Goals and Expected Nursing Interventions Rationale for Nursing Interventions Evaluations

Outcomes

Verbalize relief/control of
chest pain within
appropriate time frame for
administered medications.
Display reduced tension,
relaxed manner, ease of
movement.
Demonstrate use
of relaxation techniques.
Improvement in mood,
coping.
Assessment:
1- Monitor and document characteristic of
pain, noting verbal reports, nonverbal
cues (moaning, crying, grimacing,
restlessness, diaphoresis, clutching of
chest) and BP or heart rate changes.
2- Obtain full description of pain from
patient including location, intensity
(using scale of 0–10), duration,
characteristics (dull, crushing, described
as “like an elephant in my chest”), and
radiation. Assist patient to quantify pain
by comparing it to other experiences.
Education:
3- Instruct patient to do relaxation
techniques: deep and slow breathing,
distraction behaviors, visualization,
guided imagery. Assist as needed.!
Treatment:
4- Administer Aspirin 81 mg daily.
1 - Variation of appearance and behavior of The goal is met,
patients in pain may present a challenge in and the patient is
assessment. Most patients with an acute MI free from pain.
appear ill, distracted, and focused on pain.
Verbal history and deeper investigation of I reassessment the
precipitating factors should be postponed patient pain and it
until pain is relieved. Respirations may be is 0/10.
increased as a result of pain and
associated anxiety; release of stress- The heart rate is
induced catecholamines increases heart rate normal.
and BP.
2- Pain is a subjective experience and must The patient is
be described by patient. Provides baseline free from the
for comparison to aid in determining chest pain.
effectiveness of therapy, resolution and
progression of problem.
3- Helpful in decreasing perception and
response to pain. Provides a sense of
having some control over the situation,
increase in positive attitude.
4- Aspirin is a type of nonsteroidal anti-
inflammatory drug (NSAID). NSAIDs are
nonnarcotic pain relievers.

1-!Nursing Diagnosis: Acute pain related to Myocardial

infarction as evidenced by reports of chest pain with
radiation in bilateral arm
Goals and Expected Outcomes
The patient will display normal
laboratory results within the
normal limit and absence of
muscle weakness, and cognitive
impairment.
2-!Nursing Diagnosis: Risk for Electrolyte Imbalance related to
Vomiting as evidenced by potassium level 3.2 mmol/l.
Nursing Interventions
Assessment:
1-Monitor respiratory rate, depth, effort
and heart rate.
2- Monitor level of consciousness and
neuromuscular function, noting
movement, strength, and sensation.
3- Observe for absence or changes in
bowel sounds.
Treatment:
4-Administer potassium orally (KCL
oral 20ml daily)
Education:
5-Encourage high potassium diet such as
oranges, bananas, tomatoes, and dried
fruits.
Rationale for Nursing Interventions Evaluations
1-Respiratory muscle weakness may The goal is
progress to paralysis leading to met, the
respiratory arrest. Abnormalities in heart respiratory
conduction and contractility are rate and heart
associated with hypokalemia. rate in normal
Tachycardia may develop as well as range.
potentially life-threatening atrial and
ventricular dysrhythmias–AV blocks, AV The patient is
dissociation, ventricular tachycardia and educated well,
PVCs. and he is
2- Tetany, paresthesia, apathy, eating high
drowsiness, irritability, and coma may potassium
occur. diet.
3- Paralytic ileus commonly follows
gastric losses through vomiting, gastric The potassium
suction, or protracted diarrhea. lab result is
4-Treat or prevent low amounts of now in normal
potassium in the blood.
range.
5-Potassium may be replaced, and level
maintained through the diet when the
client is allowed oral food and fluids.
Goals and Expected Outcomes Nursing Interventions
Participate in activities that Assessment:
1-Monitor and record BP. Measure in
reduce BP/cardiac workload.
both arms and thighs three times, 3–5
min apart while patient is at rest, then
Maintain BP within individually sitting, then standing for initial
acceptable range. evaluation. Use correct cuff size and
accurate technique.
Demonstrate stable cardiac 2-Observe skin color, moisture,
rhythm and rate within patient’s temperature, and capillary refill time.
normal range.
Treatment:
3-Provide calm, restful surroundings,
Participate in activities that will minimize environmental activity and
prevent stress (stress noise. Limit the number of visitors and
management, balanced activities length of stay.
4-Provide comfort measures (back and
and rest plan).
neck massage, elevation of head).
Education:
5-Instruct in relaxation techniques,
guided imagery, distractions and low
sodium diet intake.
3- Nursing Diagnosis: Risk for injury related to hypertension as
evidence by blood pressure 177/89 mmHg.
Rationale for Nursing Interventions Evaluations
1-Comparison of pressures provides a The goal is
more complete picture of vascular partially met,
involvement or scope of problem. Severe the blood
hypertension is classified in the adult as a pressure range
diastolic pressure elevation to 110 is 142/62
mmHg; progressive diastolic readings mmHg.
above 120 mmHg are considered first
accelerated, then malignant (very severe). The cardiac
Systolic hypertension also is an rhythm is
established risk factor for normal.
cerebrovascular disease and ischemic
heart disease, when diastolic pressure is The patient is
elevated. now free from
2-Presence of pallor; cool, moist skin; stress and he
and delayed capillary refill time may be is ready to
due to peripheral vasoconstriction or discharge.
reflect cardiac decompensation and
decreased output.
3-Helps lessen sympathetic stimulation;
promotes relaxation.
4-Decreases discomfort and may reduce
sympathetic stimulation.
5-Can reduce stressful stimuli, produce
calming effect, thereby reducing BP.