- Acute Pain related to rapid heart contraction and Abnormal electrical signals in the heart as evidenced by reports of chest pain, Palpitations and Excessive sweating
- Impaired Gas Exchange related to Inadequate gas exchange and Inability of the heart to relax properly as evidenced by dyspnoea and Nasal flaring
- Risk for Decreased Cardiac Output related to Cardiac tissue death and Abnormal electrical signals in the heart as evidenced by arrythmias and tachycardia
| Assessment | Nursing Diagnosis | Planning/Outcomes | Intervention | Evaluation |
| Subjective Data: -Verbal reports from the patient -Expressions of pain, such as crying -Unpleasant feeling Objective data: -Significant changes in vital signs -Changes in appetite or eating patterns -Changes in sleep patterns | Acute Pain related to rapid heart contraction and Abnormal electrical signals in the heart as evidenced by Reports of chest pain, Palpitations and Excessive sweating | Patient will verbalize relief from chest pain. Patient will display a calm and relaxed appearance. The patient will manifest a pulse rate within expected limits | 1. Promote a calming environment. Decrease unnecessary stimuli, which could exacerbate chest pain and anxiety. Offer a quiet space with dim lighting. 2. Administer pain medications as indicated. The heart rate can be slowed by medications to treat pain in tachycardia. Morphine can lessen the workload on the heart, slowing breathing and heart rate. 3. Ask the patient to perform vagal maneuvers. Instruct the patient to cough or bear down as if having a bowel movement. These actions stimulate the vagus nerve to slow the heart rate. 4. Provide oxygen as ordered. Chest pain in tachycardia often results from excessive heart contraction and reduced oxygenated blood supply. Providing supplemental oxygen ensures cardiac muscle relaxation and adequate cardiac oxygenation and reduces the risk of cardiac tissue death (ischemia). 5. Ensure adequate rest periods. Decrease the heart rate by reducing the workload of the heart. Rest periods in between activities will allow the relaxation of the heart muscles. If the patient is at risk for tachycardia due to other medical conditions, ensure activity is limited as tolerated. | Patient verbalized relief from chest pain. Patient displayed a calm and relaxed appearance. The patient manifested a pulse rate within expected limits |
| Subjective data: -Dyspnoea -Diaphoresis -Headaches Objective data: -Altered respiratory patterns -Cyanosis -Abnormal arterial blood gas values or blood pH -Increased heart rate -Decreased oxygen saturation | Impaired Gas Exchange related to Inadequate gas exchange and Inability of the heart to relax properly as evidenced by dyspnoea and Nasal flaring | Patient will demonstrate oxygen saturation and breathing pattern within normal limits. Patient will have no complaints of difficulty breathing, dizziness, or headache. | 1. Prevent postural tachycardia syndrome (PoTS). After standing or sitting up, a condition known as postural tachycardia syndrome (PoTS) or postural orthostatic tachycardia syndrome causes an abrupt increase in heart rate. Signs include dyspnea, fainting, dizziness, and sweating. It can be prevented by increasing water and sodium to increase blood volume, eating smaller meals, and participating in aerobic exercise. 2. Promote breathing techniques Teach the patient how to use therapeutic breathing techniques. Proper breathing boosts oxygenation and CO2 exchange. 3. Treat the underlying condition. The respiratory system can be responsible for non-cardiac pathologic aetiologies of tachycardia. The inability to absorb, transfer, or carry out gas exchange can lead to tachycardia. 4. Advise the patient when to seek medical help. If there is chest pain or discomfort, shortness of breath, light-headedness, or fainting, advise the patient to get emergency medical attention to prevent complications of tachycardia and impaired gas exchange. | Patient demonstrated oxygen saturation and breathing pattern within normal limits. Patient has no complaints of difficulty breathing, dizziness, or headache. |
| Subjective Data: Verbalizes about feeling increased heartbeat Objective Data: -Altered afterload -Increased heart rate -Impaired contractility -Irregular heart rhythm | Risk for Decreased Cardiac Output related to Cardiac tissue death and Abnormal electrical signals in the heart as evidenced by arrythmias and tachycardia | Patient will not experience an arrhythmia. Patient will remain free from any complications associated with decreased cardiac output. Patient will demonstrate lifestyle modifications to maintain cardiac output and prevent tachycardia. | 1. Obtain vital signs regularly. Tachycardia can affect the patient’s other vital signs, such as a drop in blood pressure. Inadequate perfusion to other organs can quickly result in a life-threatening emergency. 2. Implement ACLS. Advanced cardiovascular life support is training and skills nurses receive to care for patients in cardiac emergencies. This may include administering medications, airway management, and resuscitation. 3. Instruct on necessary testing. The patient may need an echocardiogram, stress testing, event recording, or other diagnostic tests to assess the cause of tachycardia. 4. Assist with cardioversion. The nurse may assist with cardioversion at the bedside or administer medications prior to cardioversion, which shocks the heart back into a normal rhythm. | Patient got relief from arrhythmia. Patient remained free from complications associated with decreased cardiac output. Patient demonstrated lifestyle modifications to maintain cardiac output and prevent tachycardia. |