ASSESSMENT

Subjective: Nagdagsen ti barukong ko , as verbalized by the patient. Pain scale of 6. ( 1-3mild, 4-6 moderate, 710 severe ) Objective: The patient always turns his body side to side. Capillary refill of 3 seconds O2 saturation of 90 % Vital signs of: BP100/70mmHg RR-24bpm PR- 60bpm

DIAGNOSIS
Acute (Chest) Pain r/t myocardial ischemia resulting from coronary artery occlusion with loss/restriction of blood flow to an area of the myocardium and necrosis of the myocardium.

PLANNING
STG: Within 1 hour of nursing interventions, the client will have improved comfort in chest, as evidenced by: States a decrease in the rating of the chest pain. Is able to rest, displays reduced tension, and sleeps comfortably Requires decrease analgesia or nitroglycerin.

INTERVENTION
INDEPENDENT: 1. assess characteristics of
chest pain, including location, duration, quality, intensity, presence of radiation, precipitating and alleviating factors, and as associated symptoms, have client rate pain on a scale of 1-10 and document findings in nurses notes. 2. obtain history of previous cardiac pain and familial history of cardiac problems 3. assess respirations, BP and heart rate with each episodes of chest pain. 4. maintain bedrest during pain, with position of comfort, maintain relaxing

RATIONALE
1. pain is indication of MI. assisting the client in quantifying pain may differentiate preexisting and current pain patterns as well as identify complications. 2. this provides information that may help to differentiate current pain from previous problems and complications. 3. respirations may be increased as a result of pain and associate anxiety. 4. to reduce oxygen consumption and demand, to reduce competing stimuli and reduces anxiety. 5.pain control is priority, as it indicates

EVALUATION
STG: Within 1 hour of nursing intervention, the client had improved comfort in chest, as evidenced by:

States a decrease in the rating of the chest pain Is able to rest, displays reduced tension, and sleeps comfortably.

environment to promote calmness. 5. prepare for the administration of medications, and monitor response to drug therapy. Notify physician if pain does not

LTG: The client will have an improved feeling of control as evidenced by

Requires decrease analgesia or nitroglycerin. Goal was met. LTG: The client had an improved feeling of control as evidenced by verbalizing a sense of control over

Temperature38C WBCCK

verbalizing a sense of control over present situation and future outcomes within 2 days of nursing interventions.

abate 6. instruct patient/family in medication effects, sideeffects, contraindications and symptoms to report. DEPENDENT:

ischemia

present situation and future outcomes within 2 days of nursing intervention. Goal was met.

1. obtain a 12-lead ECG on

admission, then each time chest pain recurs for evidence of further infarction as prescribed. 2. administer analgesics as ordered, such as morphine sulfate, meferidine of Dilaudid N 3. administer betablockers as ordered. 4. administer calciumchannel blockers as ordered

IN PARTIAL FULFILLMENT OF THE REQUIREMENTS IN NCM 104 CLINICAL AREA

A NURSING CARE PLAN FOR MYOCARDIAL INFARCTION

SUBMITTED TO: MR. JERRY ABRIAM SUBMITTED BY: MADIAM, ANNABELLE P. BOCANE, LORIEN

ITRMC 11-7 MICU JULY 14, 2011