This premade nursing care plan diagnosis, and interventions for the following conditions: Chest Pain, Myocardial Infarction, MI, Heart Attack, and Acute Pain
What are nursing care plans? How do you develop a nursing care plan? What nursing care plan book do you recommend helping you develop a nursing care plan?
This care plan is listed to give an example of how a Nurse (LPN or RN) may plan to treat a patient with those conditions.
Important Disclosure: Please keep in mind that these care plans are listed for Example/Educational purposes only, and some of these treatments may change over time. Do not treat a patient based on this care plan.
Care Plans are often developed in different formats. The formatting isn’t always important, and care plan formatting may vary among different nursing schools or medical jobs. Some hospitals may have the information displayed in digital format, or use pre-made templates. The most important part of the care plan is the content, as that is the foundation on which you will base your care.
Nursing Care Plan for: Chest Pain, Myocardial Infarction, MI, Heart Attack, and Acute Pain
If you want to view a video tutorial on how to construct a care plan in nursing school, please view the video below. Otherwise, scroll down to view this completed care plan.
Scenario: |
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A 55 year old male comes into the ER with complaints of 9 on 1-10 scale chest pain that radiates from breast bone to left arm and up to his jaw. Pt states it started 6 hours ago and he thought that he was having heart burn but it has got worse and he is now experiencing shortness of breath on the littlest activity. He states he father died of a heart attack 10 years ago. VS: HR 101, BP 186/101, O2 Sat 95% on RA, RR 22, and Temp 98.6. Pt is given Nitroglycerin 0.4mg Sublingual x 1 Tab, 2 mg of Morphine, and placed on 2 L nasal cannula. Lovenox 1mg/kg subq is order as well and this is given. 1st set of Troponins are 2.58. Cardiology is consulted and pt is kept NPO pending heart cath if order by cardiology. EKG shows slight ST elevation. Pt states his chest pain is now an 8 on 1-10 scale and states the pain is still there. It has been 5 minutes since his last Sublingual Nitroglycerin and BP 176/98 and HR 100 so you give the pt another sublingual nitroglycerin.
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Nursing Diagnosis: |
| Acute pain related to myocardial ischemia as evidence by patient rating pain 9 on 1-10 scale in chest, troponin levels 2.58, and, EKG ST elevation. |
Subjective Data: |
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A 55 year old male comes into the ER with complaints of 9 on 1-10 scale chest pain that radiates from breast bone to left arm and up to his jaw. Pt states it started 6 hours ago and he thought that he was having heart burn but it has got worse and he is now experiencing shortness of breath on the littlest activity. He states he father died of a heart attack 10 years ago. Pt states his chest pain is now an 8 on 1-10 scale and states the pain is still there.
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Objective Data: |
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VS: HR 101, BP 186/101, O2 Sat 95% on RA, RR 22, and Temp 98.6. Pt is given Nitroglycerin 0.4mg Sublingual x 1 Tab, 2 mg of Morphine, and placed on 2 L nasal cannula. Lovenox 1mg/kg subq is order as well and this is given. 1st set of Troponins are 2.58. Cardiology is consulted and pt is kept NPO pending heart cath if order by cardiology. EKG shows slight ST elevation. It has been 5 minutes since his last Sublingual Nitroglycerin and BP 176/98 and HR 100 so you give the pt another sublingual nitroglycerin.
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Nursing Outcomes: |
| -The patient will report a decrease in his chest pain by rating his chest pain less 3 on 1-10 scale.-Troponins levels will be drawn every 6 hours times 3 times and any abnormal values will be report to the Cardiologist immediately per md order.
-Pt will maintain Normal Sinus Rhythm during hospitalization. -Pt SBP will be greater than or equal to 110-130 and HR 60-100 during hospitalization. |
Nursing Interventions: |
| -Pt VS will be monitored every 30 minutes by the nurse.-Nurse will assess patient chest pain every hour and educate the patient on reporting an increase in chest discomfort to the nurse immediately.
-Troponins levels will be drawn at 0200, 0800, and 1400 per md order. -Nurse will obtain an EKG when patient reports chest pain level and report any ST elevation to the MD |