Goal: Chest pain is lost or controlled
- Patients are able to demonstrate the use of relaxation techniques.
- Patients showed reduced tension, relaxed and easy to move.
Nursing Interventions and Rational - Nursing Care Plan for Acute Myocardial Infarction :
1. Monitor or record the characteristics of the pain, the report noted verbal, nonverbal cues, and the hemodynamic response (grimacing, crying, restlessness, sweating, clutching his chest, rapid breathing, blood pressure / heart frequency change).
Rationale : Variations in appearance and behavior occur as a patient because of pain assessment findings. Most patients with Acute Myocardial Infarction looks sick, distraction, and focus on the pain. History of verbal and deeper investigation of the precipitating factors should be postponed until the pain is gone. Breathing may be increased due to pain and senagai associated with anxiety, stress cause temporary loss of catecholamines increase heart rate and blood pressure.
2. Take a complete picture of the patient's pain including location, intensity (0-10), duration, quality (shallow / spread), and its spread.
Rationale : Pain as a subjective experience and should be described by the patient. Help the patient to assess pain by comparing it with other experiences.
3. Repeated observations, previous history of angina, pain resembling angina, myocardial infarction or acute pain. Discuss family history.
Rationale : to compare the existing pain from the previous pattern, according to widespread identification of complications such as infarction, pulmonary embolism, or pericarditis.
4. Instruct patient to report pain immediately.
Rational: Delay reporting pain, pain inhibiting circulation / require increased doses of the drug. In addition, severe pain can cause shock by stimulating the sympathetic nervous system, resulting in further damage and interfere with diagnostic and pain relief.
5. Help the patient relaxation techniques, eg, breathing in / slowly, behavioral distraction, visualization, imagination guidance.
Rationale : Helps in reducing perception / response to pain. Giving control of the situation, increase positive behavior.
6. Provide a quiet, slow activity, and comfortable action (eg, bed linen, dry / not folded, back rub). Approach calmly and with patient trust.
Rationale : Lowering external stimuli in which anxiety and heart strain and limited coping abilities and judgment of the current situation.
7. Check vital signs before and after the narcotic drug.
Rationale: Hypotension / respiratory depression can occur as a result of drug administration. This problem can increase the damage miokardia ventricular failure.