- Acute Pain Related to Blockage of coronary arteries and low or no oxygen-rich blood flowing to the heart as evidenced by Verbal reports of chest pain, pressure, or tightness and laboured breathing and dyspnoea
- Anxiety related to threat of death and lifestyle modification as evidenced by fearful attitude and expressed concerns or uncertainty
- Decreased Cardiac Output related to Changes in heart rate and electrical conduction and altered muscle contractility as evidenced by sudden and continuous chest pain unrelieved by rest and medication and Dysrhythmia
| Assessment | Nursing Diagnosis | Planning/Outcomes | Intervention | Evaluation |
| Subjective data: -Verbal reports from the patient -Expressions of pain, such as crying -Unpleasant feeling (such as a prick, burn, or ache) Objective data: -Significant changes in vital signs -Changes in appetite or eating patterns -Changes in sleep patterns -Guarding or protective behaviours | Acute Pain Related to Blockage of coronary arteries and low or no oxygen-rich blood flowing to the heart as evidenced by Verbal reports of chest pain, pressure, or tightness and laboured breathing and dyspnoea | Patient will verbalize pain relief or control. Patient will rate the chest pain lower than the baseline pain scale. Patient will appear relaxed and able to sleep or rest appropriately. Patient will be able to perform daily activities without assistance. | 1. Administer nitro-glycerine. When chest pain initially appears in an adult, one tablet of nitro-glycerine should be placed under the tongue or in the space between the cheek and gum. Nitro-glycerine dilates blood vessels. 2. Administer oxygen as ordered. Chest pain can happen when the demand for oxygen is not being met. Supplemental oxygen administration will improve the oxygenation for the heart to function effectively. 3. Administer morphine. Morphine may decrease the oxygen demand of the heart. It can also reduce blood pressure and slow the heart rate. Morphine will relax the patient and relieve anxiety. 4. Evaluate the effectiveness of pain control measures. Frequently assess administered pain control measures for effectiveness | Patient verbalized pain relief or control. Patient rated the chest pain lower than the baseline pain scale. Patient appeared to be relaxed and able to sleep or rest appropriately. Patient performed daily activities without assistance. |
| Subjective data: -Feeling nervous -Verbalizing a sense of impending danger -Difficulty controlling one’s worrying Objective data: -Restlessness and tense appearance -Tachycardia -Tachypnoea -Hyperventilation -Trembling/tremors -Weakness or tiredness -Difficulty concentrating -Difficulty sleeping | Anxiety related to threat of death and lifestyle modification as evidenced by fearful attitude and expressed concerns or uncertainty | Patient will be able to verbalize the cause of their anxiety. Patient will verbalize an understanding of the necessary changes following myocardial infarction. Patient will implement individual coping mechanisms. Patient will display signs of reduced anxiety such as vital signs within normal limits and a calm demeanour | 1. Recognize that the patient’s anxieties are valid. Encourage them to verbalize their feelings and assure them that they will not be judged because of it. With support, the patient is more likely to overcome this threat to their health. 2. Offer information and answer questions. The nurse should provide thorough explanations of tests, procedures, and interventions to alleviate the patient’s anxiety. Allow time for patients and families to ask questions and answer honestly. 3. Include the patient in the care planning process. Involve the patient in the care plan by allowing them to take time to prepare for scheduled treatments. Patient involvement may restore a patient’s sense of autonomy when coping with the treatment and recovery from MI. 4. Manage stress. Stress management will lower the risk of posttraumatic stress disorder (PTSD) following MI. PTSD is linked to decreased quality of life and increased risk of recurring MI. 5. Teach ways to reduce anxiety. In conjunction with the patient, uncover ways the patient can reduce anxiety such as through exercise, journaling, breathing, music, and medications. | Patient verbalized the cause of their anxiety. Patient verbalized about understanding the necessary changes following myocardial infarction. Patient implemented individual coping mechanisms. Patient displayed signs of reduced anxiety such as vital signs within normal limits and a calm demeanour |
| Subjective data: -Verbalizes difficulty in breathing -Chest Pain Objective data: -Shortness of breath -Nausea -Vomiting -Anxiety -Cool, pale, and moist skin -Tachycardia -Tachypnoea -Fatigue -Dizziness | Decreased Cardiac Output related to Changes in heart rate and electrical conduction and altered muscle contractility as evidenced by sudden and continuous chest pain unrelieved by rest and medication and Dysrhythmia | Patient will maintain blood pressure within acceptable limits set by the provider. Patient will be able to demonstrate decreased or absent dyspnoea, angina, and dysrhythmias. Patient will be able to verbalize an understanding of myocardial infarction and its management. Patient will be able to participate in activities that decrease the workload of the heart. | 1. Administer oxygen as ordered. Administer oxygen to increase perfusion to the heart and other tissues. 2. Administer thrombolytic therapy as ordered. If cardiac catheterization is not required immediately, administer thrombolytic therapy within the first 6 hours following the first symptom. Monitor for signs of bleeding. 3. Administer beta blockers as ordered. Beta-blockers are used to lower myocardial contraction force, promote myocardial perfusion, and slow the heart rate. 4. Establish IV access. IV access is used for the immediate administration of medication, IV fluids, and blood products. 5. Prepare for possible cardiac catheterization. Urgent cardiac catheterization evaluates the degree and location of coronary artery blockages. A stent may be placed to restore blood flow to myocardial tissue. 6. Encourage bed rest and activity restrictions. Bed rest lessens the workload, preventing inadequate perfusion and potential harm to the heart. Following a cardiac catheterization, the patient should be advised not to lift over 10 lbs or partake in strenuous activity. 7. Encourage cardiac rehabilitation. Cardiac rehabilitation teaches the patient about diet modifications, exercise, and recovery following MI to improve outcomes and prevent further cardiac complications. | Patient maintained blood pressure within acceptable limits set by the provider. Patient demonstrated decreased or absent dyspnoea, angina, and dysrhythmias. Patient verbalized about understanding myocardial infarction and its management. Patient participated in activities that decrease the workload of the heart. |