Care plan MI - care plan mi PDF

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Amanda Williams

Ms. Faust

Care Plan- Myocardial Infarction CARE PLAN

NANDA Nursing DX 1. Pain related to tissue ischemia as evidenced by patients’ complaints of chest pain.

2. Activity intolerance related to imbalance between myocardial oxygen supply and

Plan/ Goal 1. Patient will display verbalize control of chest pain during this shift.

2. Patient will demonstrate progressive

Interventions 1. Monitor characteristics of pain, noting verbal reports, non-verbal cues, and hemodynamic response. Variation of appearance and behavior of patients in pain may present a challenge in assessment (Ackley, 2017) 2. Obtain full description of pain from patient including location, intensity (0–10), duration, characteristics(dull/crushing), and radiation. Pain is a subjective experience and must be described by patient (Ackley, 2017). 3. Review history of previous angina, anginal equivalent, or MI pain. Discuss family history if pertinent. May differentiate current pain from preexisting patterns, as well as identify complications such as extension of infarction, pulmonary embolus, or pericarditis (Ackley, 2017). 4. Provide quiet environment, calm activities, and comfort measures (e.g., dry/wrinkle-free linens, backrub). Approach patient calmly and confidently. Decreases external stimuli, which may aggravate anxiety and cardiac strain, limit coping abilities and adjustment to current situation (Ackley, 2017). 5. Check vital signs before and after narcotic medication. Hypotension/respiratory depression can occur because of narcotic administration. These problems may increase myocardial damage in presence of ventricular insufficiency (Ackley, 2017).

Evaluation 6. Goal met. Patient verbalized control of pain during this shift.

1. Record/document heart rate and rhythm and BP changes before, during, and after activity, as indicated. Correlate with reports of chest pain/shortness of breath. Trends determine patient’s

7. Goal met. Patient demonstrated an increase in tolerance for

Amanda Williams demand as evidenced by alterations in heart rate and blood pressure with activity.

Ms. Faust

Care Plan- Myocardial Infarction

increase in tolerance for activity prior to discharge. 2.

3.

4.

5.

3. Anxiety related to change in health status as evidenced by increased tension and restlessness.

3. Patient will verbalize reduction in anxiety prior to discharge.

response to activity and may indicate myocardial oxygen deprivation that may require decrease in activity level/return to bedrest, changes in medication regimen, or use of supplemental oxygen (Ackley, 2017). Encourage rest (bed/chair) initially. Thereafter, limit activity on basis of pain/ adverse cardiac response. Provide nonstress diversional activities. Reduces myocardial workload/oxygen consumption, reducing risk of complications (Ackley, 2017). Instruct patient to avoid increasing abdominal pressure, e.g., straining during defecation. Activities that require holding the breath and bearing down (Valsalva maneuver) can result in bradycardia (temporarily reduced cardiac output) and rebound tachycardia with elevated BP (Ackley, 2017). Review signs/symptoms reflecting intolerance of present activity level or requiring notification of nurse/physician. Palpitations, pulse irregularities, development of chest pain, or dyspnea may indicate need for changes in exercise regimen or medication (Ackley, 2017). Refer to cardiac rehabilitation program. Provides continued support/additional supervision and participation in recovery and wellness process (Ackley, 2017).

1. Identify and acknowledge patient’s perception of threat/situation. Encourage expressions of, and do not deny feelings of, anger, grief, sadness, fear. Coping with the pain and emotional trauma of an MI is difficult. Patient may fear death and/or be anxious about immediate environment (Ackley, 2017). 2. Observe for verbal/nonverbal signs of anxiety, and

activity prior to discharge.

3. Goal met. Patient verbalized reduction in anxiety prior to discharge.

Amanda Williams

Ms. Faust

Care Plan- Myocardial Infarction stay with patient. Intervene if patient displays destructive behavior. Patient may not express concern directly, but words/actions may convey sense of agitation, aggression, and hostility. Intervention can help patient regain control of own behavior (Ackley, 2017). 3. Orient patient/SO to routine procedures and expected activities. Promote participation when possible. Predictability and information can decrease anxiety for patient (Ackley, 2017). 4. Encourage patient/SO to communicate with one another, sharing questions and concerns. Sharing information elicits support/comfort and can relieve tension of unexpressed worries (Ackley, 2017). 5. Encourage independence, self-care, and decision making within accepted treatment plan. Increased independence from staff promotes self-confidence and reduces feelings of abandonment that can accompany transfer from coronary unit/discharge from hospital (Ackley, 2017).

4. Risk for decreased cardiac out put related to infarcted muscle.

4. Patient will maintain hemodynamic stability during hospital stay.

1. Auscultate BP. Compare both arms and obtain lying, sitting, and standing pressures when able. Hypotension may occur related to ventricular dysfunction, hypoperfusion of the myocardium, and vagal stimulation. However, hypertension is also a common phenomenon, possibly related to pain, anxiety, catecholamine release, and/or preexisting vascular problems (Ackley, 2017). 2. Evaluate quality and equality of pulses, as indicated. Decreased cardiac output results in diminished weak/thready require pulses (Ackley, 2017). 3. Auscultate breath sounds. Crackles reflecting pulmonary congestion may develop because of depressed myocardial function (Ackley, 2017).

4. Goal met. Patient maintained hemodynamic stability during hospital stay.

Amanda Williams

Ms. Faust

Care Plan- Myocardial Infarction 4. Note response to activity and promote rest appropriately. Overexertion increases oxygen consumption/demands and can compromise myocardial function (Ackley, 2017). 5. Administer supplemental oxygen, as indicated. Increases amount of oxygen available for myocardial uptake, reducing ischemia and resultant cellular irritation/dysrhythmias (Ackley, 2017).

Reference:

Amanda Williams

Ms. Faust

Care Plan- Myocardial Infarction

Ackley, B.J.; Ladwig, G.B., & Makie, M. (2017). Nursing diagnosis handbook: An evidence-based guide to planning care (11th ed). St. Louis, MO: Elsevier....