NURSING CARE PLAN

Assessment Nursing Diagnosis Inference Planning Intervention Rationale Evaluation

SUBJECTIVE: Acute pain related Angina can result After 8 hours of  Assess for vital signs  To differentiate After 8 hours of
to decreased from any condition nursing and symptoms of angina pain nursing
The patient reports: myocardial blood in which there’s a interventions pain such as facial from pain interventions and
flow. decrease in oxygen and health grimacing, rubbing of related to other health teachings my
 “Pinot dughan ko delivery by the teachings the neck or jaw, causes. patient was free
kag lingin gd ulo coronary arteries, patient will: reluctance to move, from pain,
ko.” an increase in increased blood maintains stable
 Chest pain, cardiac workload,  Remain free pressure, and vital signs, and
heaviness, or or an increase in from pain tachycardia. Note relaxed body
pressure that may the myocardium’s  Maintain onset, duration,  To monitor the posture. Able to
radiate to the oxygen stable vital location, and pattern effectiveness of verbalize, “Medyo
shoulders, arms, requirements. The signs. of pain. medications ng mayo na matyag
neck, jaw, or most common  Maintain  Use a pain rating given for pain ko ah. Salamat gd.”
upper abdomen. cause is relaxed scale to assess the relief. Rated pain as 3 in
 Client rated pain atherosclerosis, but body patient’s perception  To decrease the scale of 1-10.
as 6 in the scale of angina can result posture. of the pain’s severity. myocardial
1-10 from aortic  Administer oxygen demands
stenosis, mitral sublingual through
OBJECTIVE: stenosis or nitroglycerin as vasodilation,
insufficiency, ordered. preload and after
 Tachycardia hypotension, load reduction
 Elevated blood hyperthyroidism, and decreased
pressure anemia, ventricular cardiac work
 Jugular vein arrhythmias, or load.
distention hypertension  To minimize
Cool, clammy skin ischemia
 Instruct the patient to produced by
notify a nurse increased
V/S as taken: immediately when myocardial
experiencing pain. work load.
T – 36.3°C Have the patient stop
current activity, and
P – 88 beats/min. place him on bed rest
in a semi- to high  To provide
R – 18 cycles/min. Fowler’s position. optimal
oxygenation to
BP – 120/60 mmHg  Administer oxygen as the myocardium.
ordered.  To document
ischemic
changes.
 Obtain a 12-lead
ECG immediately  To decrease
during acute chest anxiety and
pain. promote comfort

 Stay with the patient