MYOCARDIAL INFARCTION NURSING DIAGNOSIS
- 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.
- Impaired tissue cardiopulmonary perfusion related to thrombus in coronary artery secondary to infarction.
- Impaired gas exchange related to decreased cardiac output secondary to MI as manifested by dyspnea
- Impaired nutrition less than body requirement related to dyspnea secondary to MI as manifested by anorexia
- Anxiety related to hospitalization secondary to MI as manifested by emotional behavior
- Knowledge deficit regarding disease process, prognosis, treatment and follow-up care
- 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
- verbalization of reduction in pain and presence of comfort
- 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
- verbalization of relief of pain and feeling of comfort,
- 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,
- normal breathing pattern
- Pulse: 78b/min
- 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,
- verbalization of improved appetite
- normal breathing pattern
- improved activity
- 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,
- verbalization of comfort,
- gain of knowledge on disease process and its prognosis effectively mingled with the family members
- 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,
- verbalization by the patient ,
- 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,
- improved activity
- vital signs stable following the activities
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