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
sisig, lechon, shrimp, any; identify
and fatty foods like frequency, duration,
adobo and grilled intensity, and
pork chop. location of pain.
3. Monitor for 3. BP may initially
Objective Data: changes in vital signs rise because of
- V/S are taken as during pain episode. sympathetic
follow: stimulation and then
BP– 150/100 fall if cardiac output
PR – 123 with cardiac is compromised.
arrhythmia 4. Evaluate heart rate 4. Client with
RR – 20, and rhythm, as changes may have
T – 37.8C indicated. increased risk of
- Laboratory: acute life-threatening
LDL – elevated HDL- dysrhythmias, which
decrease Triglyceride occur in response to
– elevated Total ischemic changes and
Cholesterol – stress.
elevated TROPONIN 5. Allow patient to sit 5. To reduce the
T – elevated or rest in bed in a oxygen requirements
- Diagnostic: semi-Fowler’s of the ischemic
ECG – ST segment position. myocardium.
elevated, T wave 7. Assist or instruct in 7. Helpful in
inverted 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:
8. Provide 8. Increases oxygen
supplemental available for
oxygen, as indicated. myocardial uptake
and reversal of
ischemia
9. Administer 9.
medication(s)
promptly, as
indicated; for
example:
- Nitrates: - Nitrate can be used
Nitroglycerin as chronic therapy to
help prevent
episodes of angina.
- Calcium channel - By reducing calcium
blockers: Amlodipine influx into muscle
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
heart muscle
- Opiod: Morphine - to relieve chest pain

Collaborative:
10. Evaluate for MI 10. If the pain is
and refer to a higher- significant and
acuity nursing unit continues after these
interventions.