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Nursing Care Plan

For Acute Coronary Syndrome


NURSING CARE PLAN
for Acute Pain
ASSESSMENT NURSING DIAGNOSIS
Subjective: Acute pain related to increased
“ Sakit akong dughan” as lactic acid production
verbalized by the patient secondary to decreased blood
and oxygen supply to
Objective: myocardium
Facial grimaces
Restlessness
Tachycardia
Tachypnea
Sleep disturbance
Irritability
Pain scale 7/10
NURSING CARE PLAN
for Acute Pain
PLANNING
Short term goal:
After 4 hours of nursing intervention the patient will
report relief of pain

Long term goal:


After 2 days of nursing intervention, the patient will
demonstrate use of relaxation techniques and
divertional activities as indication for individual
situation
NURSING CARE PLAN
for Acute Pain
INTERVENTION RATIONALE
Independent:
• Establish rapport • To gain trust and cooperation
• Assess patient’s condition • To determine sign and
symptoms
• Monitored vital sign • To served as base line data
• Perform comprehensive • To determine precipitating
assessment of pain factors
• Assess respiration, BP and • Respiratory may be increased
heart rate with each episode of as a result of pain and associate
chest pain anxiety
• Observe nonverbal cues • Observations may/ may not be
congruent with verbal reports
indicating need for further
evaluation
NURSING CARE PLAN
for Acute Pain
INTERVENTION RATIONALE
Independent:
• Provide comfort • To provide non
measures such as back pharmacological
rub measures of relieving
• Provide adequate rest pain
periods • To prevent fatigue and
promote relaxation
• Maintain bed rest during • To reduce oxygen
pain, with position of consumption and
comfort, maintain demand, to reduce
relaxing environment to competing stimuli and
promote calmness reduces anxiety
NURSING CARE PLAN
for Acute Pain
INTERVENTION RATIONALE
Dependent:
• Prepare for the • Pain control is a priority,
administration of as it indicates ischemia
medications, and monitor
response to drug therapy.
Notify physician if pain
does not abate
NURSING CARE PLAN
for Acute Pain

EVALUATION:
Short term:
After 4 hours of nursing intervention the patient shall have verbalized
methods that provide relief

Long term:
After 2 days of nursing intervention the patient shall have
demonstrated use of relaxation techniques and divertional activities
as indicated for individual situation
Nursing Care Plan
Decreased Cardiac Output
NURSING CARE PLAN
for Decreased Cardiac Output
ASSESSMENT NURSING DIAGNOSIS
Subjective: Decreased cardiac output related
“ gihangak man ko” as verbalized to altered stroke volume
by the patient

Objective:
Shortness of breath
Fatigue
With oxygen hooked via nasal
cannula at 2 LPM
With cardiac dysrhythmias on
ECG
Pallor
Prolong capillary refill
NURSING CARE PLAN
for Decreased Cardiac Output
PLANNING
Short term goal:
After 4 hours of nursing intervention the patient will
participate in activities that decrease the workload of
the heart such as stress management or therapeutic
medication regimen program

Long term goal:


After 4 days of nursing intervention, the patient will
display hemodynamic stability with normalization of
ECG tracings and blood pressure readings
NURSING CARE PLAN
for Decreased Cardiac Output
INTERVENTION RATIONALE
Independent:
• Establish rapport • To gain trust and
• Assess patient’s condition cooperation
• To determine sign and
• Monitored vital sign symptoms
• Monitor ECG for • To served as base line data
dysrhythmias, conduction • Decrease in cardiac output
defects and for heart rate may result in changes in
cardiac perfusion causing
• Monitor cardiac rhythms dysrhythmias
continuously • To note for effectiveness of
medicines
NURSING CARE PLAN
for Decreased Cardiac Output
INTERVENTION RATIONALE
Independent:
• Encourage to decreased intake • Caffeine is a cardiac stimulant
of caffeine, cola and chocolates and may adversely affect
cardiac function
• Observe skin color, • Peripheral vasoconstriction
temperature, capillary refill may result in pale, cool,
time and diaphoresis clammy skin, with prolonged
capillary refill time due to
cardiac dysfunction and
decreased cardiac output
• Monitor intake and output and • To maintain adequate
calculate 24 hour fluid balance nutrition and fluid balance
NURSING CARE PLAN
for Decreased Cardiac Output
INTERVENTION RATIONALE
Independent:
Instruct client & family on • Restrictions can assist with
fluid and diet requirements decrease in fluid retention,
and restrictions of sodium thereby improving cardiac
output

Dependent:
• Administer supplemental • To provide for adequate
oxygen as ordered oxygenation
• Administer medicines as • To promote wellness
prescribed by the physician
NURSING CARE PLAN
for Decreased Cardiac Output

EVALUATION:
Short term:
After 4 hours of nursing intervention the patient shall have
participated in activities that decrease the workload of the heart such
as stress management or therapeutic medication regimen program

Long term:
After 4 days of nursing intervention the patient shall have displayed
hemodynamic stability and normalization of ECG tracings and blood
pressure readings
Nursing Care Plan
Of Activity Intolerance
NURSING CARE PLAN
for Activity Intolerance
ASSESSMENT NURSING DIAGNOSIS
Subjective: Activity Intolerance related to
“The patient verbalize: exertional cardiac dysfunction, imbalance in
dyspnea oxygen supply and consumption
as evidenced by shortness of
Objective: breath upon exertion
BP = 165/84, HR= 125, RR=28
Fatigue
With oxygen hooked via nasal
cannula at 2 LPM
Ischemic ECG changes
Pallor
Cyanosis
Need for assistance upon
movement
NURSING CARE PLAN
for Activity Intolerance
PLANNING
Short term goal:
After 4 hours of nursing intervention the patient will
use identified techniques to increase activity tolerance

Long term goal:


After 4 days of nursing intervention, the patient will be
able to increase and achieve desired activity level,
progressively, with no intolerance symptoms noted,
such as respiratory compromise
NURSING CARE PLAN
for Activity Intolerance
INTERVENTION RATIONALE
• Establish rapport • To gain trust and
• Assess patient’s condition cooperation
• To determine sign and
• Monitored vital sign symptoms
• Changes in V/S assist with
monitoring physiologic
responses to increase in
• Identify causative factors activity
leading to intolerance of • Alleviation of factors that are
activity known to create intolerance
can assist with development
of an activity level program
NURSING CARE PLAN
for Activity Intolerance
INTERVENTION RATIONALE
Independent:
• Encourage patient to assist • To help give the patient a
with planning activities, with feeling of self-worth and well-
rest periods as necessary being
• Adjust activities according to • To prevent overexertion
patient’s tolerance
• Assist patient with activities • To protect patient from injury
and monitor use of assistive
devices
NURSING CARE PLAN
for Activity Intolerance
EVALUATION:
Short term:
After 4 hours of nursing intervention the patient shall have used
identified techniques to increase activity tolerance

Long term:
After 4 days of nursing intervention the patient shall have increased
and achieved desired activity level, progressively, with no intolerance
symptoms noted, such as respiratory compromise
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