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Assessment Subjective data: Sumasakit yung puso ko pati sa balikat at likod ko, as verbalized by the patient Objective data:

- Pain scale of 6/10 - Guarded behavior - Facial grimace

Diagnosis Acute pain related to myocardial ischemia

Planning Interventions At the end of 1 hour, the Independent: patient will be able to report pain is decreased as Assessed level of pain manifested by: using a pain scale - Pain scale of 03/10 Encouraged bed rest - No guarded behavior - No facial grimace Positioned head of the bed to semi fowlers

Rationale

To serve as baseline data Help decrease chest discomfort and dyspnea Venous return to the heart (preload) decreases, which reduces the work of the heart. To distract attention and reduce tension To promote relaxation

Evaluation At the end of 1 hour, the patient was able to report pain is decreased as manifested by: - Pain scale of 2/10 - No guarded behavior - No facial grimace

Encouraged focus breathing

Provided comfort measures such as back rubbing Provided diversional activities (talking to relatives and other patients) Encouraged rest periods

To divert attention from discomfort

To prevent fatigue and to conserve energy To provide feeling of security and comfort

Suggested SO to be present always for support

Provided a well ventilated and quiet environment Monitored for complaints of severe pain

Promotes relaxation

To prevent further aggravation of the condition

Dependent: Administered medication ( Amvasc 5 mg/tab OD, Arixtra 2.5 mg SQ OD) as ordered Relieve symptoms, and aid in minimizing or avoiding permanent injury to the myocardium To reduce pain associated with low levels of myocardial oxygen.

Maintained oxygen at 2 lpm

Assessment Subjective data: Sumasakit ang puso ko at nahihirapan akong huminga, as verbalized by the patient Objective data: -capillary refill within 5 seconds -BP of 150/90 mmHg -cold to touch -urine output of 20ml/hour -absence of edema

Diagnosis Ineffective tissue perfusion ( heart muscle) related to decrease blood flow

Planning Interventions At the end of eight hours, Independent : the patient will be able to demonstrate increased Determined vital signs perfusion as manifested by: Checked skin - BP is not more temperature than 120/80 - Absence of edema - Warm to touch Assessed peripheral - Capillary refill pulses within 3 seconds - Urine output of 30 ml/hour

Rationale To serve as baseline data To determine and ensure adequate tissue perfusion Weak, thready peripheral pulses may reflect hypotension, vasoconstriction, shunting and venous congestion To identify / determine adequate perfusion Helpful in reducing myocardial oxygen consumption. To promote comfort & decrease tissue O2 demand To avoid fatigue and decrease the oxygen demand on myocardium. To decrease tension level and oxygen demand

Evaluation Goal partially met. At the end of eight hours, the patient was able to demonstrate increased perfusion as manifested by: -BP of 130/90 -No edema -Warm to touch -capillary refill within 3 seconds -urine output of 200ml for 8 hours

Performed blanch test

Encouraged bed rest Provided quiet & restful atmosphere Instructed to avoid tiring activities

Encouraged use of relaxation techniques ( e.g deep breathing)

Monitored vital signs

To monitor changes from the baseline data

Dependent: Administered medications (Amvasc 5mg/tab OD, Carvid 6.25m g/tab BID) as prescribed Maintained oxygen at 2lpm

Pharmacologic treatment to ensure adequate tissue perfusion To support oxygen uptake in the tissues

Assessment Subjective: Sumasakit ang puso ko at nahihirapan akong huminga, as verbalized by the patient

Objective: - BP- 150/90 - Pulse 56 bpm - Urine output of 20ml/hour

Diagnosis Planning Interventions Decreased cardiac output At the end of eight hours, Independent : related to increase the patient will be able vascular resistance to achieve adequate Determined vital signs cardiac output as evidenced by: -BP not more than 120/ 80 Assessed peripheral -pulse rate within 60pulses 100bpm; full pulsations, bilateral -Adequate urinary output of 30 ml/hour Encouraged bed rest

Rationale To serve as baseline data

Weak, thready peripheral pulses may reflect hypotension, vasoconstriction, shunting and venous congestion Helpful in reducing myocardial oxygen consumption. To promote comfort & decrease tissue O2 demand To avoid fatigue and decrease the oxygen demand on myocardium. To decrease tension level and oxygen demand

Evaluation Goal partially met. At the end of eight hours, the patient was able to achieve adequate cardiac output as evidenced by: -BP of 130/90 -pulse rate of 62 bpm; full pulsations, bilateral -urine output of 200ml for 8 hours

Provided quiet & restful atmosphere Instructed to avoid tiring activities

Encouraged use of relaxation techniques ( e.g deep breathing

Monitored vital signs

To monitor changes from the baseline data

Dependent: Administered medications (Amvasc 5mg/tab OD, Carvid 6.25m g/tab BID, Lanoxin 0.25mg tab OD) as prescribed Maintained oxygen at 2lpm Pharmacologic treatment to ensure adequate cardiac output

To support oxygen uptake in the tissues

Assessment Subjective: Hindi ako masyadong nagtratrabaho kasi mabilis akong mapagod at nahihirapan akong huminga as verbalized by the patient.

Diagnosis

Planning

Interventions Assess vital signs Assess cardiopulmonary response to physical activity. Note progression/ Accelerating degree of fatigue. Teach methods to conserve energy, such as stopping to rest for 3 minutes during a 10minute walk, sitting down instead of standing to brush Hair. Promote comfort measures Assist client in learning and demonstrating appropriate safety measures Provide activity within activity tolerance Encourage participation in self-care

Rationale To provide baseline data Provides comparative baseline.

Evaluation

Activity intolerance r/t At the end of eight hours, decrease oxygen supply the patient will be able to demonstrate a decrease in physiological signs of intolerance as manifested by: RR within 16-20 cpm Bp not more than 120/80 mmHg pulse rate of 60100bpm verbalization of feelings of activity tolerance no difficulty of breathing noted

To reduce workload of the heart and oxygen consumption

Provide for relief of pain To prevent injuries and to reduce workload of the heart and oxygen consumption To reduce tension and conserve energy To promote selfconcept and sense of independence

Provide ample time to perform mobility-related tasks Emphasize importance of assistance

To reduce fatigue and prevent over exertion to prevent client from injury