Defining Nursing Scientific Desired Nursing Intervention Rationale

Characteristics Diagnosis Analysis Outcome

S: “di ko na kaya, Alteration Acute Myocardial After 2-3 hours 1. Assess the -Assisting the client in
masyadong in comfort: Infarction is a life of appropriate characteristic of quantifying pain may
masakit ang Acute Pain threatening Nursing Chest pain differentiate pre-
dibdib ko”as related to condition Intervention including the existing and current
verbalized by the myocardial characterized by the patient will location, duration, pain pattern.
pt. ischemia the formation of be able to quality, intensity
secondary localized necrotic report and have the client
O: received pt. to blood areas within the improved rate the chest pain
On bed with flow myocardium. The comfort in the from 0-10. -Respiration may be
ongoing D5LRS restriction most common chest, as 2. Assess respiration, increased as a result
1L@20 gtts/min to an area cause of AMI is evidenced by blood pressure and of pain and anxiety. BP
-conscious and of the complete or decreased heart rate with and Heart rate
coherent myocardiu nearly complete rating of chest every episode of increases due to the
-with o2 m occlusion of a pain and the chest pain. release of stress
inhalation of 3- coronary artery, ability to rest induced
4L/hr. usually and sleep catecholamine.
-facial grimace precipitated by comfortably. 3. Monitor the -Pain management is
noted rupture of response to drug a priority because it
-with pain scale vulnerable therapy. Notify the may indicate ischemia.
of=8 where 0 is atherosclerotic physician if pain
rated as no pain plaque and does note abate
and 10 as worst subsequent with in15-20 min. -External stimuli may
pain. thrombus 4. Provide care in a worsen anxiety,
-with vital signs formation. calm and efficient cardiac strain and
of: The most manner. coping ability.
T= 37.4 C common -Morphine is an opiate
P= 115 bpm manifestation of analgesic that alters
R= 25 cpm AMI is chest pain 5. Administer the clients perception
BP= 130/90 but unlike angina Morphine as of pain and reduces
mmHg pectoris it is ordered preload time
unrelieved by vasoconstriction.
nitroglycerine. -Nitrates relax smooth
The pain may muscles of coronary
radiate to the 6. Administer nitrates blood vessels thus
 Cardiovascular System: Acute Myocardial Infarction

Cardiovascular System: Acute Myocardial Infarction

Defining Nursing Scientific Desired Nursing Intervention Rationale

Characteristics Diagnosi Analysis Outcome
s

O: received pt. After 2-3 Acute Myocardial After 2-3 1. Assess mental -Cerebral perfusion is
On bed with hours of Infarction is a life hours of status-be alert to directly related to
ongoing D5LRS appropria threatening appropriate restlessness and cardiac output
1L@20 gtts/min te condition Nursing unresponsiveness. - It may reflect
-awake Nursing characterized by Intervention 2. Monitor lung pulmonary congestion
-weakness and Interventi the formation of the patient sounds such as related to alteration of
dizziness noted on the localized necrotic will be able to crackles and cardiac function
-with o2 patient areas within the improve rhonchi. -It is related to hypo
inhalation of 3- will be myocardium. AMI cardiac perfusion, vagal
4L/hr. able to usually follows output as 3. Monitor blood stimulation,
-with vital signs improve the sudden evidenced by pressure- watch out dysrhythmia or
of: cardiac occlusion of a normal for hypertension ventricular
T= 37.4 C output as coronary artery cardiac rate, and hypotension. dysfunction.
P= 115 bpm evidence and the abrupt rhythm, and
R= 25 cpm d by cessation of blood absence of 4. Monitor Urine -Urine output less
BP= 130/90 normal and oxygen flow chest pain. output. than0.5ml/kg/hour
mmHg cardiac to the heart may reflect decreased
rate, muscle. renal perfusion as a
rhythm, Because the heart result of decreased
and must function cardiac output.
absence continuously, -Decreased peripheral
of chest blockage of blood 5. Assess peripheral perfusion may indicate
pain. to the muscle and perfusion-such as decreased cardiac
the development pallor, mottling, output.
of necrotic areas cyanosis,
can be lethal. paresthesia,
diaphoresis and -Assess the effects of
peripheral pulse. medications on
6. Maintain myocardial
 hemodynamic contractility and
stability by function.
monitoring the
effects of beta-
blockers and -Prevent external
inotropic agents. stimuli that can
7. Provide comfort aggravate the
measure, safe and patient’s condition.
relaxing
environment.

S: “di ko na kaya, masyadong masakit ang dibdib ko”as verbalized by the pt.
O: received pt. On bed with ongoing D5LRS 1L@20 gtts/min
-conscious and coherent

-with o2 inhalation of 3-4L/hr.

-facial grimace noted

-with pain scale of=8 where 0 is rated as no pain and 10 as worst pain.

-with vital signs of:

T= 37.4 C

P= 115 bpm

R= 25 cpm

BP= 130/90 mmHg

A: After 2-3 hours of appropriate Nursing Intervention the patient will be able to improve cardiac output as
evidenced by normal cardiac rate, rhythm, and absence of chest pain.
P: After 2-3 hours of appropriate Nursing Intervention the patient will be able to improve cardiac output as
evidenced by normal cardiac rate, rhythm, and absence of chest pain.

I:
Nursing Intervention

1. Assessed mental status-be alert to restlessness and unresponsiveness.

2. Monitored lung sounds such as crackles and rhonchi.

3. Monitored blood pressure- watch out for hypertension and hypotension.

3. Monitored Urine output.

4. Assessed peripheral perfusion-such as pallor, mottling, cyanosis, paresthesia, diaphoresis and peripheral pulse.
5. Maintained hemodynamic stability by monitoring the effects of beta-blockers and inotropic agents.
6. Provided comfort measure, safe and relaxing environment.

7.

E: The patient verbalized a relief of pain.