IX.

NURSING CARE PLAN

ASSESSMENT
July 11, 2016
Subjective:
Sakit akong
dughan karon,
murag gina
dat-ugan. As
verbalized by
patient
-With a pain
score of 7 out of
10, as 10 being
the highest
Objective:
7/11/16 8:00PM
Vital signs:
BP:187/70mmhg
HR:60bpm
(with TPI)
RR:18cpm

DIAGNOSIS
Acute
Pain related
to a
decrease in
myocardial
blood flow
as
evidenced
by chest
pain

ANALYSIS
Acute pain
is an
unpleasant
sensory and
emotional
experience
arising from
actual or
potential
tissue
damage,
sudden or
slow onset
of any
intensity
from mild to
severe with
an
anticipated
or
predictable
end and a
duration of
less than 6
months.

GOAL
Short term:

INTERVENTION
Independent:

RATIONALE

After 1 hour of
nursing
intervention the
patient will be
able to:

1. Monitor and
record the
characteristics of
pain

Indicates
need for
Short term:
effectiveness
of
After 1 hour of
interventions nursing
intervention
the patient
To evaluate
verbalized
clients
relief from
response to
pain, with a
pain
pain scale rate
of 4 out of 10
from 7 out of
To promote
10, as 10
nonbeing the
pharmacolog highest
ical pain
managemen
t

1. Report relief
from pain,
with a pain
scale rate of
0 or 3 out of
10 from 7
out of 10 as
10 being the
highest
2. Demonstrate
use of
relaxation
technique

2. Use pain rating

scale

3. Provide comfort
measures such
as pillows and
comforter.

EVALUATION
Goals Partially
Met

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O2 sat:100%
Long Term:
(+) Guarding
behavior
(+) Facial
Grimace

After 5 days of
nursing
intervention the
patient will
report absence
of pain

4. Maintain a cool
and quiet
environment

Patient was
also able to
To provide
demonstrate
comfort
the use of
5. Encourage
relaxation
relaxation
skills like deep
technique such as To distract
breathing
focused breathing attention and exercises
reduce
tension
Long Term:
6. Encourage
Goals Partially
verbalization of
Met
feelings
To determine
clients
After 5 days of
severity of
nursing
pain and
intervention
assist client
the patient
to explore
showed
methods to
minimal
Dependent:
control pain
reports of
chest pain and
Administer
was tolerable
Paracetamol
Analgesics
as claimed.
(Biogesic) 1 tab
to help
every 4 hours as
relieve pain
needed as ordered
by physician

Page | 47

ASSESSMENT DIAGNOSIS
July 11, 2016
Ineffective
Airway
Subjective:
Clearance
related to
Naa koy ubo
retained
pero lisod e
secretions
gawas ang
plema. As
verbalized by
patient
Objective:
at ER (7/11/16
6:00PM)
Vital signs:
BP:160/90
mmHg
HR:36 bpm
RR: 18 cpm
O2 sat 93%
(+) Bibasal
rales

(+)non-

ANALYSIS
The
inflammation
and
increased
secretions
make it
difficult to
maintain a
patent
airway,
which is
caused by
decrease
ability to
expel the
excessive
mucus
produced
that will lead
to extensive
obstruction
of the
airway.

GOAL
Short term:

INTERVENTION
Independent:

RATIONALE

EVALUATION
Goals Met

After 8 hours of
nursing
intervention the
patient will be
able to:

1. Monitor vital signs

To evaluate
degree of
compromise

Short term:

1. Demonstrate
behaviors to
improve
airway
patency.
2. Expectorate
retained
secretions
3. Improve in
respiration
and difficulty
of breathing
will be
relieved.

Long Term:

2. Auscultate breath
sounds

3. Elevate head of
bed

4. Keep
environment
allergen-free

5. Encourage client
to increase oral
fluid intake of at

To ascertain
status and
note progress
or
complications

To maximize
respiratory
effort

To prevent
allergic
reactions

After 8 hours
of nursing
intervention
the patient
showed
behaviors to
improve
airway
patency.
The patient
was able to
expectorate
retained
secretions and
respirations
were
improving with
evidenced of
an oxygen
saturation of
100%.

To help
Page | 48

productive
cough

After 5 days of
nursing
intervention the
patient will
maintain a
patent airway
and clear breath
sounds.

least 1L per day

within level of
cardiac tolerance

liquefy
secretions

6. Encourage
adequate rest

Dependent:

Long Term:
Goals Met
To promote
wellness

1. Administer
oxygen inhalation
at 2LPM via nasal To aid in
cannula as
ventilation
ordered by
physician
2. Administer Piptaz
4.5 grams IV
every 8 hours as
ordered by
physician

Difficulty of
breathing was
also relieved.

Treatment of
respiratory
problems or
infections

After 5 days of
nursing
intervention
the patient
maintained a
patent airway
and with clear
breath sounds.
Oxygen
inhalation was
gradually
decreased to
0.5 LPM the
following day
then
discontinued
on the 5th day
of admission

Piptaz of 4.5
Page | 49

grams was
also
decreased to
2.5 grams IV
every 8 hours
on the fifth day
of admission

ASSESSMENT

DIAGNOSIS

ANALYSIS

GOAL

INTERVENTION

RATIONALE

EVALUATION
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July 11, 2016

Subjective:

Objective:
Upon
admission at
ER (7/11/16
6:00PM)
BP-160/90
mmHg
HR- 36bpm
RR-18cpm
O2 sat-93%
Electrolyte
results
(7/12/16)

Decreased
Cardiac
Output
related to
alterations in
rate and
rhythm of
electrical
conduction
secondary to
Myocardial
Infarction

Decreased
cardiac
output is a
state in
which
inadequate
blood is
pumped by
the heart to
meet the
metabolic
demands of
the body
caused by
cardiac
dysfunction
s, blood
flow
obstructions
, electrolyte
imbalances,
and more

Short Term:

Independent:

After 8 hours of
nursing intervention,
the client will be able
to:

1. Monitor vital
signs
and cardiac
rhythm.

To assess
client status

1. Participate in
activities that
reduce the
workload of the
heart

2. Auscultate for
breath
sounds and
listen for
murmurs.

Murmurs
may reveal a
valvular
cause for
chest pain

3. Note skin
color and
presence and
quality of
pulses.

Reduced
peripheral
circulation
leads to
decrease
cardiac
output thus
having pale
or gray color
skin and
diminish
peripheral
pulses.

2. Maintain a blood
pressure within
normal range of
120/80 to 130/90
mmHg
Long Term:

Potassium 3.5
(3.5 - 5.3
mEq/L)

After 5 days of
nursing interventions,
the client will be able
to:

Calcium 1.07
(1.12-1.32
mmol/L)

1. Demonstrate
hemodynamic
stability of blood

Short Term:
Goals partially
met
After 8 hours
of nursing
intervention,
the client
showed active
participation in
activities that
reduces the
workload of
the heart
Blood
pressure was
reduced from
160/90 mmHg
to 140/60
mmHg

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pressure
(7/11/16/)
ECG tracing
shows 3rd
degree AV
block

2. Manifest absence
of angina

4. Evaluate
mental
status, noting
development
of confusion,
disorientation

Reduced
perfusion of
the brain can
produce
observable
changes in
sensorium

5. Encourage
immediate
reporting of
pain for
prompt
administratio
n of
medications
as indicated.

To minimize
cardiac
complication

6. Maintain on
bed rest in
position of
comfort

To reducing
myocardial
workload

7. Provide for
adequate rest

Conserves
energy and

Long Term:
Goals partially
met
After 5 days of
nursing
interventions,
the client was
able to
illustrate a
hemodynamic
stability of
blood pressure
within range of
100/80 to 140/
90 mmHg
There were
though
minimal
episodes of
angina
Patient was
then advised
for a coronary
angiogram but
family refused
and opted to
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periods.
Perform selfcare activities

8. Stress
importance of
avoiding
straining
down
especially
during
defecation

reduces
cardiac
workload.

have a
permanent
pacemaker
insertion
instead.

To prevent
vagal
stimulation

Dependent:
1. Administer
oxygen
inhalation at
2LPM via
nasal
cannula as
ordered by
physician

To improve
ventilation

2. Administer
Calcium

These
medications
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Channel
Blockers,
BetaBlockers,
ASA,
Antiplatelet
and Heparin
medications
as ordered by
physician

ASSESSMENT
July 11, 2016

DIAGNOSIS
Risk for
bleeding

ANALYSIS
Temporary
cardiac pacing

GOAL
Short term:

INTERVENTION
Independent:

decrease
cardiac
workload by
reducing
heart rate
and systolic
BP

RATIONALE

EVALUATION
Goals Met.

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Objective:
- S/P
Temporary
pacemaker
insertion
(7/11/16
8:00pm)
-

Post op
dressing on
right groin
On Aspirin
and
Enoxaparin
medications

related to an
invasive
device as
evidenced by
a temporary
pacemaker
insertion

provides
electrical
stimulation to a
heart that is
compromised
by
disturbances in
the conduction
system,
resulting in
hemodynamic
instability. A
temporary
pacemaker is
done to treat a
bradycardic
dysrhythmia.
It is
recommended
when the
condition is
temporary and
when a
permanent
pacemaker is
either not
necessary or is
not
immediately

After 1 hour
of nursing
intervention,
the client will
be able to
demonstrate
behaviors
that reduce
the risk for
bleeding.

1. Assess site for

any signs of
bleeding

To determine
any possible
bleeding
episodes

2. Observe for
To assess
presence of
changes in
petechiae,
affected area
bleeding from
one more sites.

Long Term:
After 5 days
of nursing
intervention,
the patient
will be free
from any
signs of
bleeding
episodes.

3. Monitor vital
signs.

4. Note changes
in mentation
and level of
consciousness

An increase in
pulse with
decreased
blood pressure
can indicate
loss of
circulating
blood volume.

Short Term:
After 1 hour of
nursing
intervention,
the client was
able to
demonstrate
and follow
behaviors that
reduced the
risk for
bleeding.
Long Term:
After 5 days of
nursing
intervention,
the patient was
free from any
signs of
bleeding

Changes may
indicate
Page | 55

available.

5. Apply pressure
to dressing
site.

6. Instruct client
to maintain
affected leg on
neutral position
and avoid
bending

cerebral
perfusion
secondary to
hypovolemia,
hypoxemia.

Applying
pressure
reduces
bleeding
tendencies
Maintaining
site on neutral
position and
avoidance of
bending
reduces the
chance of
bleeding

Dependent:
1. Monitor
hemoglobin,
hematocrit
and clotting
factors.
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2. Daily dressing
and
assessment
on affected
area

Indicators of
anemia, active
bleeding, or
impending
complication.

To make free
from
microorganism
and aide in
wound healing
To determine
for signs of
bleeding

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