Nursing diagnoses

1. Acute pain associated with myocardial ischemia due to coronary artery

occlusion with loss or limited blood flow to the myocardium and necrosis of
the blood myocardium

Definition: an unpleasant, sensory and emotional experience that arises

due to actual or potential tissue damage or depicted in terms of
damage in such a way (International Association for the study of Pain) : onset
which is abrupt or slow from light to heavy intensity with the end that can
anticipated or predicted and lasts <6 months.

Characteristics Restrictions:
Changes in appetite, changes in blood pressure, changes in heart frequency,
changes in respiratory rate, gesture reports, diaphoresis, distraction behavior
(eg,walking around looking for other people and / or other activities, activities
that are repeated), expressing behavior (eg, restlessness, whining, crying),
masks faces (eg less glowing, chaotic eyes, diffuse or fixed eye movement
at a grimacing focus), the attitude of protecting the pain area, the focus
narrows (eg. pain perception disorder, constraint of thought process, decrease
interaction with people and environment), observable pain indications,
position changes for avoid pain, protective posture, pupil dilatation, reported
pain relief verbal, sleep disorders.

Related Factors: Injury agents (eg biological, chemical, physical,

psychological)

2. Decrease in cardiac output b.d negative initropic changes in the heart because
ischemia, injury, or infarction of the myocardium, evidenced by rate changes
awareness, weakness, puisng, loss of peripheral pulse, abnormal heart sound,
hemodynamic disorders, and pulmonary cardiac arrest.

Definition: The inadequacy of blood pumped by the heart to meet

metabolic needs of the body
Characteristics Restrictions: Changes in frequency / rhythm of the heart:
arrhythmias, bradycardia, tachycardia, ECG changes,
palpitations. Preload changes: decrease in central venous pressure (CVP),
decreased pulmonary artery wedge pressure (PAWP), edema,
fatigue, increased CVP, increased PAWP, jugular venous distention,
murmurs, weight gain
 Afterload changes: moist skin, decreased peripheral pulse, decreased
resistance pulmonary vascular resistance (PVR), decreased resistance
systemic (systemic vascular resistance, SVR), dyspnea, PVR enhancement, 12
SVR enhancement. Oliguria, elongated capillary filling, skin discoloration,
variations in blood pressure readings.

Changes in contractility: cough, crackle, decreased heart index, decrease in

fraction ejection, orthopnea, nocturnal paroximal dyspnea, decreased LVSWI
(left ventricular stroke work index), decreased stroke volume index (SVI), S3
sound, S4 sound Behavior / emotion: anxiety, anxiety

Related Factors:
Afterload changes, changes in contractility, changes in heart frequency,
preload changes, cadence changes, stroke volume changes

Nursing Intervention
a. Acute pain
Aim :
1. Shows pain control
2. Indicates the level of pain

Noc
1. Comfort Level: A positive perception level of physical convenience and
psychological
2. Pain control: Individual action to control pain
3. Pain level: Severity of pain that can be observed or reported
Criteria results
1. Show pain
2. Indicates the level of pain

NIC Intervention:
Nursing Activities Assessment
1. Use the patient's own report as the first choice to collect
assessment information.
2. Ask the patient to assess pain or discomfort on a scale of 0 to 10 (0
= no pain or discomfort, 10 = severe pain)
3. Use the pain chart to monitor pain relief by analgesic and
possible side effects.
4. Assess the impact of religion, culture, beliefs, and environment on pain and
patient response.
5. In assessing the pain of the patient, use words that match age and grade
patient development.
6. Pain Management (NIC):
Conduct a comprehensive pain assessment including location, characteristics,
onset and duration, frequency, quality, intensity or severity of pain, and factor
its precipitation. Observation of non verbal cues of discomfort, especially in
those who do not able to communicate effectively.
Collaborative Activities
1. Manage early postoperative pain with scheduled opiate administration (eg,
every 4 hours for 36 hours) or PCA
2. Pain Management (NIC): Use pain control before the pain becomes more
severe 16 Report to the doctor if the action is unsuccessful or if the complaint
is current is a significant change from past apsient pain experience.
Other Activities
1. Adjust the dose frequency as indicated by pain and effect assessment
side
2. Help the patient identify effective comfort measures in the past
such as, distraction, relaxation, or warm / cold compresses
3. Attend near the patient to meet the needs of comfort and other activities
to aid relaxation, includes the following actions:
Make position changes, back massage, and relaxation
Replace bed linen, when needed
Take care with no haste, with a supportive attitude
Involve the patient in decision-making concerning activities
care
4. Help the patient to focus more on the activity, not on the pain and the
sense of not
convenient by making diversions via television, radio, tape, and
interaction
with visitors
5. Use a positive approach to optimize the patient's response to
analgesics (eg "This medicine will reduce your pain")
6. Exploration of the fear of addiction. To persuade the patient, ask "if
no pain, do you still need this medicine? "
7. Pain Benefits (NIC):
Involve the patient in the modalities of pain relief, if possible
Take control of environmental factors that can affect the patient's response
to discomfort (eg room temperature, lighting, and noise)
 Ensure administration of therapeutic analgesia or nonpharmacologic
strategies before perform a painful procedure

b. Decrease in cardiac output b.d negative initropic changes in the heart because
ischemia, injury, or infarction of the myocardium, evidenced by rate changes
awareness, weakness, puisng, loss of peripheral pulse, abnormal heart sound,
hemodynamic disorders, and pulmonary cardiac arrest.

Aim :
1. Demonstrates a satisfactory cardiac output, evidenced by the effectiveness of the
pump
heart
.2. Shows the status of circulation, evidenced by the following indicator: interference
extreme weight, moderate, mild or uninterrupted
Noc
1. The severity of blood loss
2. Effectiveness of heart pump
3. Circulatory status
4. Perfusion of tissue: abdominal organs
5. Status of vital signs

Criteria results
1. Demonstrates satisfactory cardiac output, evidenced by effectiveness
heart pump, circulatory status, tissue perfusion (abdominal organs), and perfusion
network (peripheral)
2. Shows the status of circulation, evidenced by the emergency indicator.
NIC Intervention
1. Reduction of flush: limits the loss of blood volume during episodes
bleeding
2. Heart care: limits complications due to unbalance between
myocardial oxygen supply and needs in symptomatic patients
damage to heart function.
3. Heart care, acute: limiting complications for the patient being
experiencing episodes of imbalance between supply and oxygen demand
myocardium, which causes damage to heart function.
Promotion of cerebral perfusion: promotes adequate and limiting perfusion
complications for patients experiencing or at risk of experiencing an inability
cerebral perfusion.
5. Circulatory care: arterial insufficiency: improves arterial circulation.
6. Circulatory care: mechanical aids: provide temporary circulation support
through the use of mechanical devices or pumps.
7. Circulatory care: venous insuvisence: improves venous circulation
8. Treatment of the embolus: lung: limit the complications for patients who
experience, or at risk of blockage of the pulmonary circulation.
9.Hemodynamic regulation: optimizing heart frequency, preload afterload, and
contractility.

in general, nursing actions for this diagnosis focus on monitoring

vital signs and symptoms of decreased cardiac output, a study of causes
underlying mis, hypovolaemia, dysrhythmias, protocol or protocol program
to address the decrease in cardiac output, and the implementation of support
measures, such as position changes and hydration.
Assessment
1. Assess and document blood pressure, aanya sinosis, respiratory status, and
mental status.
2. Monitor signs of excess fluid (eg, dependent edema, severe cysts
body)
3. Assess tolerance of patient activity by observing the onset of breath
short, painful, palpitations or dizziness
4. Evaluate the patient's response to oxygen therapy
5. Assess cognitive impairment
6. Hemodynamic regulation (NIC):
7. Monitor pacemaker function if necessary
Peripheral pulsation, capillary refill, and temperature and color
ektsremitas
Monitor intake and output, urine output and patient weight if necessary
Monitor systemic and pulmonary vascular resistance, if necessary
Auscultation of lung sound to crackle sound or additional breath sounds
others Monitor and document heart, rhythm and pulse frequency
Counseling for patient / family
1. Explain the purpose of giving oxygen per nasal cannula or hood
2. Instruct the maintenance of the accuracy of intake and output
3. Teach the use, dosage, frequency, and side effects of drugs
 4. Teach to report and describe the onset of palpitations and pain,
duration, sparking factor, area, quality, and intensity
5.Instruct patient and family in planning for home care,
including limiting dietary restriction activities, and the use of therapeutic
devices
6. Provide information about stress reduction techniques, such as biofeedback,
progressive muscle relaxation, meditation and physical exercise
7.Teach the need to weigh everyday
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Collaborative activity
1. Consult a physician regarding the parameters of administration or
discontinuation of blood pressure medication
2.Give and titrate antiarrhythmic, inotropic, nitroglycerin, and fasodilator
drugs
to maintain contractility, preload and afterload in accordance with
medical program or protocol
3. Provide anti-coagulant to prevent peripheral thrombus formation, accordingly
with a program or protocol
4.Increase afterload decline (for example, with intra-aortic balloon pump)
in accordance with the medical / protocol program
5.Refer the nurse to the social worker, case manager, or service
community health and home health services
6. Refer to the social worker for skills evaluation
pay for prescription drugs
7. Refer to the heart rehab center if needed
Other activities
1. Change the client's position to a flat or trendelenburg position when blood
pressure
patients are in a lower range than the usual
2. For sudden, severe or prolonged hypotension, attach intravenous access to
administration of intravenous fluids or medications to increase blood pressure
3. Connect the effects of laboratory values, oxygen, drugs, activity, anxiety and /
or
pain in dysrhythmias
4. Do not measure the temperature of the rectum
 5. Change the patient's position every two hours or maintain other appropriate
activities
needed or needed to decrease the peripheral circulation stasis
6. Hemodynamic regulation (NIC)
7. Minimize or remove environmental stressors
Install the urine catheter, if necessary.

Implementation of Nursing
The documentation of the intervention is a record of the actions of the nurse.
The documentation of the intervention records the implementation, the maintenance
plan, the fulfillment of the criteria results and independent nursing actions and
collaborative actions. The implementation of nursing actions is tailored to the
intervention of each the above diagnosis.