Nursing Process Record 1

Patient’s Name: Patient A. Attending Physician: Not indicated in the scenario.

Medical Diagnosis: (1) Acute Anterolateral MI, generally uncomplicated.

(2) Atherosclerotic Cardiovascular Disease.

(3) Untreated Hypertension.

NANDA Nursing Diagnosis: Nursing Diagnosis Priority #1: Decreased Cardiac Output [00029] related to decreased myocardial tissue perfusion secondary to Acute Anterolateral
Myocardial Infarction, generally uncomplicated as evidenced by chest pain during regular palpitations with mild distress accompanied by diaphoresis, shortness of breath, nausea, and
sinus bradycardia of 55 bpm.

NANDA Definition: Inadequate volume of blood pumped by the heart to meet the metabolic demands of the body.

Cues/Defining Characteristics Nursing Outcomes Classification (NOC) Nursing Interventions Classification (NIC) Evaluation

Subjective:
A. Present Illness
(+) patient reported aching in his
chest pain and slight, regular
palpitations.
(+) Verbalized “ache is still present
when I go to bed, when I wake
several times during the night, and
when I get up in the morning.
(+) Patient reported with complaints
of chest pain accompanied by
diaphoresis, and shortness of breath
and nausea.
NOC 1: Circulation Status.
[040101] Systolic Blood Pressure.
1 – Severe deviation from normal range.
2 – Substantial deviation from normal range.
3 – Moderate deviation from normal range.
4 – Mild deviation from normal range.
5 – No deviation from normal.
[040103] Pulse Pressure.
1 – Severe deviation from normal range.
2 – Substantial deviation from normal range.
NIC 1: Circulatory Care: Arterial NOC 1: Circulation Status.
Insufficiency.
[040101] Systolic Blood Pressure.
● Monitor degree of discomfort or pain
2 – Substantial deviation from normal
with exercise, at night, or while
range.
resting.
● Place extremity in a dependent During the course of patient’s hospitalization,
position, as appropriate. after being treated with medications, such as
● Administer antiplatelet or 0.5 mg IV atropine sulfate twice and 150 mg
anticoagulant medications, as of amiodarone IV over 10 minutes followed
appropriate. by an amiodarone drip at 1 mg/minute for 6
● Instruct the patient on factors that hours, then 0.5 mg/minute for 12 hours, his
interfere with circulation (e.g., blood pressure decreases but still considered
smoking, restrictive clothing, as high blood pressure as evidenced by 130/90
exposure to cold temperatures, and mmHg.
crossing of legs and feet).
Objective: 3 – Moderate deviation from normal range. ● Monitor fluid status, including intake [040103] Pulse Pressure.
and output.
(+) Mild distress. 4 – Mild deviation from normal range. 4 – Mild deviation from normal range.
● Change the patient’s position at least
(+) High blood pressure as
5 – No deviation from normal. every 2 hours, as appropriate. During the course of his hospitalization, his
evidenced by 145/90 mmHg.
● Encourage the patient to exercise, as blood pressure decreases after being treated
(+) Sinus bradycardia as evidenced [040104] Mean Blood Pressure. tolerated. with medications. Furthermore, the result
by 55 bpm.
1 – Severe deviation from normal range. came as 130/90 mmHg which means that he
B. During Management NIC 1.2 Laboratory Data Interpretation.
has pulse pressure of 35 mmHg which is
(+) Nausea associated with 2 – Substantial deviation from normal range. ● Use the reference ranges from the considered as mild deviation from the normal
Diaphoresis.
3 – Moderate deviation from normal range. laboratory that is performing the range.
(+) blood pressure of 130/68 mmHg
particular test(s).
when treated with 0.5 mg IV atropine 4 – Mild deviation from normal range. [040104] Mean Blood Pressure.
● Recognize physiological factors that
sulfate twice.
5 – No deviation from normal. can affect laboratory values, including 4 – Mild deviation from normal range.
(+) blood pressure of 130/90 mmHg
gender, age, diet (especially
when treated with 150 mg During the course of his hospitalization, his
[040123] Fatigue. hydration), and time of day, activity
amiodarone IV over 10 minutes for 6 blood pressure decreased after being treated
level, and stress.
hours, then 0.5 mg/minute for 12 1 – Severe. with medications. Furthermore, the result
● Report results of lab tests to patient,
hours. came as 130/90 mmHg which means that he
2 – Substantial. as appropriate.
Laboratory: ● Analyze whether results obtained are has mean arterial blood pressure of 103.33
3 – Moderate. which is considered as mild deviation from
consistent with patient behavior and
Serum Cardiac Enzyme. the normal range.
4 – Mild. clinical status.
(+) CK: 164 IU/L. [040123] Fatigue.
5 – None. NIC 1.3 Pain Management

● Perform a comprehensive assessment 5 – None.

[040156] Intermittent Claudication.
Diagnostic: of pain to include location, Patient does not feel or experience fatigue
1 – Severe. characteristics, onset/duration, anymore although being hardworking is
● ECG done with ST elevation. frequency, quality, intensity or
2 – Substantial. innate to patient’s trait, but after being
severity of pain, and precipitating enlighten with health education about ways
3 – Moderate. factors. and prevention to reduce the level of
4 – Mild. ● Use therapeutic communication hypertension that he usually had before as
Medications: strategies to acknowledge the pain evidenced by propranolol as medication
experience and convey acceptance of
A. Pharmacological Management
1. IV Morphine Sulfate.
2. 0.5 atropine sulfate
3. 150 mg of amiodarone drip at 1
mg/minute for 6 hours, then 0.5
mg/minute for 12 hours.
4. Propanolol as maintenance of his
medication to treat his
hypertension.
5 – None.
NOC 2: Tissue Perfusion: Cardiac.
[040515] Apical Heart Rate.
1 – Severe deviation from normal range.
2 – Substantial deviation from normal range.
3 – Moderate deviation from normal range.
4 – Mild deviation from normal range.
5 – No deviation from normal.
[040517] Systolic Blood Pressure.
1 – Severe deviation from normal range.
2 – Substantial deviation from normal range.
3 – Moderate deviation from normal range.
4 – Mild deviation from normal range.
5 – No deviation from normal.
[040509] Electrocardiogram Findings.
1 – Severe deviation from normal range.
2 – Substantial deviation from normal range.
NIC 1.4 Nausea Management.
3 – Moderate deviation from normal range.
4 – Mild deviation from normal range.
5 – No deviation from normal.
the patient’s response to pain.
● Explore patient’s knowledge and
beliefs about pain.
● Explore with patient the factors that
improve/worsen pain.
● Evaluate past experiences with pain to
include individual or family history of
chronic pain or resulting disability, as
appropriate.
● Provide information about the pain,
such as causes of the pain, how long it
will last, and anticipated discomforts
from procedures.
● Reduce or eliminate factors that
precipitate or increase the pain
experience (e.g., fear, fatigue,
monotony, and lack of knowledge).
● Select and implement a variety of
measures (e.g., pharmacological,
nonpharmacological, interpersonal)
to facilitate pain relief, as appropriate.
● Encourage patient to use adequate
pain medication.
● Promote adequate rest/sleep to
facilitate pain relief.
● Encourage patient to monitor own
nausea experience.
● Encourage patient to learn strategies
for managing own nausea.
● Perform complete assessment of
maintenance, he plans to return to driving his
cab, but for fewer hours per week. No chest
pain, diaphoresis, irregular heartbeats were
being noted. All vital signs were in normal
range except his blood pressure.
[040156] Intermittent Claudication.
5 – None.
Patient has no further chest pain when being
active to activities and when being at rest. No
diaphoresis or even anxiety were being
observed as clinical manifestations to the said
medical diagnosis.
NOC 2: Tissue Perfusion: Cardiac.
[040515] Apical Heart Rate.
5 – No deviation from normal.
Patient apical heart rate became stable after
treated with prescribed medications such as
atropine and amiodarone as evidenced by 60
beats per minute.
[040517] Systolic Blood Pressure.
3 – Moderate deviation from normal range.
Patient’s blood pressure has decreased to
130/90 after treated with prescribed
medications such as atropine sulfate and
amiodarone, but still within unhealthy range
and at risk for recurring the above-mentioned
[040510] Cardiac Enzymes.
1 – Severe deviation from normal range.
2 – Substantial deviation from normal range.
3 – Moderate deviation from normal range.
4 – Mild deviation from normal range.
5 – No deviation from normal.
[040512] Exercise Stress Test Findings.
1 – Severe deviation from normal range.
2 – Substantial deviation from normal range.
3 – Moderate deviation from normal range.
4 – Mild deviation from normal range.
5 – No deviation from normal.
[040504] Angina.
1 – Severe.
2 – Substantial.
3 – Moderate.
4 – Mild.
5 – None.
[040520] Arrhythmia.
NIC 2: Vital Signs Monitoring.
1 – Severe.
nausea, including frequency, duration,
severity, and precipitating factors.
● Ensure that effective antiemetic drugs
are given to prevent nausea when
possible.
● Reduce or eliminate personal factors
that precipitate or increase the nausea
(anxiety, fear, fatigue, and lack of
knowledge).
● Teach the use of nonpharmacological
techniques (e.g., biofeedback,
hypnosis, relaxation, guided imagery,
music therapy, distraction,
acupressure) to manage nausea.
● Promote adequate rest and sleep to
facilitate nausea relief.
● Use frequent oral hygiene to promote
comfort, unless it stimulates nausea
● Encourage eating small amounts of
food that are appealing to the
nauseated person.
● Provide information about the nausea,
such as causes of the nausea and how
long it will last.
● Assist to seek and provide emotional
support.
● Monitor effects of nausea
management throughout.
● Monitor blood pressure, pulse,
temperature, and respiratory status, as
cardiac disease if patient is noncompliance
with medication regimen.
[040509] Electrocardiogram Findings.
4 – Mild deviation from normal range.
Patient’s ECG finding showed gradually
diminishing ST elevation from previous level
which indicates that no chest pain is
experience, anxiety, and diaphoresis.
Furthermore more, no ischemic situation
happen from these above-mentioned clinical
manifestations.
[040510] Cardiac Enzymes.
5 – No deviation from normal.
Patient’s LDH is within normal range which
indicate that no chest pain is experienced in
the advent of deteriorated myocardial injury.
[040512] Exercise Stress Test Findings.
5 – No deviation from normal.
Patient underwent treadmill test to determine
abnormal heart rhythms (arrhythmias) and to
diagnose the presence of coronary artery
disease which he had clinically showed during
admission of 55 bpm as a means of sinus
bradycardia and chest pain because of
ischemia that happens in the heart muscle
2 – Substantial. appropriate. during contraction. Furthermore, as treadmill
● Note trends and wide fluctuations in test is done, there was 50% effort with
3 – Moderate.
blood pressure. negative results.
4 – Mild. ● Monitor blood pressure while patient
[040504] Angina.
is lying, sitting, and standing before
5 – None. and after position change, as 5 – None.
[040522] Bradycardia. appropriate.
● Monitor blood pressure after patient Patient did not show any clinical
1 – Severe. has taken medications, if possible. manifestation such as angina that would relate
● Auscultate blood pressures in both to his medical diagnosis. Moreover, no
2 – Substantial. complain of chest pain before, during, and
arms and compare, as appropriate.
3 – Moderate. ● Monitor blood pressure, pulse, and after activities.
respirations before, during, and after [040520] Arrhythmia.
4 – Mild.
activity, as appropriate.
5 – None. ● Monitor for and report signs and 5 – None.
symptoms of hypothermia and Patient heart rate became stable. No signs and
[040505] Profuse Diaphoresis.
hyperthermia. symptoms of having bradycardia and
1 – Severe. ● Monitor presence and quality of tachycardia towards the patient.
pulses.
2 – Substantial. [040522] Bradycardia.
● Take apical and radial pulses
3 – Moderate. simultaneously and note the
5 – None.
difference, as appropriate.
4 – Mild. ● Monitor for a widening or narrowing Patient has normal resting heart rate as
5 – None. pulse pressure. evidenced by 60 bpm.
● Monitor cardiac rhythm and rate.
[040506] Nausea. [040505] Profuse Diaphoresis.
● Monitor heart tones.
● Monitor respiratory rate and rhythm 5 – None.
1 – Severe.
(e.g., depth and symmetry).
2 – Substantial. Patient is not in mild distress anymore, no
● Monitor lung sounds.
anxiousness is being noted as evidenced by
● Monitor pulse oximetry.
3 – Moderate. profuse diaphoresis as a clinical manifestation
● Monitor for abnormal respiratory
of MI during an attempt to get more oxygen
patterns (e.g., CheyneStokes,
4 – Mild.
5 – None.
NOC 3: Tissue Perfusion: Pulmonary.
[040814] Respiratory Rhythm.
1 – Severe deviation from normal range.
2 – Substantial deviation from normal range.
3 – Moderate deviation from normal range.
4 – Mild deviation from normal range.
5 – No deviation from normal.
[040815] Respiratory Rate.
1 – Severe deviation from normal range.
2 – Substantial deviation from normal range.
3 – Moderate deviation from normal range.
4 – Mild deviation from normal range.
5 – No deviation from normal.
[040816] Systolic Blood Pressure.
1 – Severe deviation from normal range.
2 – Substantial deviation from normal range.
3 – Moderate deviation from normal range.
4 – Mild deviation from normal range.
Kussmaul, Biot, apneustic, ataxic,
and excessive sighing).
● Monitor for presence of Cushing triad
(e.g., wide pulse pressure,
bradycardia, and increase in systolic
BP).
● Identify possible causes of changes in
vital signs.
NIC 2.1 Anxiety Reduction.
● Provide factual information
concerning diagnosis, treatment, and
prognosis.
● Stay with patient to promote safety
and reduce fear.
● Encourage family to stay with patient,
as appropriate.
● • Encourage verbalization of feelings,
perceptions, and fears.
● Identify when level of anxiety
changes.
● Help patient identify situations that
precipitate anxiety.
● Administer medications to reduce
anxiety, as appropriate.
● Assess for verbal and nonverbal signs
of anxiety.
NIC 1.5 Medication Management
● Determine what drugs are needed, precipitates
and administer according to cardiovascular disease, specifically MI.
prescriptive authority and/or protocol.
as a compensation to meet the metabolic
demands of the body.
[040506] Nausea.
3 – Moderate.
Patient has no further chest pain, but he
reports that his nausea persist after meals.
NOC 3: Tissue Perfusion: Pulmonary.
[040814] Respiratory Rhythm.
5 – No deviation from normal.
Patient has a regular respiratory rhythm as
evidenced by 18 breaths per minute.
[040815] Respiratory Rate.
5 – No deviation from normal.
Patient has a regular respiratory rhythm as
evidenced by 18 breaths per minute.
[040816] Systolic Blood Pressure.
3 – Moderate deviation from normal range.
Patient’s blood pressure after being treated
with atropine sulfate and amiodarone is
130/90 mmHg which is still considered as
high blood pressure. This might be due to his
obesity as evidenced by 28.6 which
him from getting the
5 – No deviation from normal. ● Monitor patient for the therapeutic [040805] Chest Pain.
effect of the medication.
[040805] Chest Pain. 5 – None.
● Monitor adherence with medication
1 – Severe. regimen. Patient did not experience any clinical
● Determine factors that may preclude manifestation such as chest pain that would
2 – Substantial. the patient from taking drugs as relate to his medical diagnosis. Moreover, no
3 – Moderate. prescribed. complains of experiencing it before, during,
● Develop strategies with the patient to and after activities.
4 – Mild. enhance compliance with prescribed
medication regimen. [040808] Unexplained Anxiety.
5 – None.
● Teach patient and/or family members 5 – None.
[040808] Unexplained Anxiety. the expected action and side effects of
the medication. Patient has no further chest pain, no
1 – Severe. diaphoresis as indication of his anxiety during
● Develop strategies to manage side
2 – Substantial. effects of drugs. angina events.

3 – Moderate. [040823] Shortness of Breath.

4 – Mild. 5 – None.

5 – None. Patient was able to manage his breathing and

did not experience shortness of breath as a
[040823] Shortness of Breath. result from chest pain.
1 – Severe. NOC 4: Vital Signs.
2 – Substantial. [080202] Apical Heart Rate.
3 – Moderate. 5 – No deviation from normal.
4 – Mild. Patient’s apical heart rate is normal as
5 – None. evidenced by 60 beats per minute.

NOC 4: Vital Signs. [080208] Apical Heart Rhythm.

[080202] Apical Heart Rate.
1 – Severe deviation from normal range.
2 – Substantial deviation from normal range.
3 – Moderate deviation from normal range.
4 – Mild deviation from normal range.
5 – No deviation from normal.
[080208] Apical Heart Rhythm.
1 – Severe deviation from normal range.
2 – Substantial deviation from normal range.
3 – Moderate deviation from normal range.
4 – Mild deviation from normal range.
5 – No deviation from normal.
[080204] Respiratory Rate.
1 – Severe deviation from normal range.
2 – Substantial deviation from normal range.
3 – Moderate deviation from normal range.
4 – Mild deviation from normal range.
5 – No deviation from normal.
[080210] Respiratory Rhythm.
1 – Severe deviation from normal range.
5 – No deviation from normal.
Patient’s has regular heart rhythm. No signs
of tachycardia and bradycardia.
[080204] Respiratory Rate.
5 – No deviation from normal.
Patient’s has a normal heart rate as evidenced
by 18 breaths per minute.
[080210] Respiratory Rhythm.
Patient’s has regular respiratory rhythm. No
signs of tachypnea and bradypnea.
[080205] Systolic Blood Pressure.
3 – Moderate deviation from normal range.
Patient’s blood pressure has decreased to
130/90 after being treated with prescribed
medications such as atropine sulfate and
amiodarone, but still within unhealthy range
and at risk for recurring the above-mentioned
cardiac disease if patient is noncompliance
with medication regimen.
[080209] Pulse Pressure.
4 – Mild deviation from normal range.
During the course of his hospitalization, his
blood pressure decreases after being treated
with medications. Furthermore, the result
came as 130/90 mmHg which means that he
2 – Substantial deviation from normal range. has pulse pressure of 35 mmHg which is
considered as mild deviation from the normal
3 – Moderate deviation from normal range.
range.
4 – Mild deviation from normal range.

5 – No deviation from normal.

[080205] Systolic Blood Pressure.

1 – Severe deviation from normal range.

2 – Substantial deviation from normal range.

3 – Moderate deviation from normal range.

4 – Mild deviation from normal range.

5 – No deviation from normal.

[080209] Pulse Pressure.

1 – Severe deviation from normal range.

2 – Substantial deviation from normal range.

3 – Moderate deviation from normal range.

4 – Mild deviation from normal range.

5 – No deviation from normal.