NURSING CARE PLAN

Name of Patient: Nicholas Chung Ching Pui Civil Status: Married

Age: Nationality:
Sex: Male Religion:
Address: Wuhan,China Ward: Surgical Ward

ASSESSMENT NURSING SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS BACKGROUN
D
SUBJECTIVE: Acute pain Heart attack After 8 hours of Independent: After 8 hours of
“I had this very related to happens when nursing - Establish rapport -To gain nursing
intolerable, feeling of tissue there is interventions, the trust and interventions, the
digestion and pain in ischemia as marked patient will be cooperation patient was able
the middle of my chest evidences reduction or able to: - Assess for vital signs - Variation of to
radiating form my left by chest loss of blood 1. Verbalize and symptoms of appearance 1. Verbalize
arm to my fingers, and pain flow through relief/contro pain such as facial and behavior relief/control
painful jaw”, as radiating one or more l of chest grimacing, rubbing of patients in of chest pain
verbalized by patient. from left of the pain of neck or jaw, pain may 2. Display
arm down coronary 2. Display reluctance to move, present a reduced
OBJECTIVE: to the arteries, reduced increased blood challenge in tension,
- Facial fingers resulting in tension, pressure, and assessment. relaxed
grimace cardiac muscle relaxed tachycardia. Note Most patients manner,
noted ischemia and manner, onset, duration, with an acute ease of
necrosis. ease of location, and MI appear ill, movement.
- restlessness Results from movement. pattern of pain distracted, and 3. Demonstrate
prolonged 3. Demonstrate focused on use of
- Changes level myocardial use of pain. relaxation
of ischemia due relaxation techniques.
consciousness to reduced techniques. - Obtain full - Pain is a
blood flow description of pain subjective
- Vital signs are through one from patient experience
as follows: of the including location, and must be
T: 37.8 C coronary intensity (using scale described by
P: 86bpm arteries. of 0–10), duration, patient.
R: 19bpm characteristics (dull, Provides
BP: 170/110mmHg crushing, described baseline for
- Elevated as “like an elephant comparison
temperature in my chest”), and to aid in
and blood radiation. Assist determining
pressure patient to quantify effectiveness
pain by comparing it of therapy,
to other resolution
experiences. and
progression
of problem.

- Review history of - Delay in

previous angina, reporting pain
anginal equivalent, hinders pain
or MI pain. Discuss relief and may
family history if require
pertinent. increased
dosage of
medication to
achieve relief
thereby
creating further
damage and
interfering with
diagnostics and
relief of pain.

- Instruct patient to - Decreases

report pain external stimuli,
immediately. Provide which may
quiet environment, aggravate
calm activities, and anxiety and
comfort measures. cardiac strain,
Approach patient limit coping
calmly and confidently. abilities and
adjustment to
current
situation.

- Instruct patient to do - Helpful in