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NURSING CARE PLAN 1: CUES/EVIDENCE SUBJECTIVE: Verbalized, sakit akung dughan, murag gikumot ug gi bira-bira NURSING DIAGNOSIS Acute

Pain r/t myocardial ischemia OBJECTIVES Within my 1 day of nursing care, patient will experience decrease pain as evidenced by: Vital signs are within normal range: OBJECTIVES: Restlessness Facial Grimacing Weak Pulse Cold and Clammy skin Shortness of Breath Pain Scale of 10/10 Vital Signs: PR= 88 bpm RR=35 cpm BP=150/ 110 mmHg PR=60-90 bpm, regular RR=16-20 cpm, 5 use of accessory muscles BP=140-120 / 60-90 mmHg Experiences less chest pain, pain scale of 5/10 Diminished or absence of non-verbal indications, less facial grimacing Able to rest, displays reduced tension, and sleeps comfortably INTERVENTIONS Independent: Establish rapport with patients. Instruct client to report pain immediately. RATIONALE To increase compliance and cooperation. Severe pain may induced shock by stimulating the sympathetic nervous system, thereby creating further damage and interfering with diagnostic and relief of pain. To reduce oxygen consumption and demand, to reduce anxiety. Decreases external stimuli, which may aggravate anxiety and cardiac strain, limit coping Goal met: abilities and adjustment to Diminished of non-verbal current situation. indications as evidenced by less facial grimacing Reduce competing stimuli and reduces anxiety. Goal met: Able to rest, displays Hopeful in decreasing reduced tension and sleeps perception of (response to comfortably, verbalized Goal met: Experienced less chest pain, pain scale of 3/10 EVALUATION At the end of my 1-day nursing care, patient experienced decreased pain as evidenced by: Goal met: Vital Signs are within normal range PR=85 RR=18 BP=113/65

Maintain bed rest during pain, with position of comfort. Provide quiet environment, calm activities and comfort, measures (such as dry, wrinkle free linens, backrub).

Approach client calmly and confidently. Assist/Instruct in relaxation techniques (deep/slow breathing,

distraction behaviours, guided imagery).

pain provides a sense of having some control over the situation, increase in positive attitude. Hypotension respiratory depression can occur as a result of narcotic administration. These problems may increase myocardial damage in presence of ventricular insufficiency. Increases amount of oxygen available for myocardial update and thereby may relieve discomfort associated with tissue ischemia Aspirin is the mainline medication to be given first to all acute MI clients. ASA possesses anti-inflammatory, analgesic and antiplatelet qualities that assist in the stabilization of plaque while decreasing clotting potential.

makatulog naku ug maayu pero dali raku kamata kung nay magsaba

Monitor vital signs before and after administration of narcotic medication.

Collaborative: Assist in administration of supplemental oxygen by means of nasal cannula

Administer medications as indicated: Aspirin (ASA)

Antianginal; isosorbite dinitrate

Nitrate are useful for pain control by coronary vasodilation effects, which increase coronary blood flow and myocardial perfusion. Peripheral vasodilation effects reduce the volume of blood returning to the heart (preload, thereby decreasing myocardial workload and oxygen demand. Theories: Florence Nightingales Environmental Theory The act of utilizing the environment of the patient to assist him in his recover.s Hildegard Peplaus Interpersonal RelationsTheory An interpersonal process of therapeutic interactions between an individual who is sick or in need of health services and a

nurse especially educated to recognize, respond to the need for help . Faye Glenn Abdellas concept of twenty one Nursing problems, to facilitate the maintenance of a supply of oxygen.