NURSING

DIAGNOSIS

NURSING DIAGNOSIS
# 1 . C H E S T PA I N R E L AT E D T O D E C R E A S E D
B LO O D P E R F U S I O N T O M YO C A R D I U M
# 2 . S H O R T N E S S O F B R E AT H I N G R E L AT E D
T O A N I N A D E Q U AT E B L O O D S U P P LY
# 3 . A C T I V I T Y I N T O L E R A N C E R E L AT E D T O
I M B A L A N C E B E T W E E N M YO C A R D I A L
O X Y G E N S U P P LY A N D D E M A N D
# 4 . A N X I E T Y R E L AT E D T O A C U T E

M YO C A R D I A L I N FA R C T I O N

#1.Chest pain related to decrease blood perfusion to

myocardium

Objective: Chest pain relieve

Nursing Intervention

Outcomes

1. Assess & record description of pain

and response to intervention eg, using
wong baker scale 5-10 severity.
R: to know severity of chest pain

Patient had been assessed by using

numeric rating scale
Pain score : 3/10 at movement
0/10 at rest

2. Monitor vital sign

R: to detech early sign of complication

Blood pressure : 115/59 mmhg

temperature : 37.6
pulse: 79 bpm
respiration rate : 22 rpm
Pain score : 3/10 at movement
0/10 at rest

3. Maintain patient CRIB

R: to reduce myocardial oxygen
demand

Patient CRIB

Nursing Intervention

Outcomes

4. Administer oxygen therapy as

ordered eg, nasal prong 3-4l/min
R: to increase oxygen supply to
myocardium

Patient had given oxygen therapy

3l/min via nasal prong

5. Administer medication as perscribed

eg, aspirin or IV streptokinase
R: to increase coronary artery perfusion

Medication served as perscribed

6. Assess the effectiveness of drug after

hour.
R: to detect effectiveness of drug

Patient tolerate with the medication.

Patient dont have any allergies.

7. Avoid patient perform any heavy

workload
R: heavy workload can cause cardiac
workload

Patient CRIB

Nursing Intervention

Outcomes

8. Repeat any sign and symptoms of

decease in cardiac output eg, decrease
blood pressure, decrease urine output,
increase heart rate and clammy skin
R: to detect any early sign of chest pain

Blood pressure : 126/80 mmhg

temperature : 36.1
pulse: 82 bpm
respiration rate : 20 rpm
Pain score : 1/10 at movement
0/10 at rest

9. Plan nursing intervention wisely

R: to give time to patient rest

Nursing intervention planned according

to time

10. Place patient in conducive

environment eg, far from noise,limit
visitors
R: to enhance quality of rest

Avoid noise environment and visitor

restricted

Nursing evaluation : Patients pain score 0/10 while and resting.

#2. Shortness of breathe related to

inadequate of oxygen supply in blood
Objective : Patient can breathe spontaneously
Nursing Intervention

Outcomes

1. Assess general condition of patient

- skin color, patient appearance,
capillary refill.
R: to detect any abnormalities

Skin: no pale
Facial appearance: restless
Capillary refill : less than 3 second

2. Position patient to comfortable

position such as high fowlers
R: to increase lung expansion

Position patient was changed to high

fowlers

3. Administer oxygen therapy as

prescribed by doctor such as 3l via
nasal prong
R: to increase oxygen supply to
myocardium

Oxygen given 3l by nasal prong and

patient SPO2 is 100 %

Nursing Intervention

Outcomes

4. Monitor vital sigh for blood pressure,

heart rate, respiration rate
R: to detect any abnormalities of
decrease in cardiac output

Blood pressure : 120/79 mmhg

temperature : 37.0
pulse: 81 bpm
respiration rate : 20 rpm
Pain score : 1/10 at movement
0/10 at rest

5. Teach patient in breathing exercise

eg, deep breathing exercise
R: to increase lung expansion

Student nurse and physiotherapy had

given health education regarding deep
breathing exercise

Nursing intervention : Patient breathing normally.

#3. Activity intolerance related to imbalance

between myocardial oxygen supply and
demand.
Objective: Progression of patient increase gradually in
tolerance of activity.
Nursing Intervention

Outcomes

1. Monitor vital sign for heart rate and

rhythm and changes in blood pressure
before, during and after activity
R: determine patients response to
activity

Blood pressure : 126/85 mmhg

temperature : 36.9
pulse: 84 bpm
respiration rate : 20 rpm
Pain score : 1/10 at movement
0/10 at rest

2. Encourage patient to rest in bed

R: to reduce my0cardial workload and
avoid any complication

Patient rest in bed

Nursing Intervention

Outcomes

3. Limit patients activity such as do not

ambulate for few days
R: to reduce myocardial workload and
avoid any complication

Patient do not ambulate

4. Instruct patient to avoid increasing

abdominal pressure such as straining
during defecation
R: to reduce cardiac output and
rebound tachycardia with elevated
blood pressure

Patient on diapers and using urinal

5. Observe sign and symptoms

reflecting intolerance of present activity
level.
R: to detect the development of chest
pain or dyspnea may indicate for
changes in excersie regime

Patient does not show any sign and

symptoms reflecting intolerance of
present activity level.

Nursing Intervention

Outcomes

6. Refer to cardiac rehabilitation

Patient was seen by Madam Fuziah
program as planned by doctor
(occupational therapist)
R: to provide continuous support or
additional supervision and participation
in recovery process
Nursing intervention: Patient progression increasing