Impaired tissue profusion related to tissue ischemia secondary to coronary artery occlusion as evidenced by patient report of chest

pain, EKG readings, restlessness

Acute Pain secondary to tissue ischemia (coronary artery occlusion)

Nursing Interventions

Rationale

Monitor and document characteristic of

pain, noting verbal reports, nonverbal cues
(moaning, crying, grimacing, restlessness,
diaphoresis, clutching of chest) and BP or
heart rate changes.

Variation of appearance and behavior of patients in

pain may present a challenge in assessment. Most
patients with an acute MI appear ill, distracted, and
focused on pain. Verbal history and deeper
investigation of precipitating factors should be
postponed until pain is relieved. Respirations may be
increased as a result of pain and associated anxiety;
release of stress-induced catecholamines increases
heart rate and BP.

Obtain full description of pain from patient

including location, intensity (using scale of
010), duration, characteristics
(dull, crushing, described as like an
elephant in my chest), and radiation.

Pain is a subjective experience and must be described

by patient. Provides baseline for comparison to aid in
determining effectiveness of therapy, resolution and
progression of problem.

Assist patient to quantify pain by

comparing it to other experiences.
Instruct patient to report pain immediately.
Provide quiet environment, calm activities,
and comfort measures. Approach patient
calmly and confidently.
Instruct patient to do relaxation
techniques: deep and slow breathing,
distraction behaviors, visualization, guided
imagery. Assist as needed.

Decreases external stimuli, which may aggravate

anxiety and cardiac strain, limit coping abilities and
adjustment to current situation.
Helpful in decreasing perception and response to
pain. Provides a sense of having some control over
the situation, increase in positive attitude.

Check vital signs before and after narcotic

medication.

Hypotension and respiratory depression can occur as

a result of narcotic administration. These problems
may increase myocardial damage in presence of
ventricular insufficiency.

Administer supplemental oxygen by

means of nasal cannula or face mask, as
indicated.

Increases amount of oxygen available for myocardial

uptake and thereby may relieve discomfort associated
with tissue ischemia.

Administer medications as indicated:

Antianginals: nitroglycerin (Nitro-Bid,
Nitrostat, Nitro-Dur), isosorbide dinitrate
(Isordil), mononitrate (Imdur)

Nitrates are useful for pain control by coronary

vasodilating effects, which increase coronary blood
flow and myocardial perfusion. Peripheral
vasodilation effects reduce the volume of blood
returning to the heart (preload), thereby decreasing

myocardial workload and oxygen demand.

Beta-blockers: atenolol (Tenormin),
pindolol(Visken), propranolol (Inderal),
nadolol (Corgard), metoprolol (Lopressor)

Analgesics: morphine, meperidine

(Demerol)

Important second-line agents for pain control through

effect of blocking sympathetic stimulation, thereby
reducing heart rate, systolic BP, and myocardial
oxygen demand.May be given alone or with
nitrates. Note: beta-blockers may be contraindicated
if myocardial contractility is severely impaired,
because negative inotropic properties can further
reduce contractility.
Although intravenous (IV) morphine is the usual drug
of choice, other injectable narcotics may be used in
acute-phase and/or recurrent chest pain unrelieved by
nitroglycerin to reduce severe pain, provide sedation,
and decrease myocardial workload. IM injections
should be avoided, if possible, because they can alter
the CPK diagnostic indicator and are not well
absorbed in underperfused tissue.