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Nursing Diagnosis for Coronary Artery Disease : Acute Pain related to a decrease in

myocardial blood flow, increased cardiac workload / oxygen consumption

Outcomes:

 Stating chest pain disappeared / controlled.


 Demonstrating the use of relaxation techniques.
 Showed reduced tension, relaxed, easy to move.

Interventions:

1. Monitor / record the characteristics of pain, note the verbal report, nonverbal cues, and the
hemodynamic response (grimacing, crying, restlessness, sweating, gripping his chest, rapid
breathing, BP / heart rate change).

Rational: Variations in the appearance and behavior of the patient as pain occurs as the
assessment findings. Most patients with acute myocardial infarction looks sick, distraction and
focus on the pain. Verbal history and education in the precipitating factors should be postponed
until the pain is gone. Breathing may be increased as a result of pain and is associated with
anxiety, stress cause temporary loss of catecholamines will increase the heart rate and BP.

2. Take full assessment of the patient's pain at the site; intensity (0-10); duration; quality
(shallow / spread) and deployment.

Rational : Pain as a subjective experience and should be described by the patient. Help the
patient to assess pain by comparing it with other experiences.

3. Review the history of previous angina, pain resembling angina, or myocardial infarction pain.
Discuss family history.

Rational : There can compare the pain of the previous pattern, according to widespread
identification of complications such as infarction, pulmonary embolism, or pericarditis.

4. Instruct the patient to report pain immediately.

Reporting delay distribution of pain inhibiting pain / need improvement. Doses of the drug. In
addition, severe pain can cause shock to stimulate the sympathetic nervous system, resulting in
further damage and interfere with diagnostic and pain relief.

5. Provide a quiet environment, the activity slowly, and the action comfortable. Approach calmly
and with patient trust.
Rational: Lowering external stimuli in which anxiety and heart strain and limited coping abilities
and judgment of the current situation.

6. Aids patients relaxation techniques, eg deep breathing / slow, behavioral distraction,


visualization, guided imagery.

Rational: Assist in the reduction in the perception / pain response. Giving control of the situation,
increase positive behavior.

7. Check vital signs before and after drug administration.

Rational: Hypotension / respiratory depression can occur as a result of drug administration. This
problem can increase the damage miokardia the presence of ventricular failure.

8. Provide supplemental oxygen by nasal cannula or mask as indicated.

Rational: Increase the amount of oxygen available for myocardial consumption and reduce
discomfort with respect to tissue ischemia.

Source : http://painnursingdiagnosis.blogspot.com/2014/04/acute-pain-nursing-care-plan-
for.html