WRITING NOTES

Myocardial infraction

No Diagnose NOC NIC

1. Decrease cardiac output After do the nurses treatment for 1. Cardiac care
related contractility 2x24 hours patients cardiac a. Perform a
output will be better with result comprehensive
DO: criteria are: appraisal of
1. The patiens has peripheral
a cyanosis 1. Cardiac pump effectiveness circulation,e.g :
2. The patiens has a. Systolic blood pressure check peripheral
a dyspnea b. Diastolic blood pressure pulse,edema,capilary
3. The patiens has c. Angina refill,color and
a odema temperature of
DS : 2. Circulation extremity
1. The patiens a. Pulse pressure b. Monitor vital sign
complains of b. Oxygen saturation frequently
nausea c. Fatique c. Monitor
2. The patiens d. Urine output cardiovascular status
complains of d. Document cardiac
anxiety dysrhytmias

2. Hemodynamic
regulation
a. Auscultate heart
sound
b. Monitor
intake/output, urin
output and patient
weight, as
appropriate
c. Monitor and
document heart rate,
rhythm and pulses
2 Acute pain related After do the nurses treatment for 1. Paint Management
factors biological injury 2x24 hours patients acute pain a. Perform a
agent (e.g. ischemia) will be better with result criteria comprehensive
are: assessment of pain
DO : 1. Pain Control to include location,
1. The patient has a. Recognizes pain onset characteristics,
a fatique b. Uses diary to monitor onset/duration,
2. The patient has symptoms over time frequency, quality,
a dizziness c. Uses analgesics as intensity or severity
3. The patient has recommended of pain, and
a wince 2. Pain Level precipitating
DS : a. Reported pain factors
1. The patient b. Length of pain episodes b. Provide
complains of c. Facial expressins of information about
 pain pain the pain, such as
2. The patient courses of the pain,
complains of 3. Vital Signs and anticipated
worried of the a. Apical heart rate discomforts from
disease b. Radial pulse rate procedures
c. Systolic blood pressure c. Control
d. Diastolic blood pressure environmental
factors that may
influence the
patients response to
discomfort (e.g.,
room temperature,
lighting, noise)

2. Analgesic
administration
a. Determine pain
location,
characteristics,
quality, and
severity before
medicating patient
b. Check medical
order for drug,
dose, and
frequency of
analgesic
prescribed
c. Check history for
drug allergies
3 Activity intolerance After do the nurses treatment for 1. Activity therapy
related factors 2x24 hours patients activity a. Assist patient to
imbalance between intolerance will be better with identify meaningful
oxygen supply / result criteria are: activities
demand b. Determin patients
1. Activity Tolerance commitment to
DO : a. Upper body strength increasing
1. The patient has b. Lower body strength frequency and or
a dyspnea c. Oxygen saturation with range of activity
2. The patient has activity c. Make environment
a pallor 2. Self Care : Activities of safe continuous
3. The patient has daily living (ADL) large muscle
a fatique a. Ease of performing movement, as
DS : activities of daily living indicated
1. The patient (ADL)
complains of b. Ability to speak with 2. Cardiac care
pain after do physical activity a. Monitor
activities c. Walking pace respiratory status
for symptoms of
3. Vital signs : heart failure
a. Pulse rate with activity b. Monitor vital signs
b. Respiratory rate with frequently
activity c. Monitor
c. Systolic blood pressure cardiovascular
with activity status
d. Diastolic blod pressure
with activity