Nursing care for Mr J evolved around his actual and potential problems. The actual problems were: an alteration in comfort (chest pain) related to myocardial ischemia, decreased cardiac output related to reperfusion dysrhythmias, and knowledge deficit regarding treatment with thrombolytic therapy. The potential problems were: fluid volume deficit related to lysis of clots in the cerebral vasculature, and alteration in myocardial tissue perfusion related to reocclusion of the coronary artery. Objectives focused on relief of chest pain, prompt initiation of thrombolytic therapy, maintenance of hemodynamics and cardiac output with early interventions, prevention of bleeding and initiation of patient education.

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