Quiz 3 Nursing 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 the necrosis of the myocardium Short-term Goal: Within 1 hour of nursing intervention, the client will have improved comfort in chest Long-term Goal: Within 2 days of nursing intervention, the client will have improved feeling of control as evidenced by verbalizing a sense of control over present situation and future outcomes Cues Subjective: The client reports chest pain radiating to the left arm, neck and back Objective: Restlessness Facial grimacing Fatigue Peripheral cyanosis Weak pulse Cold and clammy skin Palpitations Shortness of breath Elevated temperature Pain scale of Nursing Problem Chest Pain Scientific Reason Coronary artery or one of its smaller branches is suddenly blocked. The part of the heart muscle supplied by this artery loses its blood (and oxygen) supply if the vessel is blocked. This part of the heart muscle is at risk of dying unless the blockage is quickly removed. Intervention 1. Assess characteristics of chest pain 2. Obtain history of previous cardiac pain and familial history of cardiac problems 3. Assess RR, PR, BP in episodes of chest pain 4. Maintain bed rest during chest pain, with comfortable position, maintain calm environment to promote relaxation 5. Prepare for administration of medications, and monitor response to therapy. Notify Rationale 1. Assisting the client in quantifying pain may differentiate preexisting and current pain patterns as well as identify complications 2. 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 apriority, as it indicates ischemia Evaluation Standard: 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, requires decrease analgesia or nitroglycerin Criteria: The clients chest pain was decreased to 4/10 and decreased in episodes

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When a part physician if pain of the heart does not abate muscle is 6. Instruct patient in damaged it is NTG SL said to be administration after infarcted. The hospitalization. term Instruct patient in myocardial activity alterations infarction (MI) and limitations means 7. Instruct patient and damaged family in heart medications effects, muscle. contraindications, side effects and symptoms to report 8. Obtain a 12 lead ECG on admission, then each time chest pain recurs for evidence of further infarction as prescribed 9. Administer analgesics as ordered, such as morphine sulfate, meferidine 10. Administer beta blockers as ordered 11. Administer Calcium channel blockers as ordered

6. to decrease myocardial oxygen demand and workload on the heart 7. to promote knowledge and compliance with therapeutic regimen and to alleviate fear of unknown 8. serial ECG and stat ECGs record changes that can give evidence of further cardiac damage and location of MI 9. Morphine is the drug of choice to control MI pain, but other analgesics maybe used to reduce pain and reduce the workload on the heart 10. to block sympathetic stimulation, reduce heart rate and lowers myocardial demand 11. to increase coronary blood flow and collateral circulation which can decrease pain due to ischemia