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Cad NCP

The document outlines an assessment, diagnosis, plan, interventions, and evaluation for a patient experiencing acute chest pain related to subendocardial ischemia. The diagnosis was acute pain from increased cardiac workload evidenced by chest pain, shortness of breath, and history of hypertension. The plan was for the patient to report pain levels, maintain stable vitals, and find relief after 8 hours of nursing intervention. Interventions included identifying pain triggers, instructing rest and medication, and providing health resources. After 8 hours the goal was met as the patient was pain-free with stable vitals.

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Krizzia Mae F. Mayores
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3K views1 page

Cad NCP

The document outlines an assessment, diagnosis, plan, interventions, and evaluation for a patient experiencing acute chest pain related to subendocardial ischemia. The diagnosis was acute pain from increased cardiac workload evidenced by chest pain, shortness of breath, and history of hypertension. The plan was for the patient to report pain levels, maintain stable vitals, and find relief after 8 hours of nursing intervention. Interventions included identifying pain triggers, instructing rest and medication, and providing health resources. After 8 hours the goal was met as the patient was pain-free with stable vitals.

Uploaded by

Krizzia Mae F. Mayores
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS EVALUATION

SUBJECTIVE Acute pain related to After 8 hours of nursing Assist the patient to identify After 8 hours of nursing
subendocardial ischemia as intervention, the patient will: angina precipitating events. intervention, the goal met.
The patient report: evidenced by severe chest pain The patient was free from
● Chest pain radiating into both and shortness of breath. ● Report chest pain Instruct the patient to stop pain as verbal report of
arms (+) Shortness of breath ● Maintain stable vital activity and rest if chest pain absence of chest pain. The
● Episodes of transient substernal Acute pain related to increased signs occurs and to take patient has stable vital signs
and shoulder pain cardiac workload/oxygen ● Demonstrate relief of nitroglycerin as prescribed. and absence of restlessness.
● History of hypertension consumption as evidenced by pain
diaphoresis and patient’s Instruct the patient to seek
OBJECTIVE history of hypertension and medical attention if pain
baseline vital signs. persists.
● Diaphoresis
Risk for decreased cardiac Instruct the patient
output related to Immobility regarding prescribed
and Inactivity as evidenced by medications.
his overweight and stress.
Provide community
resources to the client
regarding exercise, smoking
reduction, and stress
reduction.

MAYORES, KRIZZIA MAE F. SEPTEMBER 14, 2021


BSN 3-A RLE (GROUP 3)
NURSING CARE PLAN

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