ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Acute (Chest) Pain r/t Short-term goal: INDEPENDENT: Short-term goal:
The client reports of chest pain myocardial ischemia resulting Within 1 hour of nursing 1. Assess characteristics of 1. Pain is indication of MI. Within 1 hour of nursing
radiating to the left arm and from coronary artery occlusion interventions, the client will chest pain, including location, Assisting the client in intervention, the client had
neck and back. with loss/restriction of blood have improved comfort in duration, quality, intensity, quantifying pain may improved comfort in chest, as
flow to an area of the chest, as evidenced by: presence of radiation, differentiate pre-existing and evidenced by:
Objective: myocardium and necrosis of • States a decrease in the precipitating and alleviating current pain patterns as well as • States a decrease in the
• Restlessness the myocardium. rating of the chest pain. factors, and as associated identify complications. rating of the chest pain.
• Facial grimacing • Is able to rest, displays symptoms, have client rate pain • Is able to rest, displays
• Fatigue reduced tension, and sleeps on a scale of 1-10 and reduced tension, and sleeps
• Peripheral cyanosis comfortably. document findings. comfortably.
• Weak pulse • Requires decrease analgesia • Requires decrease analgesia
• Cold and clammy skin or nitroglycerin. 2. Obtain history of previous 2. This provides information or nitroglycerin.
• Palpitations cardiac pain and familial history that may help to differentiate
• Shortness of breath of cardiac problems. current pain from previous Goal was met.
• Elevated temperature problems and complications.
• Pain scale of 8/10
3. Assess respirations, BP and 3. Respirations may be
heart rate with each episodes increased as a result of pain
of chest pain. and associate anxiety.

4. Maintain bed rest during 4. To reduce oxygen

pain, with position of comfort, consumption and demand, to
maintain relaxing environment reduce competing stimuli and
to promote calmness. reduces anxiety.

5. Prepare for the 5. Pain control is a priority, as it

administration of medications, indicates ischemia.
and monitor response to drug
therapy. Notify physician if pain
does not abate.

6. Instruct patient in 6. To decrease myocardial

nitroglycerin SL administration oxygen demand and work load
after hospitalization. Instruct on the heart.
patient inactivity alterations and
limitations.

7. Instruct patient/family in 7. To promote knowledge and

medication effects, side-effects, compliance with therapeutic
and contraindications and regimen and to alleviate fear of
symptoms to report. unknown.

DEPENDENT:
1. Obtain a 12-leadECG on 1. Serial ECG and stat ECGs
admission, then each time record changes that can give
chest pain recurs for evidence evidence of further cardiac
of further infarction as damage and location of MI.
prescribed.

2. Administer analgesics as 2. Morphine is the drug of

ordered, such as morphine choice to control MI pain, but
sulfate, meferidine or Dilaudid other analgesics maybe used to
N. reduce pain and reduce the
workload on the heart.

3. Administer beta-blockers as 3. To block sympathetic

ordered. stimulation, reduce heart rate
and lowers myocardial demand.

4. Administer calcium-channel 4. To increase coronary blood

blockers as ordered. flow and collateral circulation
that can decrease pain due to
ischemia.
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Activity Intolerance r/t cardiac Short-term goal: INDEPENDENT: Short-term goal:
The client reports of increased dysfunction, changes in oxygen Within 8 hours of nursing 1. Monitor heart rate, rhythm, 1. Changes in VS assist with Within 8hours of nursing
work of breathing associated supply and consumption as interventions, the client will be respirations and blood pressure monitoring physiologic interventions, the client
with feelings of weakness and evidenced by shortness of able to tolerate activity without for abnormalities. Notify responses to increase in tolerated activity without
tiredness. breath. excessive dyspnea and will be physician of significant changes activity. excessive dyspnea and had
able to utilize breathing in VS. been able to utilize breathing
Objective: techniques and energy techniques and energy
• Increased heart rate conservation techniques 2. Identify causative factors 2. Alleviation of factors that are conservation techniques
• Increased blood pressure effectively. leading to intolerance of known to create intolerance can effectively.
• Dyspnea with exertion activity. assist with development of an
• Pallor activity level program. Goal was met.
• Fatigue and weakness
• Decreased oxygen saturation 3. Encourage patient to assist 3. To help give the patient a
• Ischemic ECG changes with planning activities, with feeling of self-worth and well-
rest periods as necessary. being.

4. Instruct patient in energy 4. To decrease energy

conservation techniques. expenditure and fatigue.

5. Assist with active or passive 5. To maintain joint mobility and

ROM exercises at least QID. muscle tone.

6. Turn patient at least every 2 6. To improve respiratory

hours, and PRN. function and prevent skin
breakdown.

7. Instruct patient in isometric 7. To improve breathing and to

and breathing exercises. increase activity level.

8. Provide patient/family with 8. To promote self worth and

exercise regimen, with written involves patient and his family
instructions. with self-care.
DEPENDENT:
1. Assist patient with 1. To gradually increase the
ambulation, as ordered, with body to compensate for the
progressive increases as increase in overload.

patient’s tolerance permits.

 ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Deficient Knowledge r/t new Short-term goal: INDEPENDENT: Short-term goal:
The client verbalizes questions diagnosis and lack of The client will be able to 1. Monitor patient’s readiness 1. To promote optimal learning The client verbalized and
regarding problems and understanding of medical verbalize and demonstrate to learn and determine best environment when patient show demonstrated understanding of
misconceptions about his condition. understanding of information methods to use for teaching. willingness to learn. information given regarding
condition. given regarding condition, condition, medications, and
medications, and treatment 2. Provide time for individual 2. To establish trust. treatment regimen within 1 hour
Objective: regimen within 1 hour of interaction with patient. of nursing interventions.
• Lack of improvement of nursing interventions.
previous regimen. 3. Instruct patient on 3. To provide information to Goal was met.
• Inadequate follow-up on procedures that may be manage medication regimen
instructions given. performed. Instruct patient on and to ensure compliance.
• Anxiety medications, dose, effects, side
• Lack of understanding. effects, contraindications, and
signs/symptoms to report to
physician.

4. Instruct in dietary needs and 4. Client may need to increase

restrictions, such as limiting dietary potassium if placed on
sodium or increasing diuretics; sodium should be
potassium. limited because of the potential
for fluid retention.

5. Provide printed materials 5. To provide reference for the

when possible for patient/family patient and family to refer.
to reviews.

6. Have patient demonstrate all 6. To provide information that

skills that will be necessary for patient has gained a full
post discharge. understanding of instructions.

7. Instruct exercises to be 7. These are helpful in

performed, and to avoid improving cardiac function.
overtaxing activities.
DEPENDENT:
1. Refer patient to cardiac 1. To provide further
rehabilitation as ordered. improvement and rehabilitation
post discharge.