ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

Subjective: Independent:
After 2-3 ✔ Variation of
Pain related to hours of ✔ Monitor/document appearance After 2-3 hours
tissue nursing characteristics of and behavior of of nursing
Objective: pain, noting verbal interventions
ischemia interventions patients in pain
✔ Pallor (coronary) as the patient will may present a the patient was
reports, nonverbal able to
✔ Erratic behavior evidenced by be able to cues (e.g., moaning, challenge in
✔ Hypotension chest pain verbalize assessment. verbalize
crying, relief/control of
✔ Cardiac rhythm with or without relief/control of Most patients
changes radiation. chest pain restlessness, with chest pain
✔ Vomiting within diaphoresis, an acute MI within
✔ Fever appropriate clutching chest, appear ill, appropriate
✔ Diaphoresis time frame for rapid distracted, and time frame for
administered focused on administered
medications. breathing), and pain. medications.
hemodynamic Verbal history
Display response (BP/heart Display
and deeper reduced
reduced rate investigation of
tension, tension, relaxed
Changes). precipitating manner, ease
relaxed Factors should
manner, ease of movement.
be postponed
of movement. until pain is
relieved.
Respirations
may be
increased as a
result of pain
and
associated
 anxiety;
release of
stress-induced
catecholamines
increases heart
rate and BP.
✔ Pain is a
subjective
experience and
must be
described
by
patient.
Provides
baseline for
comparison to
aid in
determining
effectiveness of
therapy,
resolution/
Progression of
problem.
✔ Obtain full ✔ May
description differentiate
of pain from current pain
patient from
including preexisting
location, intensity patterns,
(0–10), duration, as well as
 characteristics identify
(dull/crushing) complications
, and radiation. such as
Assist patient extension of
to quantify pain Infarction,
by comparing pulmonary
it to other embolus, or
experiences. pericarditis.
✔ Delay in
reporting pain
✔ Review history of hinders pain
previous angina, relief/may
angina equivalent, require
or increased
MI pain. Discuss dosage of
family history if medication to
pertinent. achieve relief.
In
addition,
severe pain
may induce
shock by
stimulating the
sympathetic
nervous
✔ Instruct patient system,
to report pain thereby
immediately. creating further
damage and
interfering with
 diagnostics
and relief of
Pain.
✔ Decreases
external stimuli,
which may
aggravate
anxiety
and cardiac
strain, limit
coping abilities
and adjustment
to
Current
situation.
✔ Helpful in
decreasing
perception of/
response to
pain.
Provides a
sense of
having some
control over the
Situation,
increase in
positive
attitude.

✔ Hypotension
 can occur as a
result of
narcotic
administration.

✔ Provide quiet
environment,
calm activities,
and comfort
Measures (e.g.,
dry/wrinkle-free
linens, backrub).
Approach patient
calmly and
confidently.

✔ Assist/instruct
in relaxation
techniques,
e.g., deep/slow
breathing,
distraction
behaviors,
visualization,
guided
Imagery.
Dependent:

✔ Check vital
Signs before
and after
narcotic
medication.