A Nursing Care Plan for a Patient with Acute Myocardial Infarction

LAB INVESTIGATION Test Normal Value Patient Value Remarks T.F.F. 3.5-4.5 4.2 Normal K+ 3.5-4.5 4.2 Normal RBS <140 mg/dl 119 mg/dl Normal H.B. 12-16 mg/dl 11.5 mg/dl Normal TLC 4-18 mm >30000/cumm Increase DLC Экспортировать в Таблицы | - Lymphocytes | 22-45% | 35% | Normal | | - Monocytes | 2-8% | 3% | Normal | | - Eosinophils | 1-6% | 2% | Normal | | - Neutrophils | 40-75% | 72% | Normal | | Sodium | 135-145 mmol/L | 142 mmol/L | Normal | | Creatinine | 0.6-1.3 mg/dl | 0.95-0.5 | Normal | MEDICATION Trade Name Generic Name Dose Frequency Route Action Metolac-XR Betaloc 25 mg BD IV Beta-blocker Penicillin G-daban 1 gm BD IV Antibiotic Trybalean Clindamycin 600 mg BD IV Antibiotic Vancomycin Vancin 500 mg BD IV Antibiotic Voveran Justin 3 ml BD IV Analgesic Rantac Ranitidine 150 mg BD IV Antacid Tramadol Supridol 2 ml SOS IV Analgesic Экспортировать в Таблицы Nursing Care Plan Subjective Data: Chest pain Headache Nausea Sweating Fatigue Objective Data: ECG changes Sweating Discomfort Goals Short-term goals: To reduce pain in the chest and back To reduce restlessness To reduce anxiety levels To reduce the risk of infection Long-term goals: To maintain fluid and electrolyte balance To improve knowledge of patients Nursing Diagnosis Acute pain related to myocardial ischemia evidenced by patient rating scale on 1-10 scale in chest, troponin level 2-58, ECG ST elevation Ineffective cardiac tissue perfusion related to reduced coronary blood flow, coronary thrombosis as manifested by fatigue, dyspnea Risk of infection related to peripheral tissue perfusion related to decreased cardiac output manifested by fatigue Knowledge deficit related to self-care manifested by asking questions Altered sleep pattern related to pain manifested by observation Anxiety related to heart problems manifested by Nursing Diagnosis Acute pain related to myocardial ischemia evidenced by patient's chest pain Goal: To reduce chest pain Planning: Pain assessment, including chest pain location, duration, frequency, quality, and precipitation Check non-verbal relation of discomfort Give therapeutic communication to determine pain Implementation: Assess pain location, duration, frequency, quality, and precipitation Check facial expression relation of discomfort Use therapeutic communication techniques and analgesics Give comfortable position Rationale: To get baseline data To check perception of the patient To check level of pain For relieving pain For comfort Nursing Diagnosis Ineffective tissue perfusion related to reduced coronary blood flow manifested by fatigue, chest pain Goal: To reduce chest pain and fatigue Planning: Assess chest pain, discomfort, and location Implementation: Administer O2 as ordered Provide bed rest to the patient Obtain ECG recording to determine manifestation Auscultate the lungs sounds Rationale: To increase O2 supply To improve condition To determine the extent of disease To check lung condition Nursing Diagnosis Ineffective airway clearance related to accumulation of secretion and airway spasm Goal: To maintain airway patency Planning: Assess breathing pattern of the client Set the position to maximizing ventilation Teach breath therapy and cough efficacy Implementation: Breathing pattern is assessed. Position is maintained for proper ventilation. Educated the patient for cough Monitor vital signs Give bronchodilator as by order of doctor Rationale: To collect baseline data For easy breathing To help patient cough To reduce cardiac work To dilate bronchioles Nursing Diagnosis Altered sleeping pattern related to pain manifested by observation and insomnia Goal: To maintain sleeping pattern Planning: Assess the level of discomfort, intensity, location, and duration Implementation: Assess the level of discomfort Administer O2 as per prescription Environment modification that can reduce sleep disturbance Provide bed rest to the patient Provide sedation as per prescribed Rationale: To collect baseline data To maintain O2 level in body To improve sleep To maintain comfort To promote sleep Health Education Rest & Sleep Educate the patient about the importance of rest and adequate sleep to reduce discomfort and pain. Exercise Educate the patient about proper deep breathing exercises and coughing techniques. Educate the patient to do night exercises. Diet Educate the patient about the importance of a nutritional diet with small and frequent meals. Educate the patient about adequate fluid intake. Follow-up Educate the patient to take proper medicine and not to skip any medicine without the doctor's order. Educate the patient about the follow-up as per doctor's order and the OPD days of the doctor.