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NURSING CARE PLAN ASSESSMENT SUBJECTIVE: The patient may report: Chest pain, heaviness, or pressure that may radiate to the shoulders, arms, neck, jaw, or upper abdomen. DIAGNOSIS Acute pain related to decreased myocardial blood flow. INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

OBJECTIVE: Tachycardia Elevated blood pressure Jugular vein distention Cool, clammy skin

Angina can result from any condition in which theres a decrease in oxygen delivery by the coronary arteries, an increase in cardiac workload, or an increase in the myocardiums oxygen requirements. The most common cause is atherosclerosis, but angina can result from aortic stenosis, mitral stenosis or insufficiency, hypotension, hyperthyroidism, anemia, ventricular arrhythmias, or hypertension.

After 8 hours of nursing intervention the patient will: Remain free from pain Maintain stable vital signs. Maintain relaxed body posture.

Assess for vital signs and symptoms of pain such as facial grimacing, rubbing of neck or jaw, reluctance to move, increased blood pressure, and tachycardia. Note onset, duration, location, and pattern of pain. Use a pain rating scale to assess the patients perception of the pains severity. Administer sublingual nitroglycerin as ordered.

To differentiate angina pain from pain related to other causes.

After 8 hours of nursing intervention the patient was free from pain, maintains stable vital signs, and relaxed body posture.

Instruct the patient to notify a nurse immediately when experiencing pain. Have the patient stop current activity, and place him on bed rest in a semi- to high

To monitor the effectiveness of medications given for pain relief. To decrease myocardial oxygen demands through vasodilation, preload and after load reduction and decreased cardiac work load. To minimize ischemia produced by increased myocardial work load.

Student Nurses Community Fowlers position. Administer oxygen as ordered. Obtain a 12-lead ECG immediately during acute chest pain. Stay with the patient during chest pain episodes.

To provide optimal oxygenation to the myocardium. To document ischemic changes. To decrease anxiety and promote comfort.

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