St.

Anthony’s College
NURSING DEPARTMENT
San Jose, Antique

NURSING CARE PLAN

CUES NURSING
RATIONALE PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
SUBJECTIVE: Coronary artery INDEPENDENT: GOAL
Acute Pain disease (CAD) is a GENERAL: 1.) Monitor blood pressure, apical heart rate, 1.) Vitals are needed to be obtained as a PARTIALLY
“sakit dughan related to a condition in After 2 weeks and respirations every 5minutes during an baseline and to monitor for possible MET:
ko asta sa decrease in which plaque of nursing angina attack. complications or progressions.
liug, baga kag myocardial builds up inside interventions, 2.) Obtain full description of pain from patient 2.) Assessing the client in quantifying pain may Patient
lima.”, as blood flow, the coronary the patient including location, intensity (0-10), duration, differentiate pre-existing and current pain demonstrated
verbalized by increased arteries. The will verbalize characteristics (dull/crushing), and radiation. patterns as well as to identify complications. relief of
the patient. cardiac classic symptom relief/control 3.) Instruct patient to report pain 3.) Delay in reporting pain hinders pain pain as
workload / of coronary of chest pain . immediately. relief/may require increased dosage of evidenced by:
oxygen artery disease medication to achieve relief > verbal reports
consumption (CAD) is angina— SPECIFIC: 4.) Place patient at complete rest during 4.) Reduces myocardial oxygen demand to of absence of
OBJECTIVE: pain caused by After 8 hours anginal episodes. minimize risk of tissue injury. chest pain
loss of oxygen of nursing > the use of
5.) Recommend quiet atmosphere, bed rest if 5.) Enhances rest to lower body’s oxygen
> Pain scale and nutrients to interventions relaxation
indicated. requirements and reduces strain on the heart
of 8 the myo-cardial the patient techniques,
and lungs.
>Cool clammy tissue because of will: stable vital signs,
6.) Stay with patient who is experiencing pain 6.) Anxiety releases catecholamines, which
skin inadequate > Demonstrate absence of
>Facial coronary blood relief of pain or appears anxious. increase myocardial workload and can prolong
ischemic pain. Presence of nurse can reduce muscle tension
grimace flow. as evidenced and restlessness.
>Placing fist by stable vital feelings of fear and helplessness.
over mid- Source: signs, absence 7.) Maintain quiet, comfortable environment. 7.) Mental/emotional stress increases
sternum Doenges, M. E., of muscle Restrict visitors as necessary. myocardial workload.
>Rubbing left Moorhouse, M. F., tension and 8.) Provide light meals. Have patient rest for 1 8.) Decreases myocardial workload associated
arm & Murr, A. C. restlessness. hr. after meals. with work of digestion, reducing risk of anginal
>Restlessness (2013). Nurse's >Demonstrat attack.
pocket guide: e the use of 9.) Provide supplemental oxygen as indicated. 9.) Increases oxygen available for myocardial
Diagnoses, relaxation uptake and reversal of ischemia.
-V/S as Prioritized techniques. DEPENDENT:
follows: Interventions, and 10.) Administer anti-anginal medications as 10.) Patients with angina pectoris are given
Rationales (13th indicated. medications that promote vasodilation (e.g.
BP: 150/100 ed.). Philadelphia, nitroglycerin), workload (e.g. betablockers),
mmHg PA: F.A. Davis. reduce coronary artery spasms (e.g. calcium
P: 121 bpm channel blockers), and relieve pain (e.g.
R: 12 bpm morphine sulfate)
Submitted By: Angie G. Mandeoya BSN-4