC b. Morphine is an opiate analgesic and alters
O2 Sat – 94 % the client’s perception of pain and reduces
Pain c. Administer beta blockers such as preload time vasoconstriction.
metropolol. c. To block sympathetic stimulation, reduce
heart rate and lowers myocardial demand.
a. To improve coronary artery perfusion.
Collaboration:
a. Assist with treatment of underlying
conditions (e.,g. Stent replacement, surgical
reperfusion procedures).

Cues Nursing Diagnosis Rationale Goals / Outcome Criteria Nursing Interventions Rationale Evaluation
Subjective:
The patient reports of chest pain
(Pain scale of 7/10) and numbness of
the left shoulder.
Objective:
Facial grimace
Cold and clammy skin
ECG 12 lead result:
Elevated ST segment
Laboratory results:
Triglycerides - 160 mg/dL
LDL - 170 mg/dL
Cholesterol - 220 mg/dL
Hemoglobin - 13 g/dl
Vital sign taken as follow:
BP- 160 / 100 mmHg
RR – 26 bpm
PR – 96 cpm
Temp – 37.2 OC
O2 Sat – 94 %
Ineffective cardiac tissue Coronary circulation is
perfusion related to composed of small arteries
thrombus in coronary and veins that keep the
artery, resulting in altered heart cells supplied with
blood flow to myocardial fresh oxygen. With
tissue. myocardial Infarction,
plaques (fatty deposits)
build up, inside the lining of
coronary arteries. This build
up can partially or totally
block blood flow in the
arteries of the heart which
causes death of heart
muscle cells.
Within 30 minutes of nursing
interventions, the patient will be
able to:
 Reports beginning relief of
chest discomfort
 Appears comfortable and free
of pain.
 Displays adequate cardiac
output as evidenced by:
- Improving 12 Lead ECG
- Vital signs within normal
ranges
- Skin is warm & dry,
absence of cyanosis
Independent:
a. Monitor vital signs
b. Instruct patient to maintain
head of bed elevated, keep bed
rest, and use of bed side
commode.
c. Instruct patient in dietary
needs and restrictions (limiting
high fat diet)
Dependent
a. Administer oxygen as
prescribed.
b. Administer thrombolytic and
aspirin as prescribed.
c. Obtain a 12 – lead ECG as
prescribed.
Collaboration:
a. Refer to dietician for the
dietary needs.
a. To establish baseline data. Goal met, after 30 minutes of
b. Physical rest reduces nursing interventions, the patient
myocardial oxygen consumption. was able to;
c. Decreases coronary narrowing
or spasm and prevent build up of  Reports beginning relief of chest
plaques inside the coronary discomfort
arteries.
 Appears comfortable and free of
a. Oxygen therapy increases the pain
oxygen supply to the
myocardium.
b. Thrombolytic therapy can  Displays adequate cardiac output
break apart the thrombus and as evidenced by:
increase myocardial tissue
- Improved 12 Lead ECG
perfusion. Aspirin reduces - Vital signs within normal
coronary reocclusion.
ranges
c. ST – segment elevation - Skin is warm & dry, absence
indicates myocardial tissue of cyanosis
injury; ST- segment depression
indicates decreased myocardial
perfusion.
a. For well-balanced, low
saturated - fat, low – cholesterol
diet and other modifications as
indicated.

Cues Nursing Diagnosis Rationale Goals / Outcome Criteria Nursing Interventions Rationale Evaluation

Subjective: Risk for ineffective Due to decreased cardiac Within 1 hour of nursing Independent: a. To have baseline data and to Goal met, after 1 hour of
 The patient reports of peripheral tissue output, there is decreased interventions, the patient will be a. Monitor vital signs, MIO and determine blood circulation nursing interventions, the
chest pain perfusion related to preload and stroke volume able to: capillary refill b. Restricted activity reduces patient was able to;
decrease cardiac output. thus there is decreased  Maintain of adequate tissue b. Instruct patient to maintain bed rest oxygen demands of the heart
Objective: blood pumped out from the perfusion and elevate of the bed head to 30o and promote circulation  Maintain of adequate
Cold and clammy skin blood. Decrease in stroke c. Instruct patient to avoid activities c. Activities that requires too tissue perfusion
Cyanotic extremities volume decreases perfusion  Displays improved vital signs that increase the hearts’ stress. much workload leads to heart
Decreased capillary refill through the body. within normal range. stress and increases oxygen  Displays improved vitals
demands within normal range.
Laboratory results:  Extremities warm, dry,
Hemoglobin - 13 g/dl absence of cyanosis and  Extremities warm, dry,
capillary refill <2 seconds a. Oxygen increase arterial absence of cyanosis and
Dependent: saturation. capillary refill <2 seconds
Vital sign taken as follow: a. Administer oxygen as prescribed b. Thrombolytic therapy is the
BP- 160 / 100 mmHg b. Administer thrombolytic agents treatment of choice (when
RR – 26 bpm e.g., alteplase as prescribed. initiated within 6 hr) to
PR – 96 cpm . dissolve the clot (if that is the
Temp – 37.2 OC cause of the MI) and restore
O2 Sat – 94 % perfusion of the myocardium.

Collaboration:
a. Obtain blood extraction needed for a. Normal values indicate
laboratory (haemoglobin, hematocrit adequate tissue perfusion.
and RBC) as prescribed.