Student Nurses Community

NURSING CARE PLAN Myocardial Infarction

ASSESSMENT
Subjective:
The client reports
of chest pain
radiating to the left
arm and neck and
back.
Objective:
Restlessness
Facial
grimacing
Fatigue
Peripheral
cyanosis
Weak pulse
Cold and
clammy skin
Palpitations
Shortness of
breath
Elevated
temperature
Pain scale of
8/10

DIAGNOSIS

PLANNING

INTERVENTION

RATIONALE

EVALUATION

Acute (Chest)
Pain r/t
myocardial
ischemia
resulting from
coronary artery
occlusion with
loss/restriction
of blood flow to
an area of the
myocardium
and necrosis of
the
myocardium.

STG:
Within 1 hour
of nursing
interventions,
the client will
have improved
comfort in
chest, as
evidenced by:
States a
decrease in
the rating of
the chest
pain.
Is able to
rest, displays
reduced
tension, and
sleeps
comfortably.
Requires
decrease
analgesia or
nitroglycerin.

INDEPENDENT:
1. Assess
characteristics of
chest pain, including
location, duration,
quality, intensity,
presence of
radiation,
precipitating and
alleviating factors,
and as associated
symptoms, have
client rate pain on a
scale of 1-10 and
document findings
in nurses notes.

1. Pain is indication
of MI. assisting the
client in quantifying
pain may
differentiate preexisting and current
pain patterns as
well as identify
complications.

STG:
Within 1 hour of
nursing
intervention, the
client had
improved comfort
in chest, as
evidenced by:
States a
decrease in the
rating of the
chest pain.
Is able to rest,
displays reduced
tension, and
sleeps
comfortably.
Requires
decrease
analgesia or
nitroglycerin.
Goal was met.

LTG:
The client
will have an
improved
feeling of
control as

2. Obtain history of
previous cardiac
pain and familial
history of cardiac
problems.
3. Assess
respirations, BP and
heart rate with each
episodes of chest
pain.
4. Maintain bed rest
during pain, with

2. This provides
information that
may help to
differentiate current
pain from previous
problems and
complications.
3. Respirations may
be increased as a
result of pain and
associate anxiety.
4. To reduce oxygen
consumption and
demand, to reduce
competing stimuli
and reduces
anxiety.
5. Pain control is a

LTG:
The client had an
improved feeling
of control as
evidenced by
verbalizing a sense
of control over
present situation

Student Nurses Community

evidenced by
verbalizing a
sense of
control over
present
situation and
future
outcomes
within 2 days
of nursing
interventions.

position of comfort,
maintain relaxing
environment to
promote calmness.
5. Prepare for the
administration of
medications, and
monitor response to
drug therapy. Notify
physician if pain
does not abate.
6. istruct patient in
nitroglycerin SL
administration after
hospitalization.
Instruct patient in
activity alterations
and limitations.
7. Instruct
patient/family in
medication effects,
side-effects,
contraindications
and symptoms to
report.
DEPENDENT:
1. Obtain a 12-lead
ECG on admission,
then each time
chest pain recurs for
evidence of further
infarction as
prescribed.

priority, as it
indicates ischemia.
6. To decrease
myocardial oxygen
demand and
workload on the
heart.
7. To promote
knowledge and
compliance with
therapeutic regimen
and to alleviate fear
of unknown.
1. Serial ECG and
stat ECGs record
changes that can
give evidence of
further cardiac
damage and
location of MI.
2. Morphine is the
drug of choice to
control MI pain, but
other analgesics
may be used to
reduce pain and
reduce the
workload on the
heart.
3. To block
sympathetic
stimulation, reduce

and future
outcomes within 2
days of nursing
intervention.
Goal was met.

Student Nurses Community

2. Administer
analgesics as
ordered, such as
morphine sulfate,
meferidine of
Dilaudid N.
3. Administer betablockers as ordered.
4. Administer
calcium-channel
blockers as ordered.

heart rate and

lowers myocardial
demand.
4. To increase
coronary blood flow
and collateral
circulation which
can decrease pain
due to ischemia.

Student Nurses Community

ASSESSMENT

DIAGNOSIS

PLANNING

INTERVENTION

RATIONALE

EVALUATION

Subjective:
The client
reports of
increased work
of breathing
associated with
feelings of
weakness and
tiredness.

Activity
Intolerance
r/t cardiac
dysfunction,
changes in
oxygen
supply and
consumption
as evidenced
by shortness
of breath.

STG:
Within 3 days of
nursing
interventions, the
client will be able
to tolerate activity
without excessive
dyspnea and will
be able to utilize
breathing
techniques and
energy
conservation
techniques
effectively.

INDEPENDENT:
1. Monitor heart rate,
rhythm, respirations
and blood pressure for
abnormalities. Notify
physician of
significant changes in
VS.

1. Changes in VS assist
with monitoring
physiologic responses
to increase in activity.

STG:
Within 3 days of
nursing
interventions, the
client tolerated
activity without
excessive dyspnea
and had been able
to utilize breathing
techniques and
energy conservation
techniques
effectively.
Goal was met.

Objective:
Increased
heart
rate
Increased
blood
pressure
Dyspnea
with
exertion
Pallor
Fatigue and
weakness
Decreased
oxygen
saturatio
n
Ischemic
ECG
changes

LTG:
Within 5 days of
nursing
interventions, the
client will be able
to increase and
achieve desired
activity level,
progressively,
with no
intolerance
symptoms noted,
such as
respiratory
compromise.

2. Identify causative
factors leading to
intolerance of activity.
3. Encourage patient
to assist with planning
activities, with rest
periods as necessary.
4. Instruct patient in
energy conservation
techniques.
5. Assist with active
or passive ROM
exercises at least QID.
6. Turn patient at
least every 2 hours,
and prn.
7. Instruct patient in
isometric and
breathing exercises.

2. Alleviation of factors
that are known to
create intolerance can
assist with
development of an
activity level program.
3. to help give the
patient a feeling of selfworth and well-being.
4. To decrease energy
expenditure and
fatigue.
5. To maintain joint
mobility and muscle
tone.
6. To improve
respiratory function and
prevent skin
breakdown.
7. To improve breathing
and to increase activity
level.
8. To promote self-

LTG:
Within 5 days of
nursing
interventions, the
client increased and
achieved desired
activity level,
progressively, with
no intolerance
symptoms noted,
such as respiratory
compromise.
Goal was met.

Student Nurses Community

8. Provide
patient/family with
exercise regimen,
with written
instructions.

DEPENDENT:
1. Assisst patient with
ambulation, as
ordered, with
progressive increases
as patients tolerance
permits.

worth and involves

patient and his family
with self-care.
1. To gradually increase
the body to
compensate for the
increase in overload.

Student Nurses Community

ASSESSMENT

DIAGNOSIS

PLANNING

INTERVENTION

RATIONALE

EVALUATION

Student Nurses Community

Subjective:
The client
verbalizes
questions
regarding
problems and
misconceptions
about his
condition.
Objective:
Lack of
improvement
of previous
regimen
Inadequate
follow-up on
instructions
given.
Anxiety
Lack of
understanding.

Deficient
Knowledge r/t
new diagnosis
and lack of
understanding
of medical
condition.

STG:
The client will be
able to verbalize
and demonstrate
understanding of
information given
regarding
condition,
medications, and
treatment
regimen within 3
days of nursing
interventions.
LTG:
The client will
able to correctly
perform all tasks
prior to discharge.

INDEPENDENT:
1. Monitor patients
readiness to learn and
determine best
methods to use for
teaching.
2. Provide time for
individual interaction
with patient.
3. Instruct patient on
procedures that may
be performed.
Instruct patient on
medications, dose,
effects, side effects,
contraindications, and
signs/symptoms to
report to physician.
4. Instruct in dietary
needs and restrictions,
such as limiting sodium
or increasing
potassium.
5. Provide printed
materials when
possible for
patient/family to
reviews.
6. Have patient
demonstrate all skills
that will be necessary
for post discharge.
7. Instruct exercises to
be performed, and to
avoid overtaxing
activities.

1. To promote optimal
learning environment
when patient show
willingness to learn.
2. To establish trust.
3. To provide
information to
manage medication
regimen and to ensure
compliance.
4. Client may need to
increase dietary
potassium if placed on
diuretics; sodium
should be limited
because of the
potential for fluid
retention.
5. To provide
reference for the
patient and family to
refer.
6. To provide
information that
patient has gained a
full understanding of
instruction.
7. These are helpful in
improving cardiac
function.

STG:
The client verbalized
and demonstrated
understanding of
information given
regarding condition,
medications, and
treatment regimen
within 3 days of
nursing interventions.
Goal was met.
LTG:
The client had been
able to correctly
perform all tasks prior
to discharge.
Goal was met.

Student Nurses Community