XI.

NURSING CARE PLAN

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Acute (Chest) STG: INDEPENDENT: STG:

Within 1 hour 1. assess 1. pain is indication of Within 1 hour of
The client Pain r/t
of nursing characteristics of MI. assisting the client nursing intervention,
reports of chest myocardial chest pain, including in quantifying pain the client had
interventions,
pain radiating toischemia resulting location, duration, may differentiate pre- improved comfort in
the client will
the left arm and from coronary have improved quality, intensity, existing and current chest, as evidenced
neck and back. artery occlusion comfort in chest, presence of radiation, pain patterns as well by:
with as evidenced by: precipitating and as identify  States a
loss/restriction of  States a alleviating factors, and complications. decrease in the
blood flow to an decrease in as associated rating of the chest
Objective: the rating of symptoms, have client pain.
area of the rate pain on a scale of
 Restlessness myocardium and the chest pain.  Is able to rest,
 Facial  Is able to 1-10 and document displays reduced
necrosis of the rest, displays findings in nurse’s tension, and
grimacing myocardium. notes. sleeps
reduced
 Fatigue tension, and 2. obtain history of 2. this provides comfortably.
 Peripheral sleeps previous cardiac pain information that may  Requires
cyanosis comfortably. and familial history of help to differentiate decrease analgesia
 Requires cardiac problems. current pain from or nitroglycerin.
 Weak pulse
decrease previous problems and Goal was met.
 Cold and complications.
analgesia or
clammy skin nitroglycerin. LTG:
 Palpitations 3. assess respirations, 3. respirations may be The client had an
 Shortness of LTG: BP and heart rate with increased as a result improved feeling of
The client will each episodes of chest of pain and associate control as evidenced
breath
have an pain. anxiety. by verbalizing a
 Elevated 4. maintain bedrest 4. to reduce oxygen sense of control over
improved feeling
temperature of control as during pain, with consumption and present situation
 Pain scale of evidenced by position of comfort, demand, to reduce and future outcomes
8/10 verbalizing a maintain relaxing competing stimuli and within 2 days of
sense of control environment to reduces anxiety. nursing intervention.
over present promote calmness. Goal was met.
situation and
future outcomes
within 2 days of 5. prepare for the 5.pain control is a
nursing administration of priority, as it indicates
interventions. medications, and ischemia.
monitor response to
drug therapy. Notify
physician if pain does
not abate.
6.istruct patient in 6. to decrease
nitroglycerin SL myocardial oxygen
administration after demand and workload
hospitalization. on the heart.
Instruct patient in
activity alterations
and limitations.
7. to promote
7. instruct knowledge and
patient/family in compliance with
medication effects, therapeutic regimen
side-effects, and to alleviate fear of
contraindications and unknown.
symptoms to report.

DEPENDENT: 1. serial ECG and stat

1. obtain a 12-lead ECGs record changes
ECG on admission, that can give evidence
then each time chest of further cardiac
pain recurs for damage and location
evidence of further of MI.
infarction as
prescribed.
2. Morphine is the
2. administer drug of choice to
analgesics as ordered, control MI pain, but
such as morphine other analgesics may
sulfate, meferidine of be used to reduce
Dilaudid N. pain and reduce the
workload on the heart.

3. administer beta- 3. to block

blockers as ordered. sympathetic
stimulation, reduce
heart rate and lowers
myocardial demand.
4. administer calcium- 4. to increase
channel blockers as coronary blood flow
ordered. and collateral
circulation which can
decrease pain due to
ischemia.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
INDEPENDENT:
Subjective: Activity STG: 1. monitor heart rate, 1.changes in VS assist STG:
rhythm, respirations with monitoring Within 3 days of
The client Intolerance Within 3 days and blood pressure for physiologic responses to
reports of r/t cardiac of nursing abnormalities. Notify increase in activity.
nursing
increased dysfunction, interventions, physician of significant interventions,
work of changes in the client will be changes in VS. the client tolerated
breathing oxygen able to tolerate 2. Alleviation of factors activity without
2. Identify causative that are known to create excessive dyspnea
associated supply and activity without factors leading to intolerance can assist with
with feelings consumption excessive intolerance of activity. development of an
and had been able
of weakness as dyspnea and will activity level program. to utilize breathing
and tiredness. evidenced be able to utilize 3. encourage patient to 3. to help give the patient techniques and
by shortness breathing assist with planning a feeling of self-worth and energy
activities, with rest well-being. conservation
Objective: of breath. techniques and periods as necessary.
 Increased energy 4. instruct patient in 4. to decrease energy
techniques
heart conservation energy conservation expenditure and fatigue. effectively.
rate techniques techniques. Goal was met.
 Increased effectively. 5. assist with active or 5.to maintain joint
passive ROM exercises mobility and muscle tone. LTG:
blood at least QID.
pressure LTG: 6.to improve respiratory Within 5 days of
 Dyspnea Within 5 days 6. turn patient at least function and prevent skin nursing
with of nursing every 2 hours, and prn. breakdown. interventions, the
exertion interventions, client increased
7. instruct patient in 7. to improve breathing and achieved
 Pallor the client will be isometric and breathing and to increase activity
 Fatigue and able to increase exercises. level. desired activity
weaknes and achieve level,
s desired activity 8. provide 8. to promote self-worth progressively, with
patient/family with and involves patient and no intolerance
 Decreased level,
exercise regimen, with his family with self-care. symptoms noted,
oxygen progressively, written instructions.
saturatio with no such as respiratory
n intolerance DEPENDENT: compromise.
 Ischemic symptoms 1.Assisst patient with 1. to gradually increase Goal was met.
ambulation, as ordered, the body to compensate
ECG noted, such as
with progressive for the increase in
changes respiratory increases as patient’s overload.
compromise. tolerance permits.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
INDEPENDENT:
Subjective: Deficient STG: 1. monitor patient’s 1. to promote optimal STG:
readiness to learn and learning environment The client
The client Knowledge r/t The client will determine best methods when patient show
verbalizes new diagnosis be able to to use for teaching. willingness to learn.
verbalized and
questions and lack of verbalize and 2. provide time for 2. to establish trust. demonstrated
regarding understanding demonstrate individual interaction with understanding of
problems and of medical understanding patient. information given
3. instruct patient on 3. to provide information regarding condition,
misconceptions condition. of information procedures that may be to manage medication
about his given regarding performed. regimen and to ensure
medications, and
condition. condition, Instruct patient on compliance. treatment regimen
medications, medications, dose, within 3 days of
Objective: and treatment effects, side effects, nursing
contraindications, and interventions.
 Lack of regimen within signs/symptoms to report 4. client may need to
improvement 3 days of to physician. increase dietary
Goal was met.
of previous nursing 4. instruct in dietary potassium if placed on
regimen interventions. needs and restrictions, diuretics; sodium should LTG:
 Inadequate such as limiting sodium be limited because of The client had
or increasing potassium. the potential for fluid been able to
follow-up on LTG: retention.
instructions The client will 5. provide printed 5. to provide reference correctly perform all
given. able to correctly materials when possible for the patient and tasks prior to
 Anxiety perform all for patient/family to family to refer. discharge.
tasks prior to reviews. Goal was met.
 Lack of
6. have patient 6. to frovide information
understan- discharge. demonstrate all skills that that patient has gained
ding. will be necessary for a full understanding of
postdischarge. instruction.
7. instruct exercises to be 7. these are helpful in
performed, and to avoid improving cardiac
overtaxing activities. function.

DEPENDENT:
1. refer patient to cardiac 1. to provide further
rehabilitation as ordered improvement and
rehabilitation
postdischarge.
.