Name of patient: D.

G Age: 37 y/o, Male Diagnosis: STEMI

ASSESSMENT Subjective: Nagdagsen ti barukong ko , as verbalized by the patient. Pain scale of 6. ( 1-3- mild, 4-6 moderate, 7-10 severe ) Objective:

DIAGNOSIS

PLANNING STG: Within 1 hour of nursing interventions, the client will have improved comfort in chest, as evidenced by: States a decrease in the rating of the chest pain. Is able to rest, displays reduced tension, and sleeps comfortably

INTERVENTION

RATIONALE

EVALUATION

Acute (Chest) Pain r/t myocardial ischemia resulting from coronary artery occlusion with loss/restriction of blood flow to an area of the The patient myocardium and necrosis of the always turns myocardium. his body side to side.

Capillary refill of 5 seconds

O2 saturation of 90 % Vital signs

INDEPENDENT: STG: 1. assess 1. pain is Within 1 hour of characteristics of indication of nursing chest pain, MI. assisting the intervention, including location, client the client had duration, quality, in quantifying improved intensity, pain comfort in presence of may differentiate chest, as radiation, preevidenced precipitating and existing and by: alleviating factors, current and as associated pain patterns as States a symptoms, have well decrease in the client rate pain on as identify rating of the a scale of complications. chest pain Is 1-10 and 2. this provides able to rest, document information that displays findings in nurses may reduced notes. help to tension, and 2. obtain history of differentiate sleeps previous cardiac current pain from comfortably. pain and familial previous history of cardiac problems and Requires problems complications. decrease

Name of patient: D.G Age: 37 y/o, Male Diagnosis: STEMI

of: BP150/100mm Hg

RR-24bpm

PR- 60bpm Temperature - 38C

WBC- 16.4 CK-MB24.5 (+) Troponin I

Hgb- 113 ECG Changes:

3. assess 3. respirations analgesia or Requires respirations, may be nitroglycerin. decrease BP and heart rate increased as a Goal was met. analgesia with result LTG: or of pain and The client had an nitroglycerin each episodes of chest associate improved feeling of . pain. anxiety. control as LTG: 4. maintain bedrest 4. to reduce evidenced The client will during pain, with oxygen by verbalizing a have an position of consumption and sense of control improved feeling comfort, maintain demand, to reduce over of control as relaxing competing stimuli present situation evidenced by environment to and reduces and future verbalizing a sense promote calmness. anxiety. outcomes of control over 5. prepare for the 5.pain control is within 2 days of present priority, as it nursing situation and future administration of indicates intervention. outcomes within 2 medications, and monitor response ischemia Goal was met. days of nursing to interventions. drug therapy. Notify physician if pain does not abate 6. instruct patient/family in medication effects,

Name of patient: D.G Age: 37 y/o, Male Diagnosis: STEMI

Symmetric and peaked T wave, and atleast 1mm ST segment elevation.

side-effects, contraindications and symptoms to report. DEPENDENT: 1. obtain a 12-lead

ECG on admission, then each time chest pain recurs for evidence of further infarction as prescribed. 2. administer analgesics as ordered, such as morphine sulfate, meferidine of Dilaudid N 3. administer betablockers as ordered. 4. administer calciumchannel blockers as ordered

Name of patient: D.G Age: 37 y/o, Male Diagnosis: STEMI

INTERVENTION STG: INDEPENDENT: Subjective: Activity Within 3 days of 1. monitor heart rate, Jak kaya ti Intolerance r/t nursing interventions, rhythm, respirations aggaraw-garaw, cardiac the client will be able to and blood pressure for nalaka ak dysfunction, tolerate activity without abnormalities. Notify mabannug, as changes in excessive dyspnea and physician of verbalized by the oxygen will be able to utilize significant changes in patient. supply and breathing techniques VS. consumption and energy Objective: as evidenced conservation techniques 2. Identify causative by shortness effectively. factors leading to Vital signs of: of breath intolerance of activity. BP- 190/120 LTG: RR- 32bpm Within 5 days of 3. encourage patient to PR- 127bpm nursing interventions, assist with planning O2 sat- 89% the client will be able to activities, with rest Temp-38C increase and achieve periods as necessary. Lab results: desired activity level, 4. instruct patient in WBCprogressively, with no energy conservation 16.5 intolerance symptoms techniques. CKPMBnoted, such as 5. assist with active or 24.5 respiratory passive ROM Hgb-113 compromise. exercises at least QID. ( + ) Trop I

ASSESSMENT

DIAGNOSIS

PLANNING

RATIONALE 1.changes in VS assist with monitoring physiologic responses to increase in activity.

EVALUATION STG: Within 3 days of nursing interventions, the client tolerated activity without excessive dyspnea and had been able to 2. Alleviation of utilize breathing factors that are techniques and known to create energy intolerance can conservation assist with techniques development of an effectively. activity level Goal was met. program. 3. to help give the LTG: patient a feeling of Within 5 days self-worth and of nursing well-being. interventions, the client increased 4. to decrease and achieved energy desired activity

Name of patient: D.G Age: 37 y/o, Male Diagnosis: STEMI

Ischemic ECG changes: Inverted T wave , ST segment elevation.

6. turn patient at least expenditure and every 2 hours, and prn. fatigue.

level, progressively, with no 7. instruct patient in 5.to maintain joint intolerance isometric and mobility and symptoms noted, breathing exercises. muscle tone. such as respiratory 8. provide 6.to improve compromise. patient/family with respiratory Goal was met. exercise regimen, with function and written instructions. prevent skin breakdown. DEPENDENT: 1.Assisst patient with 7. to improve ambulation, as breathing and to ordered, with increase activity progressive increases level. as patients tolerance permits. 8. to promote selfworth and involves patient and his family with self-care.

Name of patient: D.G Age: 37 y/o, Male Diagnosis: STEMI

ASSESSMENT DIAGNOSIS Subjective: Deficient Jak maawatan nu Knowledge r/t kasatnu toy sakit new diagnosis and ko , as verbalized lack of by the patient. understanding of medical condition Objective: Patient always asking why he should have this kind of medication. Lack of improvement of previous regimen Inadequate follow-up on instructions given. Anxiety Lack of

PLANNING STG: The client will be able to verbalize and demonstrate understanding of information given regarding condition, medications, and treatment regimen within 3 days of nursing interventions.

INTERVENTION INDEPENDENT: 1. monitor patients readiness to learn and determine best methods to use for teaching. 2. provide time for individual interaction with patient. 3. instruct patient on procedures that may be performed. LTG: Instruct patient on The client will medications, dose, able to correctly effects, side perform all tasks effects, prior to discharge. contraindications, and signs/symptoms to report to physician. 4. instruct in

RATIONALE 1. to promote optimal learning environment when patient show willingness to learn. 2. to establish trust. 3. to provide information to manage medication regimen and to ensure compliance. 4. client may need to increase dietary potassium if placed on diuretics; sodium should be limited

EVALUATION STG: The client verbalized and demonstrated understanding of information given regarding condition, medications, and treatment regimen within 3 days of nursing interventions. Goal was met. LTG: The client had been able to correctly perform all tasks prior to discharge. Goal was met.

Name of patient: D.G Age: 37 y/o, Male Diagnosis: STEMI

understanding.

dietary needs and restrictions, such as limiting sodium or increasing potassium. 5. provide printed materials when possible for patient/family to reviews. 6. have patient demonstrate all skills that will be necessary for postdischarge. 7. instruct exercises to be performed, and to avoid overtaxing activities. DEPENDENT: 1. refer patient to
cardiac rehabilitation as ordered.

because of the potential for fluid retention. 5. to provide reference for the patient and family to refer. 6. to provide information that patient has gained a full understanding of instruction. 7. these are helpful in improving cardiac function. 1. to provide further improvement and rehabilitation postdischarge.

Name of patient: D.G Age: 37 y/o, Male Diagnosis: STEMI

ASSESSMENT Subjective: Nahihilo ako, as verbalized by the patient. Objective: Vital signs: PR - 85 bpm RR -30 bpm BP-160/100mmHg O2 sat: 90% Capillary refill: 5 seconds

DIAGNOSIS Ineffective tissue perfusion related to vasoconstriction of blood vessels.

PLANNING INTERVENTION After 4 hours Monitored blood of nursing pressure every intervention 4hours. the pt blood > Instructed to pressure will have enough rest decrease from on 160/ semi fowlers 100mmHg position. to > Instructed to eat 120/80mmHg low fat and low . salt diet. > Administered anti- hypertensive drug as ordered.

RATIONALE To know the base line of BP > Sodium tends to be excreted at a faster rate. > To reduce edema that may activate renin angiotensinaldoster one system. > To control the BP and to avoid other complications

EVALUATION After 4 hours of nursing intervention the patients blood pressure was decreased from 160/100mmHg to 140/90mmHg.