22

XI. NURSING CARE PLAN

Name of Patient

Assessment Nursing Diagnosis Rationale Desired Outcome Nursing Diagnosis Justification Evaluation

Subjective: Deficient knowledge r/t Predisposing factors: After 30-45 minutes After 30-45 minutes of
Patient verbalized: new diagnosis and lack Educational 1. Monitor patient’s 1. To promote
of nursing- nursing-intervention
“Wala ko nurse kabalo of understanding of Attainment (Vocational readiness to learn and optimal
kung ngaa nag amo gid medical condition Graduate), 74 years old intervention the client determine best method learning the client was able to:
ni akon sitwaysyon kay Precipitating factor: in health teaching environment
will able to:
nasakit lng man gulpi Definition:  Knowledge Deficit when patient
dughan ko sang ga ubra Absence or deficiency 1. The client will show The client verbalized
ko sa bay-bay.” of cognitive Rationale: be able to willingness to and demonstrated
information related to Client is an elderly and verbalize and 2. Provide time for learn understanding of
Objectives: specific topic ( lack of cannot comprehend to demonstrate individual interaction information given
specific information nurse’s orders understanding with the patient regarding condition,
 Lack of necessary for client/SO ↓ of information 2. To establish medications, and
improvement of to make informed Lack of knowledge given 3. Instruct patient trust. treatment regimen.
previous regimen choices regarding regarding Myocardial regarding on the Goal Partially met.
 Inadequate follow condition, treatment, Infarction, its condition, procedures that
up on instructions and/or lifestyle precautions and medications may be 3. To provide Client verbalized “ nag
given changes) possible complications and treatment performed. information to hagan hagan akon ka
 Anxiety Reference : and outcomes regimen. Instruct patient manage kulba kay gin pabalo
 Lack of ↓ 2. Verbalize on medications, medication mo ko mayo sang akon
Nurse’s Pocket Guide.
understanding Knowledge Deficit reduce in doses, effects, regimen and to masakit”
Diagnoses, Prioritized
anxiety and side effects, ensure Goal Met.
Interventions, and
Strengths: feeling relaxed contraindication compliance
Rationales.14th Edition.
after being s, signs and
Doenges ,Moorhouse
- Strong family support informed symptoms to
and Murr
regarding his report to the
Weakness: condition. doctor
4. Instruct in 4. Sodium should
-Has a hard time in dietary needs be limited
recalling important and restrictions because of the
 23

details regarding such as limiting potential fluid

condition sodium and fat retention
intake
5. Have patient 5. To provide
demonstrate all information that
skills that will patient has
be necessary for gained a full
post discharge understanding
of information

6. Instruct 6. These are

exercises to be helpful in
performed and cardiac function
to avoid
overtaxing
activities

.
 24

Name of Patient

Assessment Nursing Diagnosis Rationale Desired Outcome Nursing Diagnosis Justification Evaluation

Subjective: Acute chest pain Predisposing factors: After 30-45 minutes 1. Assess 1. Pain is After 30-45 minutes of
Client verbalized “Gin Educational of nursing characteristics of chest indication of nursing intervention,
admit ko di dai kay nag related to tissue Attainment (Vocational intervention, the client pain, including location, MI. assisting the client will be able
sakit gulpi akon na myocardia l ischemia Graduate), 74 years old will be able to: duration, quality, intensity, the client in to:
dughan na nag abot na Precipitating factor: presence of radiation, quantifying
sa ti-un nga daw resulting from coronary  Knowledge Deficit State a decrease in the precipitating and pain may
State a decrease in the
matumba na lang ko” artery occlusion with rating of the chest alleviating factors, and differentiate
Rationale: pain. as associated symptoms, pre-existing and rating of the chest pain.
loss/restriction of blood
Objectives: have client rate pain on current pain
Is able to rest, displays
 Restlessness flow to an area of the Decreased coronary Able to rest, displays a scale of 1-10 and patterns as well
reduced tension, and
myocardium as evidence blood flow reduced tension, and document findings in as identify
sleeps comfortably.
 Facial grimacing ↓ sleeps comfortably. nurse’s notes. complications.
by reports of chest GOAL MET
Vasoconstriction of 2. Obtain history
 Weak pulse pain. heart’s blood vessels Will have an improved of previous cardiac pain
The client had an
↓ feeling of control as and familial history
improved feeling of
 Pain scale of Vasospasm evidenced by of cardiac problems.
control as evidenced by
9/10 Definition: ↓ verbalizing a sense of 2. This provides
verbalizing a sense of
Unpleasant sensory and Chest pain control over present information that
control over present
emotional experience situation may help to
situation.
arising from actual or 3. Assess respirations, differentiate
GOAL MET
potential tissue BP and heart rate with current pain
damage; sudden or each episode of chest from previous
slow or onset of any pain. problems and
intensity from mild to complications.
severe with an 4. Maintain bed rest
anticipated or during pain, with
predictable end and a position of comfort,
duration of less than 6 maintain relaxing 3. Respirations
months. environment to promote may be
calmness. increased as a
Reference : 5. Prepare for the result of pain
administration and associate
Nurse’s Pocket Guide. of medications, and anxiety.
 25

Diagnoses, Prioritized monitor response to drug

Interventions, and therapy. Notify physician
Rationales.14th Edition. if pain does not abate.
Doenges ,Moorhouse 4. To reduce
and Murr . oxygen
consumption
and demand, to
reduce
competing
stimuli and
reduces anxiety

5. Pain control is a
priority, as it
indicates
ischemia
 26

Name of Patient

Assessment Nursing Diagnosis Rationale Desired Outcome Nursing Diagnosis Justification Evaluation

Objectives: Risk for tissue Predisposing factors: After 3-4 hours of Independent: After 3-4 hours of
- IVF infusing well @ perfusion R/T reduced Educational
nursing-intervention nursing-intervention
R cephalic vein coronary blood flow Attainment (Vocational
- Pulse rate of 53 secondary to Graduate), 74 years old the client will able to: 1. Inspect for 7. Systemic the client was able to:
- Jugular vein is Myocardial Infarction Precipitating factor: pallor, cyanosis, vasoconstrictio
slightly prominent Definition:  Knowledge Deficit mottling, cool n resulting from
- Heart sounds are Decrease in blood  Demonstrate and clammy diminished
slightly weak circulation to the tissue Rationale: skin. Note cardiac output
adequate  Demonstrate
- BP of 90/60 mmHg that may compromise Decrease cardiac strength of may be
taken at the left arm health output perfusion as peripheral evidenced by adequate
-Pain scale of “6” out ↓ individually pulses. decreased skin perfusion.
of 10 Reference : Compensatory renin- perfusion and
- Good skin turgor aldosterone, ADH appropriate, diminished Warm and dry
Nurse’s Pocket Guide.
-Lips are slightly dry ↓ for example pulses. skin, peripheral
Diagnoses, Prioritized
Increase blood volume warm and dry
Interventions, and pulses
↓ 2. Monitor
Rationales.14th Edition. skin, present/strong
Increase heart rate respirations. 8. Cardiac pump
Doenges ,Moorhouse
↓ peripheral failure and/or were observed.
and Murr
Increase myocardial ischemic pain Goal met.
oxygen requirement pulses may precipitate
↓ present/strong. respiratory  Vital signs with
Decrease cardiac distress; in normal range
 vital signs
output however, BP: 110/70, T:
↓ within sudden or 36.5, RR: 26,
Tissue Perfusion patient’s continued PR: 64
dyspnea may Goal Met.
normal range, indicate
3. Monitor intake, thromboemboli
note changes c pulmonary
 Patient
in urine output. complications.
alert/oriented, Record urine spe
balanced I&O, cific gravity as
indicated. 9. Decreased
 27

absence of intake or
persistent
edema, free of nausea may
pain/discomfor result in
reduced  Responsive to
t. circulating stimuli, no
volume, which edema noted,
negatively reduced pain
affects scale 6/10
perfusion and Goal Partially
organ function. met.
4. Assess for Specific gravity
Homans’ sign measurements
(pain in calf on reflect
dorsiflexion), hydration status
erythema, and renal
edema. function.

10. Indicators of
deep vein
thrombosis
(DVT),
although DVT
can be present
without a
positive
Homans’ sign.