Nursing Interventions Acute Pain for Myocardial Infarction

Myocardial infarction (MI) or acute myocardial infarction (AMI), commonly known as a heart attack, is the interruption of blood supply to a part of the heart, causing heart cells to die. This is most commonly due to occlusion (blockage) of a coronary artery following the rupture of a vulnerable atherosclerotic plaque, which is an unstable collection of lipids (fatty acids) and white blood cells (especially macrophages) in the wall of an artery. The resulting ischemia (restriction in blood supply) and oxygen shortage, if left untreated for a sufficient period of time, can cause damage or death (infarction) of heart muscle tissue (myocardium).
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Acute Pain

Definition: Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage (International Association for the Study of Pain); sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end and a duration of less than 6 months

Pain is a highly subjective state in which a variety of unpleasant sensations and a wide range of distressing factors may be experienced by the sufferer. Pain may be a symptom of injury or illness. Pain may also arise from emotional, psychological, cultural, or spiritual distress. Pain can be very difficult to explain, because it is unique to the individual; pain should be accepted as described by the sufferer. Pain assessment can be challenging, especially in elderly patients, where cognitive impairment and sensory-perceptual deficits are more common.

NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels

• Comfort Level
• Medication Response
• Pain Control

NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels

• Analgesic Administration
• Conscious Sedation
• Pain Management
• Patient-Controlled Analgesia Assistance

Expected Outcomes

• Patient verbalizes adequate relief of pain or ability to cope with incompletely relieved pain.

Nursing Intervention for Myocardial Infarction

• Observation of the characteristics, location, time, and the course of chest pain.
• Instruct the client to stop activity and rest during an attack.
• Help the client to do relaxation techniques, eg deep breathing, distraction behavior, visualization, or imagination guidance.
• Maintain oxygenation with bicanul example (2-4 lt / min)
• Monitor vital signs (pulse and blood pressure) every two hours.
• Collaboration with the health team in providing analgesic.

Pneumonia Nursing Diagnosis - Ineffective Airway Clearance and Impaired Gas Exchange

Pneumonia is an inflammation of the lung tissue affecting one or both sides of the chest that often occurs as a result of an infection. Infection can be caused by a lot of different micro-organisms – viruses (eg respiratory syncytial virus), bacteria, fungi (eg histoplasmosis) and parasites. In addition to infection, pneumonia can also be caused by corrosive chemicals breathed into the lungs or toxic smoke inhalation from a fire.

Rarely, pneumonia can result from you breathing in something that you are allergic to. This may be related to a hobby or to your employment. The medical term for pneumonia caused by an allergy is extrinsic allergic alveolitis. An example of this condition is farmer’s lung, caused by breathing in the dust from mouldy hay.

Pneumonia is still a common disease affecting around 1 per cent of the adult UK population each year. Many people die from it every year, most commonly women and especially people over the age of 70. The overall death rate due to pneumonia is currently 5 per cent, ie around 1 in 20 people contracting the condition die from it.

Half of all pneumonia cases are caused by bacteria. The bacteria, known as streptococcus pneumoniae is the main cause of the most typical pneumonia.

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Pneumonia Nursing Diagnosis - Ineffective Airway Clearance and Impaired Gas Exchange

Pneumonia Nursing Diagnosis :

1. Ineffective airway clearance related to tracheal bronchial inflammation, increased sputum production is characterized by:

• Changes in frequency, depth of breathing
• Abnormal breath sounds
• Dyspnea, cyanosis
• Effective or ineffective cough with / without sputum production.

Effective airway with the following criteria:

• Cough effective
• Breath of normal
• The sound of breathing clean
• Cyanosis

Nursing Interventions:

Assess the frequency / depth of breathing and chest movement
Rational: tachypnea, breathing shallow and asymmetrical chest movements frequently occur
because of discomfort.

Auscultation of lung area, record the time there's an area of ​​decreased airflow and breath sounds
Rational: decrease in blood flow occurred in the area of ​​consolidation with fluid.

Let the effective coughing techniques
Rational: cough is a natural cleaning mechanism for maintaining airway patent.

Sucking as indicated
Rational: stimulate coughing or clearing the airway of mechanical noise on the factors
unable to perform effectively because of cough or a decreased level of consciousness.

Give fluids at least
Rational: liquid (especially warm) mobilizing and removing secretions

Collaboration with physicians for drug delivery as indicated: mukolitik, ex.
Rational: a tool to reduce bronchial spasms with mobilization of secretions, analgesic given to improve the cough by decreasing the discomfort but should be used carefully, because it can reduce cough effort / suppress breathing.

2. Impaired gas exchange related to the oxygen-carrying blood disorder, characterized by impaired oxygen delivery:

• Dyspnea, cyanosis
• Tachycardia
• Nervous / mental changes
• Hypoxia

Nursing Intervention:
Assess the frequency / depth and ease of breathing
Rational: the manifestation of respiratory distress depends on the indication of the degree of lung involvement and general health status.

Observation of the color of skin, mucous membranes and nails. Note the presence of peripheral cyanosis (nail) or central cyanosis.
Rational: nails showed cyanosis vasoconstriction body's response to fever / chills, but cyanosis on the ears, mucous membranes and skin around the mouth indicate systemic hypoxemia.

Assess mental status.
Rational: nervous irritability, confusion and somnolence may indicate cerebral hypoxia or decreased oxygen.

Elevate the head and thrust frequently change position, breathe deeply and cough effectively.
Rationale: This action increases the maximum inspiration, increased spending secretions to improve ventilation ineffective.

Ineffective Airway Clearance related to Bronchiectasis

Ineffective Airway Clearance related to Sinusitis - Nursing Diagnosis and Interventions

Pneumonia Nursing Diagnosis - Ineffective Airway Clearance and Impaired Gas Exchange