Student Nurses’ Community

NURSING CARE PLAN

ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION
SUBJECTIVE: Acute pain Angina can result After 8 hours • Assess for vital signs • To differentiate After 8 hours of
related to from any of nursing and symptoms of pain angina pain from nursing
The patient may decreased condition in intervention such as facial pain related to intervention the
report: myocardial which there’s a the patient will: patient was free
grimacing, rubbing of other causes.
blood flow. decrease in neck or jaw, from pain,
• Chest pain, oxygen delivery • Remain reluctance to move, maintains stable
heaviness,
by the coronary free from increased blood vital signs, and
or pressure
that may
arteries, an pain pressure, and relaxed body
radiate to the increase in • Maintain tachycardia. Note posture.
shoulders, cardiac stable vital onset, duration,
arms, neck, workload, or an signs. location, and pattern
jaw, or upper increase in the • Maintain of pain.
abdomen. myocardium’s relaxed • Use a pain rating • To monitor the
oxygen body scale to assess the effectiveness of
OBJECTIVE: requirements. patient’s perception of medications given
posture.
The most the pain’s severity. for pain relief.
• Tachycardia common cause • Administer sublingual • To decrease
• Elevated is
blood
nitroglycerin as myocardial
atherosclerosis, ordered. oxygen demands
pressure
but angina can through
• Jugular vein
result from aortic vasodilation,
distention
stenosis, mitral preload and after
• Cool,
clammy skin stenosis or load reduction
insufficiency, and decreased
hypotension, cardiac work load.
hyperthyroidism, • Instruct the patient to • To minimize
anemia, notify a nurse ischemia
ventricular immediately when produced by
arrhythmias, or experiencing pain. increased
hypertension. Have the patient stop myocardial work
current activity, and load.
place him on bed rest
in a semi- to high
Student Nurses’ Community

Fowler’s position.
• Administer oxygen as • To provide
ordered. optimal
oxygenation to the
myocardium.
• Obtain a 12-lead • To document
ECG immediately ischemic
during acute chest changes.
pain.
• Stay with the patient • To decrease
during chest pain anxiety and
episodes. promote comfort.
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