Planning/Implementation/Evaluation

Med/Surg Nursing Diagnosis: Ineffective Cardiac Tissue Perfusion r/t occlusion of coronary artery aeb troponin of 0.77 and
abnormal ECG
Long-Term Goal: Pt will have adequate myocardial tissue perfusion
Outcome
Criteria
One outcome criteria
for each intervention.
Number each one.

Interventions
Label each as
assess/monitor/independent/
dependent/teaching/collaboration

1.Pt.s VS will
trend toward the
following:
BP <140/90 but
>90/50
Temp 97.6-100.4
F
Pulse 60-100
bpm reg
RR 12-20
breaths/min
SpO2 95-100%
on RA when
assessed q 4hrs
and PRN

1.Monitor VS q4 hrs and

PRN

2. Pt.s skin will

be pink, warm

2.Monitor skin color, temp

and moisture q 4hrs & PRN

Independent

Rationale
Answers why, how, what your interventions will help solve, prevent,
Or lesson the stated problem specific to each patient.

1. Monitoring VS q 4hrs. & PRN allows for comparison to

baseline vitals and allows for interventions to take place if
there is a change in health status. In response to the release
of norepinephrine and epinephrine, BP and HR may initially
be increased but can drop later if CO is compromised. HR is
often increased secondary to SNS stimulation and BP is
increased because of peripheral arterial vasoconstriction
resulting from an adrenergic response to pain and ventricular
dysfunction. Pain from myocardial ischemia causes increased
sympathetic stimulation, which increases oxygen demands
on the heart. Tachycardia and increased BP are seen during
pain and anxiety. Temperature may increase within the first
24 hrs of an MI up to 100.4 and last for as long as a week
due to the inflammatory process caused by myocardial
death. O2 sats should remain between 95-100% and if
necessary, supplemental O2 should be applied to maximize
amount of oxygen available to the myocardium. Pt did not
receive supplemental O2 as SpO2 was at 100% when
assessed. RR should remain between 12-20 bpm.
Increasing respirations can indicate patient is experiencing
pain or anxiety or that pt is SOB and respirations have
increased due to lack of circulating oxygen. An increase or
decrease in VS parameters warrants further investigation
into the cause, as early identification of ACS and intervention
will improve myocardial perfusion and reduce risk for acute
MI or death in pt.

2. Assess skin color, temp and moisture q 4hrs. to

detect changes from baseline. PT is non-verbal and has

Evaluation
Evaluate the patient
outcome, NOT the
intervention

1. Outcome partially
met
BP 172/110- 183/139
T 97.3-97.4 F
P 69-123
RR 20-41
SpO2 100% on RA

2. Outcome met

and dry when

assessed q 4 hrs.
& PRN

Independent

3. Pts troponin
will trend
towards <0.05
when resulted
per MD

3.Monitor serial cardiac

biomarkers when resulted
per MD order

Independent

4. Pt.s ECG will

show NSR when
assessed as
ordered by MD

4. Obtain 12 lead ECG as

ordered by MD

ECG changes and elevated troponin of 0.77 which is

indicative of AMI. SNS stimulation is a clinical
manifestation of MI and results in diaphoresis and
vasoconstriction of peripheral blood vessels. Skin may
be ashen, pale, cool and clammy to the touch.
Detecting a change from pink warm and dry skin to
cool, clammy and pale skin can be an indicator that the
myocardium is experiencing ischemia, which is causing
SNS stimulation and steps need to be taken to restore
blood flow and oxygenation to heart muscle to prevent
irreversible damage.
3. Troponin is a myocardial muscle protein that is released

Pt.s skin was pink,

warm and dry
throughout shift
Pt has hydrocephalus
and severe MR, SNS
may not react
appropriately.

3. Outcome not met

into circulation following damage to heart muscle. The

serum levels rise in a characteristic pattern over time with a
normal level <0.05. Levels are detectable within hours of
injury to myocardium, peak @ 24-48hrs and can be detected
up to 5-14 days after the event. Early identification of acute
coronary syndromes using troponins allows for quick
intervention to improve myocardial perfusion and decrease
permanent damage to heart muscle. Pt.s troponin was 0.77
and along with other data was suggestive of a NSTEMI.
Steps were taken, including medication protocols and
transfer to the cardiac cath. lab to provide treatment within
90 minutes to improve pt.s outcome.

4. A 12 lead ECG views the electrical activity of the heart

and provides information about the cardiac rate, rhythm and
conduction. An ECG can be used to identify myocardial
ischemia and infarction, rhythm & conduction disturbances,
chamber enlargement, electrolyte imbalances and effects of
drugs on patient. It can sometimes determine the location of
MI through electric conduction, if you can see where a lead is
not conducting.
ST- segment & T-wave changes help provide a definitive
diagnosis. UA and NSTEMI have similar ECG changes in
contrast to those seen with a STEMI. This pt. was
experiencing tachycardia, tachypnea, and elevated
troponins. An ECG was performed at 3 different times
throughout the evening due to above symptoms and the

4. Outcome not met.

Only first troponin able
to be drawn (result
0.77) in the series
before pt. was
transferred to cardiac
cath. lab at St.
Josephs Hospital

Dependent

5. Pt.s MAP will

trend towards
80-100 mmHg
when assessed q
4 hrs & PRN

5. Assess MAP q 4hrs. &

PRN

Independent

6. Pt. will remain

at baseline
mental status
when assessed q
4hrs. & PRN

6. Assess LOC q 4 hrs &

PRN

Independent

amount of artifact on ECGs. Pt has MR, in non-verbal and

was unable to follow directions and stay still for ECG. An
ECG is one of the essential tools in diagnosing chest pain,
and since this pt was unable to verbalize pain, the ECG
results were very important in the overall clinical picture of
the pt. and directing treatment. It was decided pt. was
having a NSTEMI and medication protocol and transfer to
cardiac cath. lab were initiated.

5. The MAP (mean arterial pressure) refers to the

average pressure within the arterial system that is felt
by the organs in the body. A MAP >60 mmHg is
needed to adequately perfuse and sustain the vital
organs (Lewis, p. 719), with the norm being between
80-100 mmHg. [ Formula is MAP = (SBP + 2 {DBP} ) /
3. ]
Pts MAP was trending up throughout shift from 130
mmHg to 154mmHg. MAP >110 can also pose
problems as the pressure is increasing in the arteries
and can lead to encephalopathy, intracranial or
subarachnoid hemorrhage, acute LV failure, MI, renal
failure, dissecting aortic aneurysm and retinopathy. For
this pt, the MAP of 130-154mmHg is significant as she
was showing S/S of having an acute MI and MAP
needed to be reduced by decreasing blood pressure. To
reduce threat to organ function and life. (Lewis p. 756)
6. Pt has severe MR is non-verbal and legally blind.
Although I am unable to assess A & O x3, pt. is conscious,
with eyes open, vocalizes and moves head back and forth
when hands on care is being performed, so she has a
baseline status to compare to. If pt. was no longer
responding with vocalizations, or head movement and eyes
were closed, this indicates a change in baseline which could
be due to altered cerebral tissue perfusion. Increasing
restless may be due to decrease O2 reaching the brain, from
an MI or even due to her seizure disorder and because pt is
non-verbal and cant voice complaints or changes in how she
feels, it is important to compare her LOC with her baseline,
so interventions can be taken to prevent further hypoxia.

5. Outcome not met

Last MAP was
154mmHg

6. Outcome met
Pt. remained at
baseline mental
status.

7. Pt will not have

S/S of worsening
myocardial
ischemia (change
in LOC,
dysrhythmias, skin
cool, clammy or
ashen) when
assessed after
administration of
aspirin as ordered
by MD
8. Pt. not have S/S
of worsening
myocardial
ischemia (change
in LOC,
dysrhythmia, skin
cool, clammy,
ashen) after
administration of
clopidogrel as
ordered by MD

7. Aspirin 325 mg tablet PO

STAT

9. Pt will have an
aPTT between
55-80 seconds
when assessed
as ordered by MD

9. Heparin (porcine) in 0.45%

10. Pt will have

10. Collaborate with MD for

Dependent

8. Clopidogrel 300 mg
tablet PO STAT

Dependent

NaCl (25,000unit/500mL)
parental SOLN IV titrate dose (1 X
500[25,000unit/500mL] per dose)
initial rate 12units/kg/hr Do not
exceed 1200 units per hour
aPPT adjustment
<40 60units/kg bolusX1
(5000units MAX) increase by
2units/kg/hr
55-80 therapeutic- no change
81-95 <by 2U/kg/hr
96 or higher hold infusion X1hr.
restart @ decreased rate by
3u/kg/hr (Dependent)

7. Aspirin decreases platelet aggregation and significantly

improves mortality and morbidity rates when used within
24hrs of onset of chest pain. Use of aspirin is a core
measure and treatment should start ASAP and not be
delayed. Pt is non-verbal with severe MR and unable to
indicate if chest pain is resolving or worsening. When MD
noticed changes in ECG along with elevated troponins,
increased BP, tachycardia and tachypnea a verbal order to
give aspirin now was ordered to decrease platelet
aggregation and prevent further extension of possible
thrombi, giving pt. chance to get to cardiac cath. lab without
symptoms progressing.
8. Clopidogrel is an antiplatelet agent, taken by mouth,
indicated in the reduction of atherosclerotic events (ie: MI)
by inhibiting platelet aggregation. It acts by irreversibly
inhibiting the binding of ATP to platelet receptors.
Clopidogrel 300 mg STAT is indicated in Acute Coronary
Syndrome and was ordered for this pt., along with aspirin
therapy and a Heparin drip, as data was pointing toward pt.
having NSTEMI. Antiplatelets are intended to reduce the
development or magnitude of MI when administered during
the acute phase of ACS. The combination of clopidogrel and
aspirin reduces the risk of recurrent myocardial infarction or
death by 20-30% (Mehta et al 2001; Yusuf et al 2001;
Steinhubl et al 2002). Prevents re-occlusion
9. Heparin is an anticoagulant used to treat various
thromboembolic disorders by potentiating the inhibitory
effect of antithrombin on factor Xa & thrombin. In higher
doses, as was used in this pt., heparin neutralizes thrombin,
preventing conversion of fibrinogen to fibrin preventing
thrombus formation and/or prevention of extension of the
existing thrombi. When IV heparin is administered for
NSTEMI, which is what DR believed she was having, an initial
bolus maximum amount of 5000units followed by a 12-15
unit/kg/hr infusion is recommended. The goal is to achieve
an APTT of 50-70 seconds and have increased perfusion to
myocardium decreasing irreversible damage.
(www.ncbi.nlm.nih.gov/pubmed/11382373)

10. Pt is non-verbal and unable to indicate pain in the

7. outcome not met

Pt was transferred just
minutes after receiving
aspirin so I was unable
to evaluate effects of
medication

8. Outcome not met

Pt was transferred just
minutes after receiving
clopidogrel so I was
unable to evaluate
effects of medication

9. Outcome not met

Pt was transferred
while heparin was
infusing. Unable to
assess aPTTT

10. Outcome not met

decreased pain
aeb decreased
RR, BP and HR
after
administration of
morphine sulfate
as ordered by MD
today

Morphine Sulfate IV order

STAT

Collaboration

11. Pt.s BP will

trend towards:
<140/90 but
>90/50 when
assessed after
administration of
amlodipine today

11. Amlodipine 2.5mg PO

once daily

12. Pt will have

new set of VS,
ECG and COBRA
form completed
for transfer to
cardiac cath lab
as ordered by MD

12. Anticipate transfer to

cardiac cath lab as ordered
by MD

Dependent

Independent

traditional sense. Pain assessment and relief is a priority

nursing intervention in the initial phase of ACS. Pt. had
abnormal ECG, elevated troponin, was tachypneic, had
tachycardia and an elevated BP with increased grunting and
vocalizations. If pt was suspected to be in acute phase of MI,
morphine would have a double benefit; it is an opioid
analgesic and though vasodilation. Morphine Sulfate acts as
an analgesic, but it also reduces the myocardial O2
consumption by decreasing workload of the heart and
decreases BP & HR. It can reduce anxiety & fear d/t its
sedative effects and by slowing HR. Pt is unable to
communicate and although she cant rate or describe her
CP, it should be addressed as it will only increase O2
demands, which can affect the already compromised
myocardium and induce further ischemia and extension of
infarct. Pain control is a priority and should not be
overlooked in this patient because of her MR and inability to
verbalize pain.
11. Amlodipine is a Calcium Channel Blocker used alone or
with other agents in the management of HTN & angina. It
inhibits the transport of calcium into myocardial cells,
resulting in inhibition of excitation resulting in systemic
vasodilation, decreased BP, decreased conductivity of the
heart, decreased demand for O2 and coronary vasodilation,
all of which will help pt if she having an acute MI. The
workload of the heart will be decreased and demand less O2,
while coronary arteries are dilating and receiving more blood
flow and oxygenation to myocardium.
12. Cardiac cath. Is done to primarily assess the extent and
severity of a coronary artery blockage. It measures
intracardiac pressures, O2 levels, CO & EF. Coronary arteries
are visualized with injection of contrast media & fluoroscopy;
the chambers are outlined & wall motion is observed. A
decision about medical management of pt. will be decided
per the outcome of the cardiac catheterization. Pt does not
have a legal guardian which could delay what treatment may
need to occur once cardiac cath is done as consent will come
through the surrogate court, but she is a full code, so
assessing her for a blockage that is resulting in an acute MI
is the medical course required to provide the best outcome

I did discuss with

primary nurse, but
there was so much
happening and then
the ambulance came
to transfer her to St.
Jos and the
opportunity was lost.

11. Outcome not met

BP trending up to
183/139 after
administration of
amlodipine.

12. Outcome met.

VS, ECG obtained and
COBRA form filled out
with Primary RN

13. Pt will have

NSR when
assessed on
telemetry as
ordered by MD
today

13. Collaborate with MD for

continuous cardiac
monitoring today

Collaboration

14. Pt.s SpO2

will be 95-100%
when assessed q
4 hrs and PRN

14. Administer O2 @ 2L/nc

to maintain SpO2 <92% on
RA

Dependent
15. Pt. will trend
towards 3.6-5.2
when assessed
after 4 doses of
Potassium
Chloride
10mEq/100mL
have been
infused today

15. Potassium Chloride 10

mEq/100mL IV piggyback q
2 hrs. X 4 doses today

Dependent

for MI and to restore perfusion to myocardium through

further treatment.
13. Telemetry monitors the cardiac pts HR and rhythm. It is
used for assessment of changes in patient condition. 3-5
electrodes are placed on the chest only and a portable unit is
carried by the pt or near the pt. This pt has elevated
troponins, abnormal ECG and the ECG are difficult to read
due to pt movement. Pt has MR and can not follow
directions to remain still and she is agitated by hands on
procedures/care. It may be easier to get a reading if the tele
electrodes remain on and she is allowed to relax and be
unstimulated and we would have a constant tool for
assessment of changes in HR and rhythm allowing for quick
intervention.
14. O2 sats should be 95-100% to maximize oxygen
availability to myocardium. Pt was maintaining SpO2 sats at
100% without supplemental O2. Due to pt.s severe MR
(nonverbal/blind) and increased agitation when tubes placed
(foley cath and NG tube pulled out by patient per reports in
pt HX) and the fact that her O2 was @ 100%, the primary
nurse did not want to further agitate her by putting NC on.
Pt.s lips were pink, skin was warm and dry and the
placement of nasal cannula may increase her anxiety, which
would increase pt O2 demand and could potentiate the
damage to myocardium.
15. Hypokalemia can result from abnormal losses of
potassium from a shift of K+ from ECF to ICF jor from a
deficient dietary K+ intake. The most common cause is from
abnormal losses from either the kineys or the GI tract.
Magnesium deficiency may contribute to the development of
potassium depletion. Low plasma magnesium stimulates
renin release and subsequent increased aldosterone levels,
which results in potassium excretion. Hypokalemia alters
the resting membrane potential and causes reduced
excitability in the cells, and can cause cardiac changes
including impaired repolarization, resulting from flattening of
T wave and eventually the appearance of a U wave. The
incidence of potentially lethal ventricular dysrhythmias is
increased in hypokalemia. Ptf with hypokalemia should have
cardiac monitoring to detect changes r/t potassium

13. Outcome not met

14. Outcome met

SpO2 maintained at
100% on RA

15. Outcome not met.

Pt only received 2 or
the 4 ordered doses of
KCL 10mEq/100mL and
K+ level was not
drawn again before pt
being transferred to
St. Jos.

imbalances. Pt had K+ of 3.1 and Mg or 1.5. Hypokalmia is

treated in this pt with a KCL run. Monitoring potassium
levels will allow for intervention with potassium supplements
to ensure cardiac function and decrease pt.s risk for a
cardiac event r/t hypokalemia.

Psychosocial Need (see data analysis sheet for clustered data to this nursing diagnosis).
Prioritized Psychosocial Nursing Diagnosis: Dx
Long-Term Goal: Goal
Outcome
Criteria
One outcome criteria
for each intervention.
Number each one.

Interventions
Label each as
assess/monitor/independent/
dependent/teaching/collaboration

1.

1.

2.
3.
4.

2.
3.
4.

Evaluation

Rationale

Evaluate the patient

outcome, NOT the
intervention

Answers why, how, what your interventions will help solve, prevent,
Or lesson the stated problem specific to each patient.

1. The boxes will stretch as you type, so don't worry

that they're small right now. They'll get bigger when
you put in your information and they'll be just as big as
they need to, and no bigger. :)
2.
3.
4.

1.

2.
3.
4.