ASSESSMENT DIAGNOSIS RATIONALE OF PLANNING NURSING RATIONALE OF NURSING EVALUATION

NURSING DIAGNOSIS INTERVENTION INTERVENTION

Subjective cue: “I feel Acute Pain related to Ischemia of the heart After 8 hours of  Instruct the patient  Unbearable pain may After 8 hours of
pain in my chest” decreased myocardial muscle may produce nursing intervention to notify the nurse cause vasovagal nursing
blood flow pain or other the patient will: immediately when response, decreasing intervention, the
Objective cue: symptoms, varying in chest pain occurs BP and heart rate patient was free
 Facial grimace severity from mild  remain free from from pain, relaxed
 Pain score 9/10 indigestion to a pain Source: Vera (2013). body posture and
 PR = 118 bpm choking or heavy  maintain stable vital Coronary Artery Disease maintain stable vital
 RR = 25 cpm sensation in the signs from signs
 diaphoresis upper chest that  retain relax body https://nurseslabs.com/4-
ranges from posture angina-coronary-artery-  O2 sat 95-96%
discomfort to disease-nursing-care-  RR = 19 cpm
agonizing pain plans/  PR = 98 bpm
accompanied by  BP = 100/70
severe apprehension  Place patient at  Reduces myocardial mmHg
and a feeling of complete rest during oxygen demand to
impending death anginal episodes minimize risk of tissue

Source: Medical- Source: ibid

Surgical Nursing 12th
edition, 2010 by S.
Smeltzer, B. Bare, J.
Hinkle, et al. p 763
  Elevate head of bed  Facilitates gas exchange
if patient is short of to decrease hypoxia
breath and resultant shortness
of breath

Source: ibid

 Stay with patient  Presence of nurse can

who is experiencing reduce feelings of fear
pain or appears and helplessness
anxious
Source: ibid

 Maintain quiet,  Mental/emotional

comfortable stress increases
environment. myocardial workload
Restrict visitors as
necessary Source: ibid

Patient’s Name: _____________________

Attending Physician: ____________________
Admitting Diagnosis: ____________________