ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

Subjective Data: Chronic pain related Short term goal: Independent: Short term goal:
- Patient is a smoker to increased cardiac After 20 mins of 1. Perform thorough 1. Helpful in After 15 mins of
consumes 1 pack per workload and oxygen nursing pain assessment with identifying changes nursing
day for 15 years, consumption as interventions, the each reported pain from client’s usual interventions, the
drinks alcohol evidenced by verbal patient will be able episode, using angina discomfort, patient was able to
occasionally, reports of severe to demonstrate relief appropriate pain which may have demonstrate relief of
hypertensive and live chest pain and of pain as evidenced scale. Instruct client certain charactistics pain as evidenced by
a sedentary lifestyle changes in BP by stable vital signs to notify nurse in location, duration, stable vital signs and
- The patient and absence of immediately when or intensity. absence of muscle
continues to eat muscle tension and chest pain occurs. tension and
foods to avoid. He restlessness 2. Identify 2. Helps differentiate restlessness
loves to eat pork precipitating event, if chest pain and aids in
sisig, lechon, shrimp, any; identify evaluating possible
and fatty foods like frequency, duration, progression to
adobo and grilled intensity, and unstable angina.
pork chop. location of pain. Stable angina usually
- Most of the time lasts 3 to 15 minutes
the patient forgot to and is often relieved
comply to his by rest and
maintenance sublingual
medication. nitroglycerin (NTG);
unstable angina is
Objective Data: more intense, occurs
- Dizziness unpredictably, may
- Palpitations last longer, and is not
- Tachycardia usually relieved by
- V/S are taken as NTG or rest.
follow: 3. Ask patient 3. A change may
BP– 150/100 whether the angina is indicate a worsening
PR – 123 with cardiac the same as the of the disease or a
arrhythmia patient typically different cause.
RR – 20, experiences
T – 37.8C 4. Monitor for 4. BP may initially
- Laboratory: changes in vital signs rise because of
LDL – elevated HDL- during pain episode if sympathetic
decrease Triglyceride it is different from stimulation and then
– elevated Total usual pattern of fall if cardiac output
Cholesterol – angina. is compromised.
elevated TROPONIN 5. Evaluate heart rate 5. Client with
T – elevated and rhythm, as changes may now
- Diagnostic: indicated. have unstable
ECG – ST segment angina, with an
elevated, T wave increased risk of
inverted acute life-threatening
dysrhythmias, which
occur in response to
ischemic changes and
stress.
6. Allow patient to sit 6. To reduce the
or rest in bed in a oxygen requirements
semi-Fowler’s of the ischemic
position. myocardium.
7. Alternate the 7. Balancing activity
patient’s activities and rest is an
with rest periods. important aspect of
the educational plan
for the patient and
family
8. Assist or instruct in 8. Helpful in
relaxation decreasing
techniques, such as perception of or
deep, slow breathing response to pain.
and distraction. Provides a sense of
having some control
over the situation,
increase in positive
attitude.
Dependent: 9. Increases oxygen
9. Provide available for
supplemental myocardial uptake
oxygen, as indicated. and reversal of
ischemia
10. Three categories
10. Administer of drugs are
medication(s) commonly used to
promptly, as lower the oxygen
indicated; for demand of the heart
example: muscle and to treat
or prevent episodes
of stable angina.
These categories are
nitrates, beta
blockers, and calcium
- Nitrates: channel blockers.
Nitroglycerin - Nitrate can be used
3 doses after 45 as chronic therapy to
minutes the pain still help prevent
there episodes of angina.
- Calcium channel - By reducing calcium
blockers: Amlodipine influx into muscle
5mg OD PO cells, calcium channel
blockers cause the
muscle cells to
“relax.” This relaxing
effect results in the
dilation of blood
vessels and a
reduced force of
contraction of the
Collaborative: heart muscle
11. Evaluate for MI
and refer to a higher- 11. If the pain is
acuity nursing unit significant and
continues after these
interventions.