NURSING CARE PLAN

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Acute (Chest) STG: INDEPENDENT: STG:

The client Pain r/t Within 1 1. assess 1. pain is Within 1 hour
reports of chest myocardial hour of characteristics of indication of MI. of nursing
pain radiating to ischemia nursing chest pain, assisting the intervention, the
the left arm and resulting from interventions, including location, client in client had
neck and back. coronary the client will duration, quality, quantifying pain improved
artery have improved intensity, may differentiate comfort in chest,
occlusion with comfort in presence of pre-existing and as evidenced by:
Objective: loss/restriction chest, as radiation, current pain  States a
 Restlessness of blood flow evidenced by: precipitating and patterns as well decrease in the
 Facial to an area of  States a alleviating factors, as identify rating of the
grimacing the decrease in and as associated complications. chest pain.
 Fatigue myocardium the rating of symptoms, have  Is able to
 Peripheral and necrosis the chest client rate pain on rest, displays
cyanosis of the pain. a scale of 1-10 reduced
 Weak pulse myocardium.  Is able to and document tension, and
 Cold and rest, findings in nurse’s sleeps
clammy skin displays notes. comfortably.
 Palpitations reduced 2. obtain history 2. this provides  Requires
 Shortness of tension, and of previous information that decrease
breath sleeps cardiac pain and may help to analgesia or
 Elevated comfortably. familial history of differentiate nitroglycerin.
temperature  Requires cardiac problems. current pain from Goal was met.
 Pain scale of decrease previous
8/10 analgesia or problems and LTG:
nitroglycerin. complications. The client had
3. assess an improved
LTG: respirations, BP 3. respirations feeling of control
The client and heart rate may be increased as evidenced by
will have an with each as a result of pain verbalizing a
improved episodes of chest and associate sense of control
feeling of pain. anxiety. over present
control as 4. maintain 4. to reduce situation and
evidenced by bedrest during oxygen future outcomes
verbalizing a pain, with position consumption and within 2 days of
sense of of comfort, demand, to nursing
control over maintain relaxing reduce competing intervention.
present environment to stimuli and Goal was met.
situation and promote reduces anxiety.
future calmness.
outcomes
within 2 days
of nursing 5. prepare for the 5.pain control is a
interventions. administration of priority, as it
medications, and indicates
monitor response ischemia.
to drug therapy.
Notify physician if
pain does not
abate.

6.istruct patient in 6. to decrease

nitroglycerin SL myocardial
administration oxygen demand
after and workload on
hospitalization. the heart.
Instruct patient in
activity alterations
and limitations.
7. to promote
7. instruct knowledge and
patient/family in compliance with
medication therapeutic
effects, side- regimen and to
effects, alleviate fear of
contraindications unknown.
and symptoms to
report.

1. serial ECG and

DEPENDENT: stat ECGs record
1. obtain a 12- changes that can
lead ECG on give evidence of
admission, then further cardiac
each time chest damage and
pain recurs for location of MI.
evidence of
further infarction
as prescribed. 2. Morphine is
the drug of
2. administer choice to control
analgesics as MI pain, but
ordered, such as other analgesics
morphine sulfate, may be used to
meferidine of reduce pain and
Dilaudid N. reduce the
workload on the
heart.
3. administer
beta-blockers as 3. to block
ordered. sympathetic
stimulation,
reduce heart rate
and lowers
4. administer myocardial
calcium-channel demand.
blockers as 4. to increase
ordered. coronary blood
flow and
collateral
circulation which
can decrease
pain due to
ischemia.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
INDEPENDENT:
Subjective: Activity STG: 1. monitor heart 1.changes in VS STG:
The client Intolerance Within 3 days rate, rhythm, assist with monitoring Within 3 days of
reports of r/t cardiac of nursing respirations and physiologic responses nursing
increased dysfunction, interventions, blood pressure for to increase in interventions,
work of changes in the client will be abnormalities. activity. the client tolerated
breathing oxygen able to tolerate Notify physician of activity without
associated supply and activity without significant changes excessive dyspnea
with feelings consumption excessive in VS. 2. Alleviation of and had been able
of weakness as dyspnea and will factors that are to utilize breathing
and tiredness. evidenced be able to utilize 2. Identify causative known to create techniques and
by shortness breathing factors leading to intolerance can assist energy
Objective: of breath. techniques and intolerance of with development of conservation
 Increased energy activity. an activity level techniques
heart conservation program. effectively.
rate techniques 3. encourage 3. to help give the Goal was met.
 Increased effectively. patient to assist patient a feeling of
blood with planning self-worth and well- LTG:
pressure LTG: activities, with rest being. Within 5 days of
 Dyspnea Within 5 days periods as nursing
with of nursing necessary. 4. to decrease energy interventions, the
exertion interventions, 4. instruct patient in expenditure and client increased
 Pallor the client will be energy conservation fatigue. and achieved
 Fatigue and able to increase techniques. desired activity
weaknes and achieve 5. assist with active 5.to maintain joint level,
s desired activity or passive ROM mobility and muscle progressively, with
 Decreased level, exercises at least tone. no intolerance
oxygen progressively, QID. symptoms noted,
saturatio with no 6.to improve such as respiratory
n intolerance 6. turn patient at respiratory function compromise.
 Ischemic symptoms least every 2 hours, and prevent skin Goal was met.
ECG noted, such as and prn. breakdown.
changes respiratory
compromise. 7. instruct patient in 7. to improve
isometric and breathing and to
breathing exercises. increase activity
 level.
8. provide
patient/family with 8. to promote self-
exercise regimen, worth and involves
with written patient and his family
instructions. with self-care.

DEPENDENT:
1.Assisst patient
with ambulation, as 1. to gradually
ordered, with increase the body to
progressive compensate for the
increases as increase in overload.
patient’s tolerance
permits.

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

INDEPENDENT:
Subjective: Deficient STG: 1. monitor patient’s 1. to promote STG:
The client Knowledge r/t The client will readiness to learn optimal learning The client
verbalizes new diagnosis be able to and determine best environment when verbalized and
questions and lack of verbalize and methods to use for patient show demonstrated
regarding understanding demonstrate teaching. willingness to learn. understanding of
problems and of medical understanding 2. provide time for 2. to establish trust. information given
misconceptions condition. of information individual interaction regarding condition,
about his given regarding with patient. medications, and
condition. condition, 3. instruct patient on 3. to provide treatment regimen
medications, procedures that may information to within 3 days of
Objective: and treatment be performed. manage medication nursing
 Lack of regimen within Instruct patient on regimen and to interventions.
improvement 3 days of medications, dose, ensure compliance. Goal was met.
of previous nursing effects, side effects,
regimen interventions. contraindications, LTG:
 Inadequate and signs/symptoms The client had
follow-up on LTG: to report to 4. client may need been able to
instructions The client will physician. to increase dietary correctly perform all
given. able to correctly 4. instruct in dietary potassium if placed tasks prior to
 Anxiety perform all needs and on diuretics; sodium discharge.
 Lack of tasks prior to restrictions, such as should be limited Goal was met.
understan- discharge. limiting sodium or because of the
ding. increasing potential for fluid
potassium. retention.
5. to provide
5. provide printed reference for the
materials when patient and family to
possible for refer.
patient/family to
reviews. 6. to frovide
6. have patient information that
demonstrate all skills patient has gained a
that will be full understanding of
necessary for instruction.
postdischarge. 7. these are helpful
7. instruct exercises in improving cardiac
to be performed, and function.
to avoid overtaxing
activities.
1. to provide further
DEPENDENT: improvement and
1. refer patient to rehabilitation
cardiac rehabilitation postdischarge.
as ordered