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NURSING CARE PLAN

Date Assessed August 20, 2012

ASSESSMENT DIAGNOSIS SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION


EXPLANATION
Short Term Goal: Independent: Short Term Goal:
Subjective: Acute chest Pain Occlusion of coronary
related to Coronary artery - After 15-30 minutes 1. Assess 1.) To determine what - Goal Met, AEB:
The client reports of Artery occlusion rendering care and characteristics of chest appropriate Patient will be able to
chest pain radiating to secondary to interventions, the pain (PQRST) interventions will be verbalized
the left arm, neck and Myocardial Infarction Decreased blood flow patient will be able to going to apply for decreased/relieved pain
back. to the myocardium verbalized better implementation (chest and to radiating
 P- Upon doing decreased/relieved pain of care. areas)felt, AEB:
some exertion (chest and to radiating
activities Decreased blood areas)felt, AEB: 2. Obtain history of 2.) It provides  Decreased feeling
Q- Stabbing pain supply (ischemia) previous cardiac pain information that may of fatigue
R- to left arm,  Decreased and familial history of help to differentiate  Improve breathing
neck and back feeling of fatigue cardiac problems from current pain from  Skin is within the
S- 10 out of 10 Anaerobic metabolism  Improve the S.O. previous problems and normal color
T- last more than 15 breathing complications thus it is  Vital signs within
minutes  Skin is within the a big help to perform normal range:
Lactic Acid formation normal color such interventions. BP=120/80
Objective:  Vital signs within PR= 60-100bpm
normal range: 3. Assess for 3.) An increase in vital RR= 12-20 cpm
 Restlessness Pain BP=120/80 respirations, BP and signs happens as as the Temp= 36.5
 Facial grimacing PR= 60-100bpm heart rate with each body compensate to  Pain rate scale
 Easy Fatigability RR= 12-20 cpm episodes of chest pain. pain, which can lead to from 10 down to 8
 Pallor Temp= 36.5 other serious as 10 is the highest
 Cold and clammy  Pain rate scale complications doing if
skin from 10 down to 8 continuous to increase. Long term Goal:
as 10 is the
 With Oxygen
inhalation at 2-4 highest 4. Maintain bed rest 4.) To reduce oxygen - Goal Met, AEB:
during pain, with consumption thus Patient experienced an
Lpm
Long term Goal: position of comfort. decreased oxygen improved feeling of
 Shortness of
demand. control and comfort
breath - After 1 hour of AEB:
 Vital signs taken rendering care and 5. Maintain relaxing 5.) To promote  Able to sleep and
as: interventions, the environment conducive calmness, reduce rest comfortably
BP=150/90 patient will be able to for rest. competing stimuli and  Improve breathing
PR=109 bpm have an improved reduces anxiety thus it  Vital signs within
RR= 26 cpm feeling of control and decreases oxygen normal range:
Temp= 35.0 comfort AEB: demand. BP=120/80
PR= 60-100bpm
 Able to sleep and 6. Instruct patient to 6.) To prevent RR= 12-20 cpm
rest comfortably avoid/limit activities triggering the heart to Temp= 36.5
 Improve that causes to increase the need of more  Pain rate scale
breathing cardiac workload oxygen due to from 10 down to 2
 Vital signs within ( lifting heavy objects, exertion, thus, limiting as 10 is the highest
normal range: running, stressful task) activities decrease
BP=120/80 myocardial oxygen
PR= 60-100bpm demand and workload
RR= 12-20 cpm on the heart.
Temp= 36.5
 Pain rate scale 7. Instruct 7.) To promote
from 10 down to 2 patient/family in knowledge and
as 10 is the medication effects, compliance with the
highest side-effects, said therapeutic
contraindications and regimen and for better
symptoms that need to action.
report

Collaborative:
- Administration of
medications and
oxygen
supplementation:

1.Administer oxygen 1.) To promote


adequate oxygen
supply
2. Administer 2.) Morphine Sulfate is
analgesics as ordered, the drug of choice to
such as morphine control MI pain, it
sulfate decreases the afterload
and preload (workload)
of the heart, decrease
oxygen demand, Thus,
reduces pain

3. Administer beta- 3.) To block


blockers such as sympathetic
metropolol as ordered. stimulation, reduce
heart rate and lowers
myocardial demand.

4. Perform a 12-lead 4.) ECG record


ECG and monitor for changes that can give
cardiac changes evidence of further
cardiac damage and
location of MI, thus
ECG monitoring is
important for better
prevention of damage
due to MI.
Date Assessed August 22, 2012

ASSESSMENT DIAGNOSIS SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION


EXPLANATION
Short Term Goal: Independent: Short Term Goal:
Subjective: Activity Intolerance Deficient oxygen in
related to Imbalance the coronary arteries - After 5-8 hours 1. Establish rapport 1.) To gain their trust Goal Met: Patient
- “Mabilis akong between oxygen ↓ shift duty of both to patient and and for better was able to verbalized
mapagod at Supply and Demand Use of anaerobic rendering care and S.O. intervention understanding about
manghina, simpleng secondary to pathway to for ATP interventions, the participation. her condition, AEB:
Gawain lng Myocardial Infarction production patient will be able to  Reduced feeling
nakakramdam na ako ↓ verbalized 2. Monitor vital signs, 2.) For baseline data of fatigue and
ng hirap sa paghinga” ↓ Oxygen to the understanding about before and after doing and to determine the weakness
as verbalized by the myocardium her condition, AEB: such activities. of other complication  Able to
patient ↓  Reduced feeling in relation to increase mentioned and
Inadequate amounts of fatigue and vital signs if possible. apply ways on
Objective: of oxygen to the weakness how managed
tissues  Able to mention 3. Encourage patient 3.) Informing her her condition
 Weak in ↓ and apply ways to verbalize her about her condition  Vital signs within
appearance Imbalance between on how managed feelings and concerns and limitations normal limits
 Pallor oxygen Supply and her condition regarding her present prevents her to upon performing
 Experience Demand  Participate to condition and develop further limited activities:
shortness of ↓ interventions limitations. complication and it BP=120/80
breathing Activity Intolerance  Vital signs within will be a help to PR= 60-100bpm
 Needs assistance normal limits manage properly her RR= 12-20 cpm
in doing upon performing condition. Temp= 36.5
minimal limited activities:
activities BP=120/80 4. Maintain stressful 4.) Reduces physical Long term Goal:
 Easy fatigability PR= 60-100bpm activity restrictions stress and tension, it Goal Met, Patient
 With Oxygen RR= 12-20 cpm and assist patient with decreases the demand showed measurable
inhalation at Temp= 36.5 self care activities as of oxygen thus increase in activity
2-4 Lpm needed. decreases also the tolerance, AEB:
Long term Goal: workload of the heart.
 Reduced feeling
 Vital signs taken - After 1 to 2 weeks 5. Provide frequent 5.) Resting decreases of fatigue and
as: of intervention, the rest periods, the oxygen demand of weakness
BP=130/90 patient will report especially after meals. the heart. Large meals  Demonstrate a
PR=90 bpm measurable increase may increase decrease in
RR= 20 cpm in activity tolerance, myocardial workload physiological
Temp= 37.8 AEB: and causes vagal signs of
 Functional Level stimulation thus intolerance
Classification:  Reduced feeling increases the demand  Vital signs within
Level III – means, of fatigue and of oxygen. normal limits
walk no more than weakness upon performing
50 ft on level without  Demonstrate a 6. Encourage rest 6.) Postural limited activities:
stopping; unable to decrease in periods between care hypotension/ cerebral BP=120/80
climb one flight of physiological activities. hypoxia may cause PR= 60-100bpm
stairs without signs of dizziness, fainting, RR= 12-20 cpm
stopping. intolerance and increased risk of Temp= 36.5
 Vital signs within injury  Perform ADL’s
normal limits without the need
upon performing Collaborative: of assistance and
limited activities: able to do it
BP=120/80 1. Administer beta- 1.) It blocks comfortably.
PR= 60-100bpm blockers such as sympathetic
RR= 12-20 cpm metoprolol, as stimulation, thus,
Temp= 36.5 ordered. reduces heart rate
 Perform ADL’s and lowers
without the need myocardial
of assistance and demand.
able to do it
comfortably
ASSESSMENT DIAGNOSIS SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION
EXPLANATION
Short Term Goal: Independent: Short Term Goal:
Subjective: Anxiety (moderate) Experienced chest
related to Actual pain - After the 8 hrs shift 1. Establish rapport 1.) To have a trusted Goal Met: Patient
“Hindi ko Threats to ↓ of duty of rendering nurse to patient already understand the
maipaliwanag present condition Myocardial ischemia care and interventions, relationship and to complications about
nararamdaman Secondary to reported the patient will be able have a therapeutic his condition and able
ko,malala ba Myocardial Infarction ↓ to understand the communication. to control his anxiety
kondisyon ko?hindi pa Diagnosed as complications about through proper
ako handa” as myocardial infarction his condition and able 2. Provide continuity 2.) Continuity of care explanation in her
vervalized by the ↓ to control his anxiety of care promotes security and present situation,
patient. Frequent monitoring through proper development of AEB:
needed explanation in her rapport.  Verbalized
Objective: ↓ present situation, awareness of
Conscious, irritable, AEB: 3. Encourage the 3.) Accurate feelings of
 Usually staring poor eye contact,  Verbalized patient and family to information about his anxiety
at the wall or restless awareness of ask questions and condition reduces fear  Actively interacts
ceiling. ↓ feelings of bring up common , strengthens the to family
 Unexplained Confusion anxiety concerns. nurse-patient  Open to his
facial expression ↓  Actively interacts relationship and assist conditions and
 Poor eye contact Anxiety to family the patient and familt ask questions for
 Confusion  Open to his to face the situation security and
 irritability conditions and realistically. reassurance
 Restlessness ask questions for  With eye contact
security and 4. Encourage patient 4.) Sharing  Decreased
 Ask questions
reassurance and S.O to verbalize information elicits irritability,
 Decreased
 With eye contact concerns and fears. support and comfort restlessness and
interaction to the
 Decreased and can relieve confusion.
family/S.O
irritability, tension and
restlessness and unexpressed worries. Long Term Goal :
confusion.
Long term Goal: 5. Inform them that 5.) To reassure the Goal Met: Patient
frequent assessment patient that frequent was able to accept the
- After 3-5 days of are routinely done to monitoring may reality about his
rendering care and monitor her condition prevent him to condition and readily
interventions, the and don’t necessarily develop of more participates in
patient will be able to imply a deteriorating serious complications. activities, AEB:
accept the reality condition.  Appeared relax
about his condition and report
and readily 6. Repeat the 6.) Anxiety decreases anxiety is
participates in information as learning and attention. reduced to
activities, AEB: necessary because manageable level
 Appeared relax patient and family  Open to his
and report may reduce their conditions and
anxiety is attention span. ask questions for
reduced to security and
manageable level 7. Provide a 7.) A comfortable reassurance
 Open to his comfortable And quiet environment enhances  With eye contact
conditions and environment. coping mechanisms  Decreased
ask questions for and reduces irritability,
security and myocardial workload restlessness and
reassurance and oxygen confusion.
 With eye contact consumption.
 Decreased
irritability,
restlessness and
confusion.
Date Assessed August 20, 2012

ASSESSMENT DIAGNOSIS SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION


EXPLANATION
Short Term Goal: Independent: Short Term Goal:
Subjective: Risk for Decrease Deposits from a large
cardiac output related atherosclerotic plaque - After 8 hours shift 1. Establish rapport 1.) In order to have a Goal Met: Patient
“ Mabuti naman na to increase vascular cause in increase in of duty and rendering both to patient and trusting relationship verbalized
pakiramdam ko, hindi resistance as size and bulge into the patient care and to the S.O on them. understanding about
na sumasakit ang evidenced by artery nursing interventions, his risk for decrease
dibdib ko,minsan narrowing of the patient will 2. Monitor patient’s 2.) Tachycardia may cardiac output and
minsan na lang pero coronary arteries verbalized vital signs, noting be present because of able to promote
hindi na kagaya secondary to Endothelial lining of understanding about blood pressure pain and anxiety and appropriate actions to
noon” as verbalized Myocardial coronary his risk for decrease changes. reduced cardiac promote patient’s
by the patient. Infarction activation of cardiac output and output. Changes may condition AEB:
coagulation cascade promote appropriate also occur in BP  Participates in
Objective: arteries will rupture actions to promote (hypertension or medication
patient’s condition hypotension) because regimen and in
 Experience easy Plaque protrudes in AEB: of cardiac response. restrictions
fatigability lumen of the vessels  Able to regarding to her
 Experience participate in 3. Provide a calm and 3.) It promotes condition.
dizziness and Thrombus may medication restful comfort and  Identify signs and
shortness of dislodge from a regimen and in surroundings relaxation. symptoms of
breath upon broken plaque restrictions cardiac
doing minimal regarding to her 4. Maintain activity 4.) Reduces physical decompression
activities ( Narrowed blood condition. restrictions and stress and tension. and able to seek
Standing) vessels/impedes blood  Identify signs and assisted patient Conserves attention if occur
 Experiences flow symptoms of with self care energy, reduces  Reported
chest pain, cardiac activities as cardiac workload. continuous
nausea and Decreased cardiac decompression needed. disappearance of
vomiting, and output and able to seek minimal
epigastric pain. attention if occur 5. Provided comfort 5.) Decreases occurrence of
 Restlessness  Report of measures (ex. discomfort and chest pain being
 With an Oxygen continuous Back massage and may reduce intermittently
inhalation at 2-4 disappearance of elevation of head) sympathetic felt.
Lpm minimal stimulation.  Vital signs are
 Vital signs occurrence of 6. Encouraged to do within normal
taken as: chest pain being relaxation 6.) Can reduce limits.
BP=150/90 intermittently felt. techniques such as stressful stimuli
PR=109 bpm  Vital signs are distraction and produce a Long term Goal:
RR= 26 cpm within normal calming effect.
Temp= 35.0 limits. Goal partially Met:
Long term Goal: 7. Maintain head 7.) To promote Patient reported
elevated optimal cerebral feeling of comfort and
- After 3-5 days of approximately 30 perfusion. lessen signs and
rendering patient care degrees. symptoms being felt
and interventions, the and observed through
patient will report 8. Instruct patient to 8.) Valsalva the proper
feeling of comfort and avoid activities that maneuver causes management and
lessen the possible create a Valsalva vagal stimulation, participation to
signs and symptoms of response (e.g. reducing heart intervention and
being in risk for straining to have a rate medication regimens
decrease cardiac bowel movement, (bradycardia), AEB:
output through the holding breath while which may be  -Display an
proper management moving up in bed) followed by improvement in
and participation to rebound hemodynamic
intervention and tachycardia, Stability
medication regimens which causes to  Shows proper
AEB: impair cardiac breathing pattern
 Display a output. but still have the
hemodynamic need to use an
Stability 9. Maintain on bed 9.) Decreases oxygen oxygen therapy
 Shows proper rest or semi fowlers consumption/dem for support.
breathing pattern position. and, reducing  Able to perform
and no need to myocardial basic activities
use an oxygen workload without
therapy for experiencing
support. Collaborative: dizziness and
 can perform basic minimally
activities without 1. Administer 1.) It blocks experience
experiencing Administer beta- sympathetic fatigability.
dizziness and blockers such as stimulation, thus,  Adequate cardiac
easy fatigability metoprolol, as reduces heart rate output, AEB:
 will improved ordered. and lowers stable/improving
into an active myocardial ECG result after
body tolerance. demand. performing
 Adequate cardiac PTCA done on
output 2. Administer 2.) Increases oxygen the same day.
AEB: supplemental available for
stable/improving oxygen as myocardial uptake to
ECG result after needed. improve contractility,
performing reduce ischemia, and
PTCA done on reduce lactic acid
the same day. levels.

3. Perform surgical 3) It helps to


intervention such improve the
as PTCA as condition of
needed. the patient and
it contributes
patients’
wellness and
danger.
Date Assessed August 21, 2012

ASSESSMENT DIAGNOSIS SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION


EXPLANATION
Short Term Goal: Independent: Short Term Goal:
Subjective: Ineffective Cardiac Deposits from a
Tissue Perfusion large atherosclerotic - After 8 hours of rendering 1. Monitor vital 1.) For baseline Goal Met, Patient
The patient reports related to Reduced plaque nursing intervention the signs especially data and to will showed adequate
of difficulty of Coronary Blood cause in increase in patient will show adequate blood pressure. monitor or coronary perfusion
breathing and chest Flow Secondary to size and bulge into coronary perfusion and determine for and reported feeling
discomfort. Myocardial the artery reported feeling of relieved further of relieved from
Infarction from discomforts, AEB: myocardial discomforts, AEB:
Objective: Endothelial lining of  decrease restlessness ischemia, thus
 restlessness coronary  decrease irritability preventing the  decrease
 irritability activation of  decrease feeling of occurrence of restlessness
 easy fatigability coagulation cascade fatigability other potential  decrease
 Diaphoresis arteries will rupture  Skin warm and dry and complications irritability
 Dizziness in normal color  decrease feeling
 Cold clammy Plaque protrudes in  Vital signs within 2. Asses for 2.) It is the signs of fatigability
skin lumen of the vessels normal range restlessness and symptoms  Skin warm and
 Relieved chest fatigue, changes of inadequate dry and in normal
 Pale in
Thrombus may discomfort of level of systemic color
appearance
dislodge from a  Improve breathing consciousness perfusion which  Vital signs within
 With an
broken plaque discomfort appearance of can affect normal range
Oxygen
skin color. cardiac function  Relieved chest
inhalation at 2-
Narrowed blood Long Term Goal: discomfort
4 Lpm
vessels/impedes  Improve
 Vital signs taken blood flow - After 3 Days of nursing 3. Provides period 3.) To reduce breathing
as: intervention the patient will of undisturbed myocardial discomfort
BP=150/90 Decreased cardiac be free from the signs and rest and calming oxygen demand
PR=109 bpm output symptoms of ineffective environment and work load Long Term Goal:
RR= 26 cpm cardiac tissue perfusion
Temp= 35.0 Ineffective Tissue AEB: 4. Instruct patient 4.) It promotes Goal Met, Patient
Perfusion in a complete decreases was observed as free
 Reported a comfortable bed rest. oxygen demand, from the signs and
feeling thus promoting symptoms of
 Free of pain and other adequate oxygen ineffective cardiac
signs and symptoms circulation. tissue perfusion and
ineffective tissue showed feeling of
perfusion Collaborative: wellness AEB:
 VS within normal limits
 Adequate cardiac output 1. Administer  Reported a
AEB:stable/improving medication comfortable
ECG result regimens as feeling
ordered such as:  Free of pain and
other signs and
 Morphine  Morphine symptoms
sulfate Sulfate is the ineffective tissue
drug of choice to perfusion
control MI pain,  VS within normal
it decreases the limits
afterload and  Adequate cardiac
preload output
(workload) of AEB:
the heart, stable/improving
decrease oxygen ECG result after
demand, Thus, performing
reduces pain PTCA done on
 Administer beta-  To block the same day.
blockers as sympathetic
ordered. stimulation,
reduce heart rate
and lowers
myocardial
demand.

2. Perform a 12-lead 2.) It helps in


ECG and monitor for determining
cardiac changes cardiac
insufficiency
and it helps to
monitor the
cardiac electrical
activity.

3. Administer 3.) In order to


Oxygen as improve or
ordered maintain cardiac
and systemic
tissue perfusion

4. Administer 4.) To maintain


intravenous systemic
fluids as circulation and
routinely ordered optimal cardiac
function.

5. Perform surgical 5.) It helps to


intervention such improve the
as PTCA as condition of the
needed. patient and it
contributes
patients’
wellness and
danger.

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