Risk for Decreased cardiac output and Acute Pain - NCP for Acute Myocardial Infarction

Nursing Care Plan for Acute Myocardial Infarction

Nursing Diagnosis : Acute Pain related to tissue ischemia secondary to arterial occlusion,
characterized by:

• chest pain with / without deployment
• facial grimacing
• restless
• delirium
• changes in pulse, blood pressure.

Goal:

• Pain decreased after treatment measures.

Expected outcomes:

• Chest pain is reduced, for example, from a scale of 3 to 2, or from 2 to 1.
• Facial expression relaxed / calm, not tense.
• Not restless.
• Pulse: 60-100 x / minute.
• Blood pressure: 120/80 mm Hg.

Intervention:

• Observation characteristics, location, time, and travel is chest pain.
• Instruct the client to stop activity and rest during an attack.
• Help clients do relaxation techniques, such as deep breathing, behavioral distraction, visualization or guided imagery.
• Maintain oxygenation with bi cannula, for example (2-4 L / min).
• Monitor vital signs (pulse and blood pressure) every two hours.
• Collaboration with the health care team in providing analgesic.

Nursing Diagnosis : Risk for Decreased cardiac output related to changes in factors of electricity, decreased myocardial characteristics.

Goal:

• Improved cardiac output / stable after the act of nursing.

Expected outcomes:

• No edema.
• No dysrhythmias.
• Normal urine output.
• Vital signs within normal limits.

Iintervention:

• Maintain bed rest during the acute phase.
• Assess and report any signs of decreased cardiac output, blood pressure.
• Monitor urine output.
• Assess and monitor vital signs every hour.
• Assess and monitor EKG every day.
• Give oxygen as needed.
• Respiratory and cardiac auscultation every hour as indicated.
• Maintain parenteral fluids and medications appropriate advice.
• Provide appropriate food diet.
• Avoid Valsalva maneuver, straining.