Care plan for mycardial infraction @nursesoutlook

MYOCARDIAL INFARCTION   NURSING DIAGNOSIS

1. Pain related to myocardial infarction secondary to coronary artery occlusion with loss or restriction of blood flow to an area of the myocardium as manifested by restlessness, anxiety, irritability.


2. Impaired tissue cardiopulmonary perfusion related to thrombus in coronary artery secondary to infarction.


3. Impaired gas exchange related to decreased cardiac output secondary to MI as  manifested by dyspnea


4. Impaired nutrition less than body requirement related to dyspnea  secondary to MI as manifested by anorexia


5. Anxiety related to hospitalization secondary to MI as manifested by emotional behavior


6. Knowledge deficit regarding disease process, prognosis, treatment and follow-up care


7. Risk for activity intolerance related to imbalance between oxygen supply and oxygen demand secondary to MI as manifested by weakness

Acute Pain related to myocardial infarction secondary to coronary artery occlusion with loss or restriction of blood flow to an area of the myocardium as manifested by restlessness, anxiety, irritability.

• Give a comfortable position to the patients


• Assess the pain using numerical pain scale


• Identify and position in the most comfortable position.


• Provide comfort measures.


• Schedule care activities


• Administer medications as prescribed.


• Give diversional therapy.

Client has reduction in pain as evidenced by

1. verbalization of reduction in pain and presence of comfort


2. Vitals

• Pulse: 78 b/ min


• R.R: 22 br/ min


• SpO2: 95%-96%

Ineffective tissue perfusion (cardio-pulmonary) related to thrombus in coronary artery secondary to infarction.

• Assess the condition of the patient


• Keep the client on bed rest with a quiet environment.


• Administer oxygen as ordered


• Administer thrombolytic  as ordered


• monitor ECG

Client experienced relief from pain as evidenced by 

1. verbalization of relief of pain and feeling of comfort,


2. Vital signs:

•    Pulse: 78b/min


• B.P: 130/80


• R.R: 22 br/min


• SpO2: 95%-98% without oxygen

Impaired gas exchange related to decreased cardiac output secondary to MI

• Assess the sleeping pattern of the patient.


•  Provide a fowler's or high fowler's position


• Administer oxygen as ordered, maintain continuous oximetry


• Assess the client skin and capillary refill


• Encourage the patient to do deep breathing exercise


• Assess the respiratory status for dyspnea and crackles

The client experienced improved gas exchange process as evidenced by,

1. normal breathing pattern


2. Pulse: 78b/min


3. Respiratory rate-22 breaths/ min

Imbalanced nutrition less than body requirement related to dyspnea  secondary to MI

• Assess dietary habits, recent food habits.


• Note the degree of difficulty with eating


• Auscultate bowel sounds


• Avoid gas-producing food.


• Provide easily digestible, nutritionally balanced meals

Patient achieved and maintained adequate nutritional status as evidenced by,

1. verbalization of improved appetite


2. normal breathing pattern


3. improved activity


4. weight gain by kg

Anxiety related to anticipatory fear of death secondary to MI

• Assess the level of anxiety


• Provide quiet relaxed environment and limit visitors.


• Maintain good IPR with the patient


• Clarify all the doubts of patient


• Reassure the patient with encouraging words


• Explain the disease process, treatment, outcome etc

Client will demonstrate reduced anxiety level  as  evidenced by,

1. verbalization of comfort,


2. gain of knowledge on disease process and its prognosis effectively mingled with the family members


3. actively participated in all therapeutic regimen

Deficient Knowledge regarding disease process, prognosis, treatment and follow-up care

• Assess the knowledge  level of patient


• Instruct patient on medicine schedule and wound care


• Instruct patient on dietary restrictions


• Instruct regarding activity limitations


• Clarify all doubts of patient

Client gained adequate knowledge regarding the disease process as evidenced by,

1. verbalization by the patient ,


2. involved himself in diet planning along with   the nursing personnel

Risk for activity intolerance related to imbalance between oxygen supply and oxygen demand secondary to MI

• Monitor vital signs before and immediately after activity and 3 min later


• Monitor for tachycardia, dysrhythmias, diaphoresis, weakness, etc.


• Encourage verbalization of feelings


• Provide assistance with self-care activities and provide frequent rest periods especially after meals

Patient has increased activity intolerance as evidenced by,

1. improved activity


2. vital signs stable following the activities

Nursing Care Plan for Anemia

Nursing Care Plan for Anemia 

NURSING DIAGNOSIS  

• Imbalance in nutrition less than body requirements related to inadequate nutritional intake and anorexia


• Activity intolerance related to weakness and imbalance between oxygen supply and demand.


• Fatigue related to anorexia and less intake.


• Anxiety related to hospitalization and disease process.


• Ineffective therapeutic regimen management related to lack of knowledge about appropriate nutrition and medication regimen.


• Deficient Knowledge regarding management of anemia


• Risk for hypoxemia due to deficiency of RBCs related to anemia.


• Risk for injury related to weakness and fainting secondary to anemia

Nursing Care Plan for Anemia :- Nursing Diagnosis

Imbalance in nutrition; less than body requirement related to inadequate nutritional intake and loss of appetite

• Assess the present nutritional status and dietary pattern of the client.


• Teach the patient how to keep a food diary.


• Encourage increased intake of protein, iron and vitamin-C.


• Provide appropriate information about nutritional needs and how to meet them.


• Encourage to take small ad frequent diet.

Nursing Care Plan for Anemia - 2

Activity intolerance related to weakness and imbalance between O₂ supply and demand

• To assess the activity level of the client


• To encourage alternate rest and activity periods.


• To limit the number of visitors and environmental stimuli.


• To plan activities for periods when the patient has the most energy.


• To monitor the cardio respiratory response to activity.


• To assist the patient with the regular physical activities.

Nursing Care Plan for Anemia -3

Ineffective therapeutic regimen management related to lack of knowledge about appropriate nutrition and medication regimen

• To assess the eating behaviour and the patient’s knowledge about the nutritious diet.


• Discuss the nutritional requirements with the client


• Instruct the patient on the purpose and action of each medication


• Instruct to patient on dosage route and duration of action of each medication.


• Encourage clients involvement on treatment planning

Nursing Care Plan for Anemia -4

Fatigue related to imbalance in nutrition secondary to anorexia and less intake

• To assess the condition of the client


• To provide proper rest to the client


• To advice the patient to take nutritious diet.


• To administer I.V. fluids.


• To advice the client to take small and frequent diet.


• To assist the client in his daily activities.

Nursing Care Plan for Anemia -5

Risk for Hypoxaemia due to deficiency of RBCs related to anemia.

• To assess the condition of the patient.


• To check the RBC values and O₂ saturation of the client.


• To advice the client to stick to the medication regimen.


• To advice the client to take iron-rich food


• Administer oral iron supplement as advised by the consultant

Nursing Care Plan for Anemia -6

Risk for injury due to weakness and fainting related to anemia and presence of injury prone areas.

• To assess the condition of the client.


• To provide adequate rest to client.


• To advise the client to take iron- rich food.


• To provide assistance in daily living activities.


• To provide support to the client while walking.

Nursing Care Plan for Anemia -7

Anxiety related to hospitalization and disease process(anemia)

• Assess the signs of anxiety.


• Encourage verbalisation of feelings.


• Maintain good IPR with the client


• Provide psychological support.


• Explain all the procedures before doing.

Deficient knowledge- regarding management of anaemia.

• To assess the level of knowledge of the client.


• To listen to the doubts of the client.


• To answer all the questions appropriately.


• To educate the client about his disease condition, follow up care and treatment.