? Weak and pale in appearance ? Difficulty of breathing ? Poor skin turgor ? Clutching of hands to chest ? Shortness of breath ? Restlessness VITAL SIGNS: ? BP- 130/90 mmHg ? T- 37. 5 C ? PR- 98 BPM ? RR-25BPM ? PAIN SCALE- 8 | ? ACUTE PAIN RELATED TO MYOCARDIAL ISCHEMIA. |SHORT TERM GOAL: After 8 hours of nursing intervention: ? The patient will be able to verbalize relief from chest pain and difficulty of breathing ? The patient will be able to reduce anxiety regarding his condition.
LONG TERM GOAL: After 3 days of nursing intervention: ? The patient will report pain being absent or controlled with medication administration. ? The patient will have vital signs within normal parameters ? The patient will be able to verbalize information accurately regarding medications, diet, and activity limitations. ? The patient will be able to increase his energy to reduce body weakness ? The patient’s pale appearance and skin turgor will slowly return to it’s normal state. |INDEPENDENT:
? Evaluate chest pain as to type, location, severity, relief, change with activity or rest, other symptoms concurrently noted, such as pallor, diaphoresis, radiation of pain, nausea, vomiting, shortness of breath, and vital signs changes. ? Obtain description of pain intensity using 0-10. ? Obtain history of previous cardiac pain and familial history of cardiac problems. ? Administer oxygen by nasal cannula or mask as indicated. ? Maintain bed rest during pain, with position of comfort. ? Maintain relaxing environment to promote calmness.
? Instruct patient in relaxation techniques, deep breathing, guided imagery, visualization and so forth. ? Instruct patient in activity alterations and limitations. ? Instruct patient to notify the nurse immediately of any chest pain. DEPENDENT: ? Administer analgesic as ordered, such as morphine sulfate, meperidine(demerol), or dilaudid iv. ? Administer calcium channel blockers as ordered. ? Administer anxiolytics as ordered PRN. |AFTER 8 HOURS OF INTERVENTION, THE GOAL WAS PARTIALLY MET. ? The patient was able to show expression of absence of chest pain and breathing are of normal parameters. | |.