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N U R S I N G CARE PLAN FOR ATEROSCLEROSIS

Assessment

SUBJECTIVE:
The patient
reports:

“Nahihilo ako
at sumasakit
din ang aking
dibdib.” as
verbalized by
patient.
Chest pain,
heaviness, or
pressure that
may radiate to
the shoulders,
arms, neck,
jaw, or upper
abdomen.
Client rated
pain as 6 in
the scale of 110

OBJECTIVE:

Tachycardia
Elevated blood

Nursing
Diagnosis
Acute pain
related to
decreased
myocardial
blood flow.

Inference

Planning

Atherosclerosis
is a narrowing
of arteries
caused by build
up of plaque
that can result
from any
condition in
which there’s a
decrease in
oxygen delivery
by the coronary
arteries, an
increase in
cardiac
workload,

After 8 hours
of nursing
interventions
and health
teachings
the patient
will:

Remain
free from
pain
Maintain
stable
vital
signs.
Maintain
relaxed
body
posture.

Intervention

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 patient’s
perception of the
pain’s severity.
Administer
sublingual
nitroglycerin as
ordered.

Rationale

To
differentiate
chest pain
from pain
related to
other causes.

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

Evaluation

After 8 hours of
nursing
interventions
and health
teachings my
patient was
free from pain,
maintains
stable vital
signs, and
relaxed body
posture. Able to
verbalize,
“Hindi na po
sumasakit ang
aking dibdib.”
Rated pain as 3
in the scale of
1-10.

R – 18 cycles/min.   Obtain a 12-lead ECG immediately during acute chest pain. and place him on bed rest in a semi. BP – 150/90 mmHg   load.to high Fowler’s position. To minimize ischemia produced by increased myocardial work load.   Administer oxygen as ordered. To document ischemic changes. Have the patient stop current activity.3°C P – 88 beats/min. To provide optimal oxygenation to the myocardium.  Stay with the patient during chest pain episodes. To decrease anxiety and promote comfort . clammy skin  Instruct the patient to notify a nurse immediately when experiencing pain.pressure  Jugular vein distention Cool. V/S as taken: T – 36.