NCP for ACS ST-elevation Myocardial Infarction PDF

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Summary

ACS ST-elevation Myocardial Infarction Nursing Care Plan...

Description

NURSING CARE PLAN Name of Student: _Henriette Jane L. De Leon Name of CI: Ms. Kaye Dee Rivera RN, MN

Section and Group number: __BN4A Area of Exposure: ICU

Assessment Cues

Subjective: Patient complained of pain in the chest area radiating at the left shoulder; Patient rated pain scale at 7/10; Patient Verbalized “nabudlayan ko mag ginhawa ms” Objective: Pain scale 7/10 Cardiac Monitor indicated heart rate at 100 bpm and blood pressure at 150/90 are elevated VS T 36.8 C P 100 bpm R 18 cpm BP 150/90 mmHg

Nursing Diagnosis

Acute Pain r/t tissue ischemia aeb reports of chest pain with radiation

(Rationale) Pathophysiologic / Schematic Diagram

Predisposing: 1. Family History of

Hypertension or any cardiovascular problems

After 8 hours of Nursing Intervention, the patient and significant other will be able to: Short term:

Nursing Intervention

INDEPENDENT: 1. Constantly monitor

and document any changes in BP or heart rate that may be related to the discomfort.

1. Verbalize

Definition: 2. Sex: Male

Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage (International Association for the Study of Pain); sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end and a duration of less than 6 months

Desired Outcome

3. Age: 53 years old

Precipitating:

relief/control of chest pain within appropriate time frame for administered medications.

1. Occupation:

Market Vendor 2. Display reduced 2. Diet: Unbalanced

diet; more on fatty, high sodium, and carbohydrates.

tension, relaxed manner, ease of movement.

3. Physiological,

psychological stress 4. Hypertension

Strength :

5. Lack of exercise

Able to move and perform ADL with support

6. Uncontrollable

2. Check about the

location, severity (using a 0-10 scale), duration, features (like an elephant in my chest), and radiation of the patient's discomfort. Patient should be helped to measure their suffering by comparing it to other experiences.

3. Demonstrate use

Patient’s guardian is his Wife

Source/Reference NANDA

Weight gain

Inflammation in the coronary arteries

of relaxation techniques.

3. Do deep breathing and

distraction activities with the patient. Use guided imagery to help the patient

Justification

INDEPENDENT 1. The look and behavior

of individuals in pain might be difficult to judge because of the wide range of appearances and behaviors. The majority of individuals with an acute MI seem unwell, preoccupied, and focused on their discomfort. Pain relief should be the first step in getting to know your patient. Stressinduced catecholamine release can raise heart rate and blood pressure.

Evaluation

After 8 hours of Nursing Intervention, the patient and significant other was able to: Short term: 1. Verbalize

relief. Patient was comfortable after medications was given after 15 mins. Patient verbalized “medyo okay na gawa akon dughan ms.” GOAL MET 2. Display

2. As pain is a subjective

sensation, it is up to the patient to characterize it. As a result, the success of therapy, as well as the resolution and progression of the condition, may be assessed more easily and accurately.

3. Effective in reducing

pain perception and

reduced tension. Patient was not able to clutch his heart much. His face is not grimacing anymore Patient was in semifowler’s position. GOAL MET

Assessment Cues

Nursing Diagnosis

(Rationale) Pathophysiologic / Schematic Diagram

Subjective: Patient verbalized “daw ka bug-at kis a sg lawas ko dalon”

Risk for Excess Fluid Volume r/t increased sodium or water retention

Predisposing: 1. Family History of

Hypertension or any cardiovascular problems

Definition:

Cardiac Monitor indicated heart rate at 100 bpm and blood pressure at 150/90 are elevated VS

Fluid Volume Excess (FVE), or hypervolemia, refers to an isotonic expansion of the ECF due to an increase in total body sodium content and an increase in total body water.

T 36.8 C P 100 bpm R 18 cpm BP 150/90 mmHg

After 8 hours of Nursing Intervention, the patient and significant other will be able to: Short-term: 1. Determine the

2. Sex: Male

Objective:

Desired Outcome

3. Age: 53 years old

importance of fluid balance in the system

1. Breath sounds should

be checked for crackles. Auscultate.

development of dependent edema. 3. Inspect I&O for a

drop in output and a focused look. Be sure to calculate the fluid balance.

Market Vendor 2. Diet: Unbalanced

diet; more on fatty, high sodium, and carbohydrates.

5. Maintain total fluid

intake at 2000 mL/24 hr within cardiovascular tolerance.

psychological stress

Intake: 1,170 cc Parenteral: 480 cc Oral 690 cc

6. Monitor potassium as

4. Hypertension

Source/Reference NANDA Nurselabs

indicated. 5. Lack of exercise

1. Symptoms of cardiac

decompensation, such as pulmonary edema, may be present.

Inflammation in the coronary arteries

1. Adapt to

DEPENDENT

After 8 hours of Nursing Intervention, the patient and significant other was able to: Short-term:

congestive heart failure or fluid volume excess. 3. Decreased cardiac

output results in impaired kidney perfusion, sodium and water retention, and reduced urine output.

weight reflect alterations in fluid balance.

1. Determine

importance of fluid balance. Patient verbalized “subong ko lang na bal an na law ay man kung indi parehos volume ang intake kag output ta gali ms” GOAL MET 2. Follow

5. Meets normal adult

body fluid requirements, but may require alteration or restriction in presence of cardiac decompensation. 6. Hypokalemia can

Long-term:

Evaluation

2. Suggests developing

6. Uncontrollable

Weight gain Observed that Output is less than the Input

INDEPENDENT

4. Sudden changes in

2. Follow

prescribed diet and medication given

Justification

2. Note if there is JVD,

4. Weigh daily.

1. Occupation:

3. Physiological,

Urine: 700cc x2

INDEPENDENT

Precipitating:

MIO:

Output: 700 cc

Nursing Intervention

limit effectiveness of therapy and can occur with use of potassium-depleting

prescribed diet and medication. Patient was able to plan his lifestyle change as early as now. Patient verbalized “sang una bi ms, kng mag baligya ko, puros parat...