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.
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
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.