Nursing Care Plan

For Acute Coronary Syndrome

 NURSING CARE PLAN
for Acute Pain
ASSESSMENT NURSING DIAGNOSIS
Subjective: Acute pain related to
Sakit akong dughan as increased lactic acid
verbalized by the patient production secondary to
decreased blood and
Objective: oxygen supply to
Facial grimaces myocardium
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
Independent:
Establish rapport
Assess patients condition
Monitored vital sign
Perform comprehensive
assessment of pain
Assess respiration, BP and
heart rate with each
episode of chest pain
Observe nonverbal cues
RATIONALE
To gain trust and
cooperation
To determine sign and
symptoms
To served as base line data
To determine precipitating
factors
Respiratory may be
increased as a result of
pain and associate anxiety
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 pharmacological
back rub measures of relieving
Provide adequate rest pain
periods To prevent fatigue and
promote relaxation
Maintain bed rest To reduce oxygen
during pain, with consumption and
position of comfort, demand, to reduce
maintain relaxing competing stimuli and
environment to reduces anxiety
promote calmness
 NURSING CARE PLAN
for Acute Pain
INTERVENTION RATIONALE
Dependent:
Prepare for the Pain control is a
administration of priority, as it indicates
medications, and ischemia
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
gihangak man ko as related to altered stroke
verbalized by the patient volume

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 patients cooperation
condition To determine sign and
symptoms
Monitored vital sign To served as base line
Monitor ECG for data
dysrhythmias, Decrease in cardiac
conduction defects and output may result in
for heart rate changes in cardiac
perfusion causing
Monitor cardiac rhythms dysrhythmias
continuously To note for effectiveness
 NURSING CARE PLAN
for Decreased Cardiac
Output
INTERVENTION RATIONALE
Independent:
Encourage to decreased Caffeine is a cardiac
intake of caffeine, cola and stimulant and may
chocolates 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
Monitor intake and output cardiac output
and calculate 24 hour fluid To maintain adequate
balance nutrition and fluid balance
 NURSING CARE PLAN
for Decreased Cardiac
Output
INTERVENTION RATIONALE
Independent:
Instruct client & family on Restrictions can assist
fluid and diet requirements with decrease in fluid
and restrictions of sodium retention, thereby
improving cardiac
output
Dependent:
Administer supplemental
oxygen as ordered To provide for adequate
Administer medicines as oxygenation
prescribed by the To promote wellness
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: cardiac dysfunction,
exertional dyspnea imbalance in oxygen supply
and consumption as
Objective: evidenced by shortness of
BP = 165/84, HR= 125, breath upon exertion
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 patients condition cooperation
To determine sign and
Monitored vital sign symptoms
Changes in V/S assist
with monitoring
physiologic responses to
Identify causative factors increase in activity
leading to intolerance of Alleviation of factors that
activity are 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, feeling of self-worth and
with rest periods as well-being
necessary To prevent overexertion
Adjust activities according
to patients tolerance To protect patient from
Assist patient with injury
activities 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
THANK YOU