NAME OF PATIENT: MR.

X CASE: SEVERE CHEST PAIN

ASSESSMENT NURSING PLANNING NURSING RATIONALE EVALUATION

DIAGNOSIS INTERVENTIONS
SUBJECTIVE: Acute pain related After 5 days of Instruct patient to Pain and decreased After 5 days of
“After I lifted the heavy to tissue ischemia confinement, the notify nurse cardiac output may confinement, the
object, I suddenly felt a patient will immediately when stimulate the patient demonstrates
pain in my chest and I demonstrate relief chest pain occurs. sympathetic nervous a relief of pain as
am also experiencing of of pain as evidenced system to release evidenced by stable
difficulty in breathing” by stable vital signs, excessive amounts of vital signs, absence of
as stated by the patient. absence of muscle norepinephrine, muscle tension and
OBJECTIVE: tension and Assess and document which increases restlessness.
 Restlessness restlessness. patient response platelet aggregation.
 Rapid-breathing to medication. Provides information
 Self-focused about disease
 Uncooperative progression. Aids in
@ times evaluating
HEENT: PERRLA (pupils effectiveness of
equal, round, and Identify precipitating interventions, and
reactive to light and event, if any: may indicate need for
accommodation); frequency, duration, change in therapeutic
anicteric sclera intensity and location regimen.
of pain. Helps differentiate
Chest/Lungs: Adynamic this chest pain and
precordium, crackles Evaluate reports of pain aids in evaluating
upon auscultation in jaw, neck, shoulder, possible progression
arm or hand (typically to unstable angina.
Vital signs recorded as on left side).
ff.: Cardiac pain may
BP: 140/100 mmHg radiate. Pain is often
RR: 25 bpm Place patient at referred to more
CR: 140 bpm complete rest during superficial sites
TEMP: 37°C anginal episodes. served by the same
02 SAT: 90% spinal cord nerve
Monitor heart rate and level.
 rhythm. Reduces myocardial
oxygen demand to
minimize risk of
tissue injury.
Patients with
Administer Morphine unstable angina have
Sulphate. an increased risk of
acute life-threatening
dysrhythmias, which
occur in response to
ischemic changes
and/or stress.
Potent narcotic
analgesic may be
used in acute onset
because of its several
beneficial effect.

NAME OF PATIENT: MR. X CASE: SEVERE CHEST PAIN

ASSESSMENT NURSING PLANNING NURSING RATIONALE EVALUATION

DIAGNOSIS INTERVENTIONS
SUBJECTIVE: Activity At the end of five days Document heart rate Trends determine At the end of five days
“It has been 2 days intolerance confinement the and rhythm and patient’s response confinement the
since I’ve experienced related to patients will changes in BP before, to activity and patients demonstrate
severe chest pain” as imbalance demonstrate during and after may indicate measurable/progressive
stated by the patient. between measurable/progressive activity. myocardial oxygen increased in tolerance
OBJECTIVE: myocardial increase in tolerance for deprivation that for activity with heart
 Restlessness oxygen supply activity with heart may require rate/rhythm and BP
 Rapid-breathing and demand. rate/rhythm and BP decrease in within patient’s normal
 Self-focused within patient’s normal activity level limits.
  Uncooperative limits. and/or return to
@ times bedrest, changes
HEENT: PERRLA (pupils in medication
equal, round, and regimen, or use of
reactive to light and Encourage rest supplemental
accommodation); initially. Thereafter, oxygen.
anicteric sclera limit activity on basis Reduces
of pain and/or adverse myocardial
Chest/Lungs: Adynamic cardiac response. workload and
precordium, crackles Provide nonstress oxygen
upon auscultation diversional activities. consumption,
Vital signs recorded as
reducing risk of
ff.:
complications.
BP: 140/100 mmHg
Activities that
RR: 25 bpm Instruct patient to require holding
CR: 140 bpm avoid increasing the breath and
TEMP: 37°C abdominal pressure. bearing down can
02 SAT: 90%
result in
bradycardia and
rebound
tachycardia with
Explain pattern of elevated BP.
graded increase of Progressive
activity level: getting activity provides a
up to commode or controlled
sitting in chair, demand on the
progressive heart, increasing
ambulation, and strength and
resting after meals. preventing
overexertion.
Review s/sx reflecting
intolerance of present Palpitations, pulse
activity level or irregularities,
requiring notification development of
of nurse or physician. chest pain, or
dyspnea may
 indicate need for
changes in
exercise regimen
or medication.

NAME OF PATIENT: MR. X CASE: SEVERE CHEST PAIN

ASSESSMENT NURSING PLANNING NURSING RATIONALE EVALUATION

DIAGNOSIS INTERVENTIONS
SUBJECTIVE: Decreased cardiac The patient will be Assess the patient’s vital To assist in creating an The patient has able to
“I am having a chest output related to the able to maintain signs and characteristics accurate diagnosis and maintain adequate
pain” as stated by the disease process of adequate cardiac of heart beat at least monitor effectiveness cardiac output in the
patient. coronary artery output at the end of 5 every 4 hours. Assess of medical treatment. end of 5 days
disease (CAD) days confinement. heart sounds via confinement.
OBJECTIVE:
auscultation. To increase the oxygen
HEENT: PERRLA (pupils
Administer supplemental level and achieve an
equal, round, and oxygen, as prescribed. Sp02 value of at least
reactive to light and Discontinue if Sp02 level is 94%.
accommodation); above the target range, or
anicteric sclera as ordered by the
Chest/Lungs: physician. Stress causes a
Adynamic precordium, persistent increase in
crackles upon Educate pt. on stress cortisol levels, which
auscultation management, deep has been linked to
Vital signs recorded as breathing exercises, and people with cardiac
relaxation techniques. issues.
ff.:
BP: 140/100 mmHg
RR: 25 bpm
CR: 140 bpm
TEMP: 37°C
02 SAT: 90%

NAME OF PATIENT: MR. X CASE: SEVERE CHEST PAIN

ASSESSMENT NURSING PLANNING NURSING RATIONALE EVALUATION

DIAGNOSIS INTERVENTIONS
SUBJECTIVE: Acute pain related to The patient will Assess the patient’s vital To monitor The patient
“After I lifted a heavy decreased myocardial demonstrate relief of signs and characteristics effectiveness of demonstrates relief of
object, I suddenly felt blood flow as pain as evidenced by a of pain at least 30 minutes medical treatment for pain as evidenced by a
a pain in my chest… I evidenced by pain pain score of lower after administration of the relief of pain. The pain score of lower than
score of 10 out of 10. than 3 out of 10. medications. time of monitoring of 3 out of 10.
score it as 10” as
vital signs may depend
stated by the patient.
on the peak of time of
OBJECTIVE: the drug administered.
HEENT: Elevate the head of the
PERRLA; anicteric bed if the patient is having To increased the
a shortness of breath. oxygen level and
sclera
Administer supplemental achieve an Sp02 value
Chest/Lungs: oxygen, as prescribed. of at least 94%.
Adynamic Discontinue if Sp02 level is
precordium, crackles above the target range, or
as ordered by the
upon auscultation
physician. Stress causes a
Vital signs recorded
Place the patient in persistent increase in
as ff.: complete bed rest during cortisol levels, which
BP: 140/100 angina attacks. Educate has been linked to
RR: 25 bpm pt. on stress people with cardiac
CR: 140 bpm management, deep issues.
TEMP: 37°C breathing exercises, and
02 SAT: 90% relaxation techniques.

NAME OF PATIENT: MR. X CASE: SEVERE CHEST PAIN

ASSESSMENT NURSING PLANNING NURSING RATIONALE EVALUATION

DIAGNOSIS INTERVENTIONS
SUBJECTIVE: Decreased cardiac At the end of Perform a Assessment is the At the end of
“After I lifted a heavy output related to the confinement, the comprehensive first step in confinement, the
object, I suddenly felt a disease process of patient will assessment. Assess managing pain. It patient will display
pain in my chest” as coronary artery display improved location, helps ensure that improved vital
stated by the patient. disease (CAD) vital signs and characteristics, the patient signs and muscle
OBJECTIVE: muscle tone onset, duration, receives effective tone
HEENT: frequency, quality pain relief.
and severity of
PERRLA; anicteric sclera pain. Some patients may
Observe for deny the existence
Chest/Lungs: Adynamic
nonverbal indicators of pain. These
precordium, crackles behaviors can help
of pain: moaning,
upon auscultation guarding, crying, with proper
Vital signs recorded as facial grimace. evaluation of pain.
ff.:
BP: 140/100 mmHg Vital signs are
RR: 25 bpm Obtain vital signs. usually affected
CR: 140 bpm when pain is
TEMP: 37°C Use present.
02 SAT: 90% nonpharmacological Works by
pain relief methods increasing the
(relaxation release of
exercises, breathing endorphins,
exercises, music boosting the
therapy). therapeutic effects
of pain relief
Provide optimal medications.
pain relief by Various types of
administering pain require
prescribed pain different analgesic
relief medication. approaches. Some
respond well to
non-opioid pain
relievers while
Document patient’s others demand a
response to pain combination of
management. non-opioid and low
dose opioid.
It helps the entire
healthcare team
evaluate their pain
management
strategy.