IX.

Nursing Care Plan

Assessment Nursing Planning Intervention Rationale Evaluation

Diagnosis

Subjective Data: Acute Pain related After 8 hours of Independent: Goal was met
“I had severe to myocardial nursing Assessed patient pain for To identify intensity, precipitating factors
chest pains…” as ischemia intervention, intensity using a pain rating and location to assist in accurate
verbalized by the patient will scale, for location and for diagnosis.
patient demonstrate relief precipitating factors.
of pain as
Objective Data: evidenced by Monitor vital signs, Tachycardia and elevated blood
● VAS 9/10 stable vital signs, especially pulse and blood pressure usually occur with angina and
● Chest Pain absence of pressure, every 5 minutes reflect compensatory mechanisms
● Increased RR : muscle tension until pain subsides. secondary to sympathetic nervous
24 bpm and restlessness system stimulation.
.
Assessed the response to Assessing response determines
medications every 5 effectiveness of medication and whether
minutes further interventions are required.

Established a quiet A quiet environment reduces the energy

environment. demands on the patient.

Elevated head of bed. Elevation improves chest expansion and

oxygenation.

Provided comfort To provide non pharmacological pain

measures. management.

Dependent:
Administered or assisted
with self-administration of
vasodilators, as ordered.
The vasodilator nitroglycerin enhances
blood flow to the myocardium. It reduces
the amount of blood returning to the
heart, decreasing preload which in turn
IX. Nursing Care Plan

decreases the workload of the heart.

Collaborative:
Taught patient and SO Anginal pain is often precipitated by
relaxation techniques and emotional stress that can be relieved
how to use them to reduce non-pharmacological measures such as
stress. relaxation.

Taught the patient and SO In some case, the chest pain may be
how to distinguish between more serious than stable angina. The
angina pain and signs and patient needs to understand the
symptoms of myocardial differences in order to seek emergency
infarction. care in a timely fashion.
 IX. Nursing Care Plan

Assessment Nursing Planning Intervention Rationale Evaluation

Diagnosis

Subjective Data: Ineffective tissue After 8 hours of Independent: Goal was met
“… I experienced perfusion related to nursing Assessed cardiac and Assessment establishes a baseline and
difficulty with my decreased cardiac intervention, circulatory status. detects changes that may indicate a
breathing” as output patient will display change in cardiac output or perfusion.
verbalized by the effective tissue
patient perfusion as Assessed patient pain for To identify intensity, precipitating factors
evidenced by vital intensity using a pain rating and location to assist in accurate
Objective Data: signs within scale, for location and for diagnosis.
● Paleness acceptable limits, precipitating factors.
● Chest Pain and reduced
● Difficulty of chest pain. Monitored vital signs, Tachycardia and elevated blood
breathing especially pulse and blood pressure usually occur with angina and
aggravated with . pressure, every 5 minutes reflect compensatory mechanisms
ambulation until pain subsides. secondary to sympathetic nervous
● Body Weakness system stimulation.

Monitored cardiac rhythms Notes abnormal tracings that would

on patient monitor and indicate ischemia.
results of 12 lead ECG.

Assessed the response to Assessing response determines

medications every 5 effectiveness of medication and whether
minutes. further interventions are required.

Established a quiet A quiet environment reduces the energy

environment. demands on the patient.

Elevated head of bed. Elevation improves chest expansion and

oxygenation.

Dependent:
IX. Nursing Care Plan
Assessed results of cardiac
markers—creatinine
phosphokinase, CK- MB,
total LDH, LDH-1, LDH-2,
troponin, and myoglobin
ordered by physician.
Administered or assist with
self administration of
vasodilators, as ordered.
Provided oxygen and
monitor oxygen saturation
via pulse oximetry, as
ordered.
Collaborative:
Taught patient and SO
relaxation techniques and
how to use them to reduce
stress.
Taught the patient and SO
how to distinguish between
angina pain and signs and
symptoms of myocardial
infarction.
These enzymes elevate in the presence
of myocardial infarction at differing times
and assist in ruling out a myocardial
infarction as the cause of chest pain.
The vasodilator nitroglycerin enhances
blood flow to the myocardium. It reduces
the amount of blood returning to the
heart, decreasing preload which in turn
decreases the workload of the heart.
Oxygenation increases the amount of
oxygen circulating in the blood and,
therefore, increases the amount of
available oxygen to the myocardium,
decreasing myocardial ischemia and
pain.
Anginal pain is often precipitated by
emotional stress that can be relieved
non-pharmacological measures such as
relaxation.
In some case, the chest pain may be
more serious than stable angina. The
patient needs to understand the
differences in order to seek emergency
care in a timely fashion.
 IX. Nursing Care Plan

Assessment Nursing Planning Intervention Rationale Evaluation

Diagnosis

Subjective Data: Anxiety related to After 8 hours of Independent: Goal was met
“Can we move the scheduled nursing
operation, hindi pa procedure intervention,
ko read” as patient Dependent:
verbalized by the
patient. Collaborative:
.
Objective Data:
● Pale
● Restlessness