NURSING CARE PLAN

ASSESSMENT NURSING PLANNING NURSING RATIONALE EVALUATION /

DIAGNOSIS INTERVENTION OUTCOME
Subjective Cues: Independent:

> Patient sates, “ The Pain, acute, related to Within 8 hours, > Obtained resting Baseline data is Goal met. Patient
chest pain started increased cardiac patient will: vital signs important to help demonstrated relief of
when I took the workload and determine patient’s pain as evidenced by:
stairs.” decreased mycocardial > report chest pain current health status
blood flow decreased in and evaluate efficacy > verbal reports of
frequency, duration, of nursing absence of chest pain
and severity interventions
rendered. > stable vital signs
Objective Cues: > demonstrate relief
of pain as evidenced > Placed patient on Reduces mycocardial > absence of
> facial grimacing (A state in which an by stable vital signs complete bed rest oxygen demand to restlessness and
individual experiences and absence of during anginal minimize risk of tissue grimacing
> increased heart rate and reports the restlessness and episodes. injury.
(HR= 115) presence of severe grimacing
discomfort or an > Placed patient on Relieves shortness of
> increased blood uncomfortable semi-Fowler’s breath and decreases
pressure sensation) position. myocardial workload.
(BP=150/100)
> Monitored vital signs Blood pressure may
> increased q 5 mins during initial initially rise and then
respiratory rate anginal attack. fall if cardiac output is
(RR = 26) compromised.
Tachycardia also
> diaphoresis develops and may be
sustained if cardiac
> restlessness output falls.

> ECG results reveal > Monitored heart rate Patients with unstable
depressed ST segment and rhythm angina have an
increased risk of acute
life-threatening
dysrhythmias.

> Maintained quiet, Mental and emotional

comfortable stress increases
environment; restrict myocardial workload.
visitors as necessary.

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 > Provided light meals; Decreases risk of
encouraged patient to myocardial attack by
rest for 1 hr after decreasing myocardial
meals workload.

> Instructed patient to Pain and decreased

notify nurse cardiac output may
immediately if chest complicate and
pain occurs. prolong an anginal
attack.

> Provided emotional Reduces anxiety.

support.

> Provided client Patient must be taught

teaching and discharge on the proper use of
planning on: medications along
with expected side
a. medication regimen effects (eg.
b. ways to minimize Nitroglycerin). It is
events that precipitate also important to
anginal attacks. encourage patient to
avoid stressful events,
quit smoking, avoid
overexertion, have a
regular exercise
program, and maintain
a low-fat, low
cholesterol diet and
small, frequent meals.

Dependent:

> Provided Increases oxygen

supplemental oxygen available for
as ordered myocardial
uptake/reversal of
ischemia.

> Administered Patients with angina

antianginal pectoris are given
medications as medications that
ordered promote vasodilation
(e.g. nitroglycerin),

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 reduce cardiac
workload (e.g. beta-
blockers), reduce
coronary artery spasms
(e.g. calcium channel
blockers), and relieve
pain (e.g. morphine
sulfate)

Collaborative:

> Monitored laboratory Diagnostic studies such

and serial ECG results as ECG, ECG stress
test, serum lipids,
cardiac enzymes, may
be ordered to identify
cause of angina
pectoris and other
cardiac conditions.

> Coordinated with Patients with angina

dietary department pectoris are
regarding therapeutic maintained on low-fat,
diet for patients with low-saturated
angina pectoris (low cholesterol diet.
fat, low cholesterol).

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