CUES

NURSING
DIAGNOSIS

SCIENTIFIC
BASIS

GOALS
&OUTCOME
CRITERIA

NURSING
ACTIONS AND
NURSING
ORDERS

RATIONALE OF
NURSING ORDERS

EVALUATION

SUBJECTIVE:

Acute pain
related to
Mo sinyas siya increase cardiac
kung naay sakit. workload/oxyge
As verbalized by n consumption.
the
patients
husband.

OBJECTIVE:
>Pain score of 9
out of 10
>Sleep
disturbance
>Distraction
behavior

Unpleasant sensory
and
emotional
experience arising
from actual or
potential
tissue
damage or describe
in terms of such
damage. Sudden or
slow onset of any
intensity from mild
to severe with an
anticipated
or
predictable end and
a duration of less
than six months.

After 8 hours of
nursing
interventions the
patient will be able
to:
Relieve
within 1
hour of
analgesic
administrati
on.
Follow
prescribed
pharmacolo
gical
regimen.

INDEPENDENT:
>Instruct client to
notify nurse
immediately when
chest pain occurs.

>Assess and
document client
response/effects of
medication.

>Observe for
associated
symptoms e.g,
dyspnea,
Verbalize
nausea/vomiting,
nonpharmac dizziness,
ologic
palpitations, desire
methods that to macturate.
provide
relief.
Demonstrate
use of
relaxation
skills and

>Evaluate reports of
pain jaw, neck,
shoulder, arm, or
hand.

-Pain and decreased cardiac

output may stimulate the
sympathetic nervous system
to release excessive
amounts of norepinephrine,
which increases platelet
aggregation and release of
thromboxane A2.
-Provides information about
disease progression.

-Decreased cardiac output

stimulates
sympathetic/parasympatheti
c nervous system.

-Cardiac pain may radiate;

e.g, pain is often referred to
more superficial sites
served by the same spinal

After 8 hours of
Nursing interventions
the patient was able
to:
Relieved
within 1 hour
of analgesic
administration
.
Followed
prescribed
pharmacologic
al regimen.
Verbalized
nonpharmacol
ogic methods
that provide
relief.
Demonstrated
use
of
relaxation
skills
and
diversional
activities, as
indicated, for
individual

diversional
activities, as
indicated,
for
individual
situation.

>Place client at
complete rest
during angina
episodes.
DEPENDENT:

and cord nerve level.

- Reduces myocardial
oxygen demand of
minimize risk of tissue
injury/necrosis.

>Administer
antianginal
medications
promptly as
indicated:

Nitroglyceri
n

B-blockers

-Nitroglycerin has been the

standard for treating and
preventing anginal pain for
more than 100 years.
-Reduce angina by reducing
the hearts workload.

Calcuim
channel
blockers

Morphine
sulfate

-Produce relaxation of
coronary vascular smooth
muscle, dilate coronary
arteries; decrease peripheral
vascular resistance.
-Potent narcotic analgesic
may be used in acute onset
because of its several

situation.

>Monitor serial
ECG changes.
( Marilynn E.
Doenges NCP 7th
Edition)

beneficial effects.
-Ischemia during angina
attack may cause transient
ST segment depression or
elevation and T wave
inversion.
(Marilynn E. Doenges NCP
7th Edition)

NURSING CARE PLAN

Patients Name:
Age:

Hospital No.:
Room No.:

CLINICAL PORTRAIT

Impression:
Nurses Name & Signature:

PERTINENT DATA

Physician: