NURSING

CARE

PLAN

Assessment

Nursing Diagnosis

Inference

Planning

Intervention

Rationale

Evaluation

SUBJECTIVE: The patient reports: y Pinot dughan ko kag lingin gd ulo ko. Chest pain, heaviness, or pressure that may radiate to the shoulders, arms, neck, jaw, or upper abdomen. Client rated pain as 6 in the scale of 1-10

Acute pain related to decreased myocardial blood flow.

OBJECTIVE: y y y Tachycardia Elevated blood pressure Jugular vein distention

Angina can result from any condition in which theres a decrease in oxygen delivery by the coronary arteries, an increase in cardiac workload, or an increase in the myocardiums oxygen requirements. The most common cause is atherosclerosis, but angina can result from aortic stenosis, mitral stenosis or insufficiency, hypotension, hyperthyroidism, anemia,

After 8 hours of nursing interventions and health teachings the patient will: y Remain free from pain Maintain stable vital signs. Maintain relaxed body posture.

Assess for vital signs and symptoms of pain such as facial grimacing, rubbing of neck or jaw, reluctance to move, increased blood pressure, and tachycardia. Note onset, duration, location, and pattern of pain. Use a pain rating scale to assess the patients perception of the pains severity. Administer sublingual nitroglycerin as ordered.

To differentiate angina pain from pain related to other causes.

To monitor the effectiveness of medications given for pain relief. To decrease myocardial oxygen demands through vasodilation, preload and after load reduction and

After 8 hours of nursing interventions and health teachings my patient was free from pain, maintains stable vital signs, and relaxed body posture. Able to verbalize, Medyo ng mayo na matyag ko ah. Salamat gd. Rated pain as 3 in the scale of 110.

Cool, clammy skin

ventricular arrhythmias, or hypertension y Instruct the y patient to notify a nurse immediately when experiencing pain. Have the patient stop current activity, and place him on y bed rest in a semito high Fowlers position. Administer oxygen as ordered. y

V/S as taken: T 36.3C P 88 beats/min. R 18 cycles/min. BP 120/60 mmHg

decreased cardiac work load. To minimize ischemia produced by increased myocardial work load.

To provide optimal oxygenation to the myocardium. To document ischemic changes. To decrease anxiety and promote comfort

y y Obtain a 12-lead ECG immediately during acute chest pain. Stay with the patient during chest pain episodes.